Professional Documents
Culture Documents
1501
1501
CONTENTS
t
xl
t'
) 1. Normal Growth and Disorder of Growth & Development'.................. ........................-...011
Ir
NMR}V{AL GROWTH
ANP DISORDER
OF GROWTH 6
PEVELOPMEI\TT
o Growth follows a qig44-shaped curve. The fetus grows_@l1in the EIJ half ,qf-ggstation, thereafter the rate of growth
is slowed down till the baby is born.
o lntheeailypostnatallteriodvelocityofgrowthishighduringthefirstfewmonths@Psc'u).Asecondphaseofaccelerated
growth is during puberty.
o The brain enlarges rapidly during the latter m-onJlrs oJfetal life and early months of pqstqptallife. At birth, thehead
size_is about 65 to 70 percent ofthe expected head size in adults. It reaches g0percent ofthe adult head size by the
07' IGnta 07).
age of 2 y-qqr-q(comed
Birth 3Kg
)
t year 9 Kg {3 x birth weight)6't$s
e A child gains about 2 kg every year between the age of 3 and 7 years and 3 kg per
year after that till the pupertal
groMh spurt begins.
Height
r Theaveragebirthheightis50cm(ArMsse).Theheightgaininfirstyearisaround25cm@NB13t(so%ofbirthheight@
ot)).
e The height of a child becomes double the birth height at around 4Yz years(NEEr, uPsces) and becomes triple by 12
years of age.
c After the age of 4 years, a child grows at rate of 6 cmlyear4t ez)
.
Birth 50 cm
,':,:.3,mohths "., 60cni .:.
9 months /u cm
.,. /eal..
1 ,:.: 75.im'.::
2years 90 cm
' 4r4 y,ears too
'ma"rtr
For clinical significance upper segment and lower segment should be measured separately. The lower segment extends
from the symphysis pubis to the heels. The lower segment grows rapidly after birth as compared to upper segment
giving rise to the gradual reduction in the upper segment/lower segment ratio with the progression of age.
a) Beamscale
b) Infantometer
c) Dynamometer
d) Osteometric board
Chest circumfenence
o The circumference of chest is about 3 cm less than head circumference at birth.
o The circumference of head and chest are almost same by the age of 9 months to 7 yea/K"'" 06).
Thereafter the chest
circumference exceeds the head circumference.
o The chest circumference is usually measured at the level of nipples.
o The shakir's tape is divide lnto three coloured zones, the green zone is above 1-3.5 cm is normal; yellow-orange zone
is between 12.5 - 13.5 cm and represents border line malnutrition; and red zone is below 12.5 cm which represents
severe malnutrition.
o During
l-,!years of age, mid-upper arm circumference remains reasonably static(Pcre6) between15-17 cm among
health children because fat of early infancy is gradually replaced by muscles.
o Kanawati index(ar ra) is calculated by multiplying MAC and head circumference(Ar "). It is used to diagnose
malnutrition. Normal value is > 0-32. Value less than 0.32 indicates malnutrition.
o Children accomplish maturation of different biological functions (level of development or milestone) at an anticipated
age, with a margin of few months on either sides. Thus, a childt growth (normal or abnormal) can be assessed by
evaluation of these milestones. Important milestones are :-
a j months r In ventral suspension Iifts his head above horizontal plance {Neck holding)rA' tsPc'or.
r ln prone position lifts his head and upper part of forearms.
r Head Cc,nttillAtoa, Pcto3,ol).
r Starts cooing
r Recognizes mother
r Can follow an object upto l$Oo?Gto3'ot)
r On pulling the child to sit, head lags partially (between 2-3 months). After 3 months head control develops.
7 months s Hofdsthe obJects with crude grasp from palm (palmar grasp)(Pclos)
* Pivots
* Shows strangers anxietyrPc'07')
* Resista if a toy is pulled frorn his hand.
* gabbleiPc! sl, 02, AuMs 00)
^!
I Standswithoutsupport@6l8",,:. :
* Vocabulary of 4 to 6 words
; Enjoy polysyllabic jargoning
k
Cnap rn rt Normal Grotdlr ondDisordbr of Grulxil,
o 2 yeors walking up and downstairsfiEEr'AilMse4'e3'PGto3), one step at a time i.e., brings both his fuet up on one step
before climbing to the next step (but not by alternate feet).
I Can turn pages of book one at a time?G'o3).
n Draws a vertical or horizontal line.
rt ls able to wear socks or shoes.
r Kicks ball on request
Jumps of the floor with both feet.
n Builds tower of 7 cubes.
I Makes simple r"ni"na", and uses pronounsrD'v8' 2'PGtto'AilMsss,s4).
T ls trainable for toilet and verbalizes toilet needs.
I Can unscrew lids and turn door knobs(Pcr 'o.,.
t Points 3-4 body parts.
't SofionthE '* €Jimbistairs:*ItErnatirig.feelafEs0e.estoa;,,,,,..,
:.a, * MakEStOWerof9ttlb€s{fft{5oel., "'
.a Refers ta self ai,!l'qnd kistiltsfull *amdAillloe-): : ':
11tr'
can tell astory/Petoa).: ''-
s 5 years I Draws a tilted corss (multiplication sign)
t Draws a trianglelAt 't DNB t3' NEEI)
-
5 SkiP5{nrrusrar
a Name 4 colors
t Counts 10 pennies correctly
T Can use sentence of 1 0 words.
A. S'TTINIG
a) 4 weeks
b) 3 months
c) 5 months
d) 9 months
a) 6 weeks
b) 3 months
c) 6 months
d) 9 months
a) 2 months
b) 3 months
c) 4 months
d) None
a) 2 months
b) 3 months
c) 5 months
d) 9 months
months.
a) 2 months
b) 3 months
c) 4 months
d) 6 months
i? Kg,:
i€'
a) 3 months 4'1:
rvC.
%-
b) 4 months '\e,'-
c) 6 months
d) 8 months .J"'
', i.
3€
'El
. ,,% Wiz
-t"\*ei
.*-^
i. qffi+; _>
a) 4 weeks
b) 2 months
c) 3 months
d) 4 months
a) 2 months
b) 4 months
c) 6 months
d) None
a) 2 months
b) 3 months
c) I months
d) None
a) 2 weeks
b) 4 weeks
c) 6 weeks
d) 8 weeks
a) 2 weeks
b) 4 weeks
c) 6 weeks
d) 8 weeks
a) 2 weeks
b) 4 weeks
c) 6 weeks
d) 8 weeks
a) 2 months
b7 5 months
c) , months
d.1 9 months
a) 5 months
b) 9 months
c) 1 year
d) None
a) 4 months
b) 6 months
c) 8 months
d) 10 months
a) 5 months
b) 6 months
c) 8 months
d) l0 months
a) 5 months
b) 8 months
c) 10 months
d) 13 months
a) 5 months
b) 15 months
c) 30 months
d) 4 years
a) 5 months
b) 15 months
c) 30 months
d) 4 years
E. OTHER MILESTONES
a) 2 months
b) 5 months
c) 8 months
d) l0 months
a) 2 months
b) 5 months
c) 9 months
d) I year
a) 2 months
b) 5 months
c) 9 months
d) 1 year
a) 2 months
;; 3;;;;h;
c) 4 months
d) 6 months
incisors, 2 canines and 4 molars in each jaw. They start shedding at about 6 years, when permanent teeth start appearing.
o permanent teeth are 32 in number : being 4 incisors, 2 canines (cuspids), 4 premolars (bicuspids), and 6 molars
(tricuspids), in each jaw. 6 perm4nent molars which erupt extra in each jaw without replacing any teeth are called
superadded permanent teeth, while all other permanent teeth are successional permanent teeth.
o Eruption of temporary teeth is called primary dentition and eruption of permanent teeth is called secondary dentition.
rs)
c Temporary teeth start erupting at 6 months age@t .
r:'i. Therefore, between 6-12
o Temporary teeth start falling at,6 years when permanent teeth start appearing(oNr
e8l.
years, there is mixed dentition(o""o
o First temporary tooth to appear (in primary dentition) is lower central incisors and last temporary tooth
to
rnolarlrerutael).Lhe sequence of eruption is 1'r molar > central incisor > lateral incisor > 7't premolar > 2d premolar >
17 -25years'
canine > 2,d molar > 3,d molar.Eruption of permanent teeth is completed by eruption of 3'd molar between
a EruptionofteethmaybedelayedinhypothyroidismNEE.'PGI0s'AIIM'eT),hlpopituitarism(ArrMseT),Rickets(xrrr),Down's
AilMS s7),malnutrition and cleidocranial dysplasia.
syndrome(NEEr'
e Permanent teeth appear first in lower jaw.
e Permanent teeth appear a few month earlier in females'
o Third molar appears first in lefi side of lowet jaw and then on right side.
r t Normal Grawth and Disorder of Growth & Development
SHOMT STATIJRE
* If the height of the child is below the 3rd percentile or less than 2 S.D. from
the mean, he or she is considered to be
short stature.
2) lntrauterine infections
3) Genetic disroders (chromosomal and metabolic)
Posnatal causes 1) Nutritional dwarfism (due to malnutrition)
2) Chronic visceral disease
a) Hypothyroidism
b) Achandroplasia :-
c) Mucopolysaccharidosis
d) CFI deficiency
Short stature
Enuresis
o Enuresis is defined as the voluntary or involuntary repeated discharge of urine into clothes or bed after a
developmental age when bladder control should be established (mostly mental age of 5 years).
r Diagosis of enuresis requires voiding of urine twice a week for 3 consecutive months or clinically significant distress
in child's life as a result of wetting.
r Enuresis is more common in males than females.
Tneatmemt
a No treatment is given to children below 6 years because of high spontaneous cure rate(Arr3). After 6 years, treatment
include :-
i) Behavioral therapy
x It is the treatment of choice, Most ffictive treatment is bed alarm and motivational therapy with least
chances of recurrence(Ar08). Motivational therapy includes _
a) Keep diary of wet & dry night. d) Restrict fluid at bed time.
b) Void urine before going to bed. e) Avoid punishment.
c) Change wet cloth & bedding. f) Positive reinforcement(ArI5).
x Consistent dry bed training with positive reinforcement has a success rate of B5o/o and bed and pad alarm
systems have a success rate of approximately 75o7o\r ts;
with relapse rate that are lower than those with
pharmacotherapy.
ii) Pharmacologicaltreatment
x It is used when non-pharmacological (behavioral) therapy fails. DesmopressinKarnee) is the drug of choice.
Other drugs used are impramine(uPor) and oxybutinin.
Thumb srickimg
o Thumb sucking is normal in infancy and toddlerhood, i.e. upto 4-5 years@e oz, 0s' ripmer el) .It is a
behavioral problem,
which may be self soothing, i.e. a source of pleasure(uP 07' 0s' lipnet e1).
o Presistent thumb sucking in adolescence is more common in girls and may be sign of insec rtrityop 07,0s, ripnet sl)
.
o Presistent thumb sucking in older children can cause dental malali gnment(up07,0s,lipnerei). For lessening the
effect on
dentition, thumb sucking should be discontinued before 8 years of age(ez.ussr, 7s,PGI7e).
s Treatment is not required till the age of 4-5 years. After that behavioral therapy in the form of
Ttositive reinforcement
(giving reward for not sucking the thumb) is treatment of choice. Negative reinforcemenf (application
of noxious
agents to thumb) is second line of treatment.
Breath ho!ding spells
* Breath holding spell is a paroxysmal event occuring in 0.1% - 57o of healthy children from the age of 6 months
to 6
szl
featS1IIMs .
* The name for this behaviour maybe misnomer in that it connotes prolonged inspiration. Infact, breath-holding
occurs
during expiration and is reflexive (not volitional) in nature.
e There are two major types of breath holding spells :-
A) Cyanotic form (cyanotic spells)
x This is more common and is provoked in response to frustration and anger precipitated by upsetting or scolding
infant/child.
x Cyanotic spells are dre to central sympathetic overactivity.
x Clinical features include generalized cyanosis(A[Ms e7), apnea, forced expiration, opisthotonus, shrill cry and
bradycardia. Seizures may occur due to cerebral hlpoxia, but antiepileptics are not required 6IIMI s7).
2) Pharmacological treatment: Psychostimulant ilrugs are most efiective treatmenf. Methylphenidate(Pcro8) is the
drug of choice. Amphetamines(Pcro8) and atomoxetine(Pcr08) are alternatives.
Autism
r Autism is a pervasive development disorder (PDD) which is characterized by: -
i) Marked impairment in social interaction@Gror'00)
r There is no social smile(MP06) or eye contact. These children prefer to play alone with inanimate objects and do
not like to mingle with others(ArrMs0r) (do not make friends). There is lack of attachement to parents and absence
ofseparation anxiety.
ii) Impairment in communication?Gr0l'0o'Attus06'01) (language well as non-verbal communication) as
r Delayed or absence speecharMs06), lack of verbal or facial response to sounds or voices, abnormal speech
patterns, echolalia, perseveration and prominent reversal (referring to selfas 'you' and to others as'I').
o Onset of symptoms of infantile autism (usual form of autims) is before 2.5 - 3years@P06). If onset of symptoms
are
afier 3 years, it is referred to as childhood autism.
r Autism is more common in boys and among low socio-economic groups(pcr04).
I Presently, the cause of infantile autism seems to be predominantly biologi calecl0l).
Rett's syndrome
r Age of onset is around 5 months.
: Development may proceed normally until 1 yr of age, when regression of language and motor milestones become
apparent.
r This is the characteristic features, that they begin to loose their acquired skills, e.g., cognitive and head growth
is normal during early period after which there is an arrest of growl6rez,uso,rl.
I Acquired microcephaly (Decleration of head growth due to significantly reduced brain weight(-Arus0i,).
r Most children develop peculiar sighing respirations with intermittent periods of apnea that may be associated
with cyanosis -+ Breath holding spells(ar'uso'rt.
s Austistic behaviour is a typical finding in all patienfs -+ Impaired social interaction, language and
o3).
communicationazM's
r Generalized tonic-clonic convulsions occur in the majority.
r Feeding disorder and poor weight gain are common.
r Death occurs in adolescence or in the 3.d decade.
: Cardiac arrhythmias may result in sudden, unexpected death.
Asperger syndrome
r Qualitative impairment in the development of reciprocal social interaction after the age of 3 years.
r More common in males
r Normal intelligence, The only pervasive development disorder in which intelligence is normal.
r Eccentric interests.
s No language impairments that characterize autism.
r Children with Asperger syndrome appear to be at high risk for other psychiatric disorder.
ADOLESCENCE
Adolescence
r Adolescence is defined as the period from the onset of puberty to the termination of physical growth and attainment
offina1 adult hight, i.e. adolescence is considered as a period oftransition from childhood to adulthood. Adolescence
is usually the period 10 to 20 yr@NB 13' AI0s)
.
Puberty
r Puberty is the biological process in which a child become adult, i.e. biological process which occurs during transition
from childhood to adulthood. Changes include appearance of secondary sex characteristics and development of
reproductive capacity.
In Girls
o In girls, puberty starts with onset of breast development (appearance of breast buds), called thelar che(Al 13. DNB 12,
13' AI 08' PGt ee),
between 8 and 13 years (corresponds to Tanner SMR stage - 2at 1s)) . This is followed by appearance of
pubic hair (pubarche) and axillary hair (adrenarche)Atset. Pubarche is followed by peak growth velocity, immediately
after which menarche (onset of mensturation) occurs.
Theldrche _+ Pubarche & adrenorcheote6) _.> peak growth velocity'nrn, ete6sa ) menarcheNEEr, At oo, s8)
Preadolescent Preadolescent
Sparse, lightly pigmented, straight, Breast and papilla elevated as small
medial border of labia mound; diameter of areola increased
Darker, beginning to curl, increased Breast and areola enlarged, no contour
amount separation
Coarse, curly, abundant, but less than in Areola and papilla form secondary mound
adult
Adult feminine triangle, spread to Mature, nipple projects, areola part of
medial surface of thighs general breast contour
ln Boys
o In boys,frst sign of puberty is enlargement of testis\I se),
at around 9/z years. This is followed by penis enlargement
after which pubarche (pubic hair growth) starts. Then occur peak growth velocity, adrenarche (axillary hair growth)
andfacialhair growth (beard){ectsat, in that sequence.
Testicular enlargement -+ Penis enlargement -+ Pubic hair growth -+ Peak growth velocity + Axillary hair --> facial hair.
1 None Preadolescent
2 Scanty, Iong, slightly pigmentedrntrsr Minimal change/enlarge- Enlarged scrotum(A"'), pink, tex-
ment ture altered
3 Darker, starting to curl, small amount Lengthens Lar;1er
4 Resembles adult type, but less quantity; Larger; glans and breadth Larger, scrotum dark
coarse, curly increase in size
Adult distribution, spread to medial surface Adult size Adult size
of thighs
ffi;*m :aiiwia*41z
y9or:,:,.6-,,,ecm per year:-r,,,,: :,,,., :,,::: i,
; Body weight is tripted (3 times of birth weight) at : 1 yea r of age.
y ;.;.; y.w*tgfii iiuiaru$les 14t e;of b;ii{Ew;ight} iit : 2 yea,i.':of age,','
* Body weight is 5 times the birth weight at:3 years of age.
. Weight gain during 2'd year of life:3 kg.
. Head circumference is measured from: Occipital protuberance to supraorbital ridge of forehead.
Curprrn r Normal Growth ond Disorder of Growth& Development
I
o Maximum growth of lymphoid tissue occurs : Between 4-B years.
. lmportant causes of proportionate short stafure : Familial, constitutional delay, IUGR, malnutrition. hypopituitrism (GH deficiency).
c lmportant causes of disproportionate short stature : Hypothyroidism, achondroplasia, mucopolysaccha ridosis.
o Features of constitutional delay in growth:Normal birth height, bone age < chronological age, normal growth velocity, positive family
history, IGF-1 is low for chronological age but normal for bone age.
o Features of familial short stature i low birth weight, bone age is normal for chronological age, positive family history, normal growth
velocity.
& Short ststare due to GH deficiency: Normal body porportion, bone age < chronological age, normal birth height and weight, altered
growth velocity.
@ Most common cause of short stature: Constitutional delay in growth.
* lnfantile body proportion is seen in: Achondroplasia juvenile myxedema (hypothyroidism), cretinism.
* Reverse infantile body proportion is seen in: Marfan's syndrome, Homocystinuria, Klinefelter syndrome, Frolich's syndrome, Eunuchoidism.
w Difficutty in expressing in writting, reoding problems, mathematic mistakes, problem in spelling: Specific learning disability.
w Characteristic triad of ADHD : Hyperactivity (first symptom), impulsiveness, inattention.
a Other features of ADHD: Disturbing others, difficulty in playing, does not listen to teaching, restlessness, uncontrolled desire to play
outside.
a Not a feature of ADHD : Mental retardation.
. i;::;::r:r"Uiioor*u,*: A source of pleasure. may be a sisn of insecurity, may cause matocctusion, no treatment is required upto
4-5 years.
@ To avoid malocclusion of teeth, thumb sucking should be terminated by:7-B years.
& Pica referes to: lngestion of non-nutritive substances.
@ Cretinism (hypothyroidism) is characterized by: Disproportionate short stature (short stature with short limbs).
w Chitdhood disorder which improves with age: Temper tantrum.
& Adolescence period extends from : 10 20 years (starts ,,.10 ,".t:,
, .
& First sign of puberty in girls:'lhelarche (development of breast buds).
'TI
I Disorder of Growth & Development
QUESTIONS
food. What is the most appropriate age of this baby: a) 6 weeks b) 12 weeks
(At 07) c) 6 months d) l2months
a) 3 months b) 5 months 37. At what age do first permanent teeth appear ?
c) 7 months d) 9 months (CET Nov. 13 Pattern)
ENURES!S 68. Arm span and height become same at what age (year):
(All India Dec15 Pattern)
59. 5 vear old child bed wetting Rx of choice: a)9 b) 11
(All lndia Dec.1j Pattern) c) 13 d) 1s
a) No treatment b) Imipramin 69. Pica refers to: (NEET Dec.12 Pattern)
c) Desmopressin d) Motivational therapy a) IU sucking
60. Lowest recurrence in nocturnal enuresis is seen b) Thumb sucking
with: 61 0B) c) Foreign object being put in the mouth
a) Bed alarms b) Desmopressin d) None ofabove
c) Imipramine d) Oxybutynin
61. Treatment ofnocturnal enuresis in a 14 year old ADOLESCENT
child is: (All India Dec15 Pattern)
a) Positive reinforcement
70. WHO defines adoleseent age between;
b) Punishment
(All India Dec.14 Pattern)
c) Bed alarm
d) Desmopressin a) 10-19years b) 10-14years
c) 10-25years d) 9-14years
62. Which of the following nasal spray is very effective
in eontrol of enuresis: (All India Dec.14 Pattern)
7r. Adolescent starts at the age of ? (CET Aug lj pattern)
c) Attacks ofcyanosis can occur 74. First sign of pubertal development in female isr
d) Occurs between 6 months to 5 years (All India Dec.13 Pattern)
d) Molybdenum a) Telarchy-pubarchy-menarchy
b) Puberchy-telarchy-menarchy
c) Puberchy-menarchy-telarchy
THUMB SUCKING d) Adrenarchy-telarchy-pubarchy
66. Which is incorrect about Thumb sucking: 1rMpERsi) 76, Order of development of secondary sexual charac-
a) can lead to malocclusion teristic in male: (PGr e6)
ENURESIS 68. Arm span and height become same at whatage (year)t
(All lndia Dec15 Pattern)
59. 5 year old child bed wetting Rx of choice; a)9 b) 11
(All India Dec.13 Pattern) c) 13 d) 15
a) No treatment b) Imipramin 69. Pica refers to: (NEET Dec.12 pattern)
c) Desmopressin d) Motivationaltherapy a) IU sucking
60. Lowest recurrence in nocturnal enuresis is seen b) Thumb sucking
with: (Ar 08) c) Foreign object being put in the mouth
a) Bed alarms b) Desmopressin d) None ofabove
c) Imipramine d) Oxybutynin
61. Treatment ofnocturnal enuresis in a 14 year old ADOLESCENT
child is: (All lndia Dec15 Pattern)
a) Positive reinforcement
74, WHO defines adolescent age between:
b) Punishment
c) Bed alarm (All India Dec.14 Pattern)
99. A normal infant sits briefly leaning forward on her DISORDER OF GROWTH & DEVELOPMENT
hands, reaches for and grasps a cube and transfer it
from hand to hand. She babbles but canot wave bye- 103. \faking up at night, screamingwit] fear, at2.Syexrr*
bye nor can she grasp objects with the finger and ag9 is generallya manifestation of: (PGt 01,79)
thumb. Her age is: (UPSC 2K) a) Organic illness
a) 4 months b) 7 months b) Normal development pattern
c) 10 months d) 14 months c) castration anxiety
f 00. At which one of the follo-rving age period a child can d) Separation anxiety
remove front opening garment ? (coMED 06) l(}4. Cretinism is: (uP 08)
a) 24 months b) 36 months a) Disproportionatedwarfism
c) 48 months d) 60 months b) Short stature with long trunk
f 0f . Which ef the following are the first incisors to c) Short stature with short trunk
erupt in an infant: (UPSC 07) d) Long stature with long trunk
central
a) Lower b) Lower lateral tO5. Which of the following childhood disorder improves
central
c) Upper d) Upper lateral with increase in age: (MP 2K)
III
af,, G rowih', & D eveI o p m e n t
ANSWERS
NORMAL GROWTH
t. Ans. is 'd' i.e., 4 years fRef: A.P. Ghai Bth/e p. 13 dr Vh/e p" 6)
r An infant usually doubles his birth height by the age of 4r/2 year s
) Ans. is 'a' i.e., 25 cm [Ref O.P. Gkai Bth/e p. 6]
o At birth, height is around 50 cm.
r At one year, height is around 75 crlrr.
r Thus gain in height in first year is 25 cm.
3. Ans. is t'
i.e.,4.5 year [Ref O.P. Ghai t"Bth/e p. d]
o A child acquire height of 100 cm by age of 4% year.
4. Ans. is t' i.e., 6 cmlye* fRef: O.P. Ghai \th/e p. 13 6 Vh/e p. 6; Nelson lyth/e p. 54, 551
'After 4 years, the child gains about 5 cm in height eyery year, until the age of 10 years" --
O.p Ghai.
'An average child gains approximately 7-8 cm in height between the age of 2-6 years and 6-7 cm
in height between
6-12 years". __ Nelson
Amongst given option, 6 cmlyear is the best answer.
3Kg
8. Ans. is 'd i.e., Mid arm circumference lRef Meharbqn Singh 3d/e p. 53)
r During 1-5 years of age, the mid-upper arm circumference (MUAC) remains reasonably static between 15-17 cm
among healthy chidren because fat of early infancy is gradually replaced by muscles.
DEVELOPMENTAL M I LESTON E
13. Ans. is 'a'i.e., Pincer grasp at 3 months lRef: O.P. Ghai 8th/e p. 45,46, 49 6 7h/e p. 27; CPDT 18th/e p. 751
o Pincer grasp develops by 9 months 1 1 months)(9-
r Child can sit with support by 5 months
o Social smile will be present at 3 months (social smile develops by 2 months).
e 2 year old child makes simple sentences and can use pleurals.
t4. Ans. is 'b' i.e., l0 IRel O.P. Ghai 8th/e p. 49 & Vh/e p. 28)
15. Ans. is 'b' i.e., Climb stairs runninglRef: O.P. Ghai 9th/e p. 49, 5A, 51 /2 Vh/e p. 28, 3A; Nelson 18th/e p. 441
lmportant milestones of a 3 years child
o Rides tricycle o Knows his age and sex.
o Stands momentarily on one foot. r Repeat a sentence of6 syllables
o Draws acircle e Has a vocabulary of 250 words.
o Can dress or undress himself completely o Counts 3 objects correctly.
r Builds tower of 10 cubes o Can withhold and postpone bowel movement.
16. Ans. is 'b' i.e., 3 year lRef: O.P. Ghai 7h/e p. j}l
17. Ans. is'd'i.e., 2 years fRef: Nelson 18'h/e table 32-1, table 591-11
e At2years, a child can make simple sentences and uses pronouns.
t8. Ans. is 'd i.e., 2 and3 yeffs lRef: O.P. Ghai 8'h/e p. 50-52 6 Vh/e p. 28; Nelson 18th/e p. 49f
r A child learns to feed herself with spoon without spilling its contents by the age of 15 months.
o A child can dress or undress herselfcompletelyby the age of3 years.
r A child knows his gender by the age of 3 years.
So, the given milestones develop between the age of 15 months and 3 years.
Amongst the given options best answer is 'a' i.e., 2 and 3 years.
19. Ans. is 'a' i.e., 6 month fRef: Clinical pediatrics 2il/e p. 17)
o Purposeful movement through space starts at 6-8 months.
r During this period, children begin to move towards and away from objects or people independently.
20. Ans. is 'b' i.e., 5 years lRef Nelson 18th/e p. 49; O.P. Ghai 6th/e p. 44-461
A:€
3 years Draws a circle
al_gg-e.! rT::=
5 years Draws a triangle
of Growth & Development
11 Aae . is'H i.e., l'k years {Ref: O. n Ghai */e p. 30; Nelson 18e/e p. 49)
I 12 months
18 months
. 36 months 10
24. Ano. io '{ i.e., Draws a triangle t&ef: O.p. Ghai */e p. 50, 51 6 fr/e p, 28; Nelson l}*/e p. 491
o A child can draw a triangle by 5 years.
o A child can draw a circle by 3 years.
o A child can make a tower of 9 cubes by 30 months.
o A child can go up and downstairs with one step at a time by 2 years.
r A child can stand momentarily on one foot by 3 years
ob'
L). Ans. is i.e., 3 year {Ref. Nelson 1*/e p. 50)
o Handedness develops by the age of 3 years (36 months).
26. Ans. is 'a' i.e., Mirror play fRef: O.P. Ghai 8th/e p. 49-51; Nelson 18th/e p. 491
o A child enjoys watching his own image in the mirror (mirror play) by 6 months.
o A child crawls in the bed by 8 months.
o Full creeping and crawling develop by 10 months.
o Pincer grasps develops by 9 months.
27. Ans. is 'b' i.e., 5 months {Ref: O.P. Ghai 8th/e p. 52 6 Vh/e p. 30; Nelson 18th/e p. 491
I
o Mouthing develops by 4 months, while stranger anxiety develops by 7 months.
o So, the age of this child is between 4 to 7 months.
o Amongst the given options best answer is 5 months.
28. Ans. is t' i.e., Build a tower of 3-4cubes [Rel O.P. Ghai 8th/e p. 49 dt Vh/e p. 28; Nelson 18'h/e p. 45, 49; CPDT 18th/e
p. 7s1
o A child starts trying to build a tower of cubes (2 cubes) by the age of 1 year.
About other options
o Child can stand with support by 9 months.
e Chiid can play peak-a-boo game by 10 months.
CrraPft.ri.:r
o Child can pick up a pellet with thumb and index finger (pincer grasp) by 9 months.
30. Ans. is'd'i.e., Sustain head level with the body when placed in ventral suipension lRef: Nekon 18e/e p.
4ej
Important rnile stones of a 2 months child.
o In ventral suspension, lifts his head in the horizontal plane (in the plane ofthe body).
e Social smile develops
o Follow object with steady movement of eye.
About other options
r Parachute reflex develops during 9th month of life --- CPDT 18'h/e p. 709
e Control of head develops by 3 months
c A child can Iift head and chest off a flat surface with extended elborv by 6 months.
31. Ans. is 'c' i.e., 4 years lR$: Nelson lSthle Ch*p. 8-9\
r word sentences = 19 month
2
o 6 word sentences = 48 month
o 10 word sentences = 60 month
o IQ is defined by as the mental age divided by the chronological age multiplied by f 00.
M0ntal Age '.,
I.Q.=---------x100
Chronological age 1
r child 6 years of age with an IQ of 50%, means that his mental age is that of
So a a3 year old child.
e Thus we have to look for the developmental milestones of a 3 year old child.
t At 3 years of age, a child can identifu two colours.
: A 3 year old child can speak a small sentence but he cannot read a sentence.
t At 3 years, a child can ride a tricycle (not a bicycle).
t A child copies a triangle at 5 years of age.
34. Ans. is'H i.e., 15 months lRef. Nelson l8thle p. 48,49)
o Vocabulary of 4-6 words in adilition to jargon is achieved by 15 months of age. However <20o/o of speech is
understood and hence main mode of communication continnues to be non-verbal,
"Object permanence, a major milestone, develops around 9 months when the infant understands that objects continue to
exist even ifthey are not seen". Smith's Anaesthesia for infants and children
--
'A major milestone is the achiyement by 9 months of object permanency (constancy), the understanding that object continue
to exist, even when not seen". Nelson
--
Note : Child fully understands object performance at 18-24 months.
htiia,b- ilaiaer of Growth & Devetopment
ERT"'PTION OF TEETH
36. Ans. is t' i.e ., 6 months lRef: Netson l9tt /e p" 4Z-Z3l
o Rule of six :-
r Primary (temporary) dentition begins --> 6 months.
r Secondary (permanent) dentition begins -+ 6 years.
MISCELLANEOUS
r By the age of 1 year, ratio of ICF to the ECF volume approaches adult level.
1.3 _ 1.0
1.0 : 1.0
43. Ans. is'H i.e., pBl,Iw[Rel NCxRr sanskrit-Textbook r class lt; Nelson 18il'/e chap. 322]
t Bilabial words are pronounced or articulated with both lips, as the consonants b, p, m, and w.
: Baby starts producing bilabial words by 4th month of age.
SHORT STATURE
44. Ans. is'a' i.e., Constitutional delay in growth lRe! A.p. Ghai Bth/e p. j7 b 7,/e p. 19)
r The child in this question has :
c In constitutional delay the bone age is less than chronological age, while in familial short stature bone age is normal
for the chronological age.
o So, the most likely diagnois of this child is constitutional delay in growth.
Short stature
I
YV
Normal growth velocity Altered growth velocity
+ +
Normal variant short stature Short stature other than normal variant
'1,
+ v
Bone age < chronological age Bone = chropological age
v v
Constitutional delay Familial short stature
Short stature
I
Y-_}
Normal growth velocity Altered g rowth velocity
+ +
Normal variant short stature Short stature other than normal variant
'J,
v v
Bone age < chrlonological age
+ +"
Bone = ch ronolooical aoe
18. Ans. is'a'1.e",lu{orma} body proportion [ftef A.F. Ghai 8't'le p. 35-36 6 7h/e p. 474-475]
PSYCHOLOGICAL PROBLEMS
49. Ans. is t' i.e., Specific learning disability [Ref: O.P. Ghai 8th/e p. 59-60 6 Vh/e p. j9; Nelson 1"6th/e p. 150, 151
50. Ans" is 'd' i.e., All of the ahove fR"ef: O.P. Ghai Sthle p' 38'4A; Nelsan ISoh/e p. 148)
51. Ans. is 'H i.e., Attention deficit hyperactive child iRe/ 0.F. Ghai Sthle p. 59 6 Vh/e p. 381
52. Ans. is 'b' i.e., Behaviour therapy lRef: A.P. Gkai 9'h/e p. 59 dt(h/e p. 38; Nelson 18th/e p. 1481
o This child has -+ i) Restlessness ii) Inattentivenessiii) Uncontrolled desire to play outside
o Al1 are features of attention deficit hyperkinetic disorder.
1)Psychosocial treatment
2. Behavior therapy
r The goal of behavior therapy is to identift targeted behaviors
that cause impairment in childs life so that child
can work on progressively improving his or her
skill in these area.
3. Medications
r The drugs used for ADHD are -+ i) Methylphenidate (Doc) ii) Amphetamines iii) Atomoxetine
53. Ane ts xi i-e.,,stants before 2{ years of age{Ref GteaiStulc p-,az r{tgt? yieild py&iatry zdlo p. zzl
Autism
r Autism is aneurologic disroder characterized by _
1. Qualitative impairment in social interaction
2. Qualitative impairment in communication.
3' Restricted repetitive and streotyped patterns
ofbehaviour, interests, and activities.
o Onset of syfiI,toms is usually before 3 years of age.
o 3-5 times more common in boys, but more
severe when occurs in girls.
o More common among low socio-economic
groups.
54. An* is h' i.e.' Autism tRef. o.p. Ghai Be/e p. 61 & fl/e p. 40; High yielit
psychiatry p/e p. 22)
r Delayed speech' difficulty in communication and concentration
in a 3 year old child suggests the diagnosis of autism.
55- Am" is W i-e- Vision pr*a&lems LR€f:$_e Ghai #/e p- dt; CFU{ t#/a p_ 95, tti6 r
ENURESIS
59-
o No treatment is given to. children below
6 years of age because ofhigh spontaneous
o After 6 years treatment include. cure rate.
i) Behaviorat therapy: This is the treatment of choice.
ii) Pharmacological treatmenf : It is used when non-pharmacological (behavioral)
therapy) fails . Desmopressin is
the drug of choice. other drugs used are impramii" '
o*yiiiinir.
""a
60. Ans. is h' i.e., Bed alarms {Ref t*/e p.
Nelson 113, I lal
o First line treatment for enuresis is behavioral
therapy. It consisls of rewarding the child for
being dry at night, child
oefore retiring and the use of conditionlrg d.',ric.s
f".g. u.a ahrm-that ring. *rr." rrr. child wets a special
:*JJr1*to
o Consistent dry bed training with positive reinforcement has a success rate of 85% and bed and pad alarm systems have
a success rate of approximately 75o/o with relapse rate that are lower than those with pharmacotherapy.
61. Ans. is'a'i.e., Positive reinforcement fRef: Ghai Vhle p. 35]
o Consistent dry bed training with positive reinforcement has a success rate of 85% and bed and pad alarm systems have
a success rate of approximately 75o/o with relapse rate that are lower than those with pharmacotherapy.
62. Ans. is 'b' i.e., Desmopressin [RS A.P. Ghqi 8e/e p. 6 Thle p. 36; Nelson l9*le p. 113, 114]
505
63. Ans. is t' i.e., Imipramine lRef: A.P Ghai Sthle p. 5a5 d* flle p. j6j
r Desmopressin is best answer.
o But it is not given in options.
r Amongst the given options only imipramine is used in enuresis.
64. Ans. is 'a'i.e., Antiepileptic treatment is necessary lRef. Nelson l8.*/e p. 2476, 2477; CPDT 18th/e p" 911
o Antiepileptics are never required (please refer to text of the chapter).
e Other options are correct.
65. Ans. is t' i.e., tron [Ref Pediatrics by Lucy M. Osbom p. 758; Netsan l9hle Chapter 594f
"A subgroup of infants with breath holding spells have iron deficiency anemia. Iron therapy may treat not only the
anemia, but also th6 breath-holding spells. Pallid infantile syncope may respond to atropine sulfate, which is used on
an ongoing basis if spells are frequent, or intermittently if spells are situationally predictable (such as with venepuncture)'i
THUMB SUCKING
MISCELLANEOUS
Arm span r
o It is the distance between the tips of middle fingers of both arms outstretched at right angles to the body, measured
across the back ofthe child.
r In under-5 children , arm span is 1 to 2 cm smaller than body length.
r During 10-12 years ofage , arm span = height.
r In adults arm span is more in adults by 2 cm.
r Abnormally large arm span is seen in patients with : (1) Arachnodactyly (Marfan syndrome) (2) Eunuchoidism
(3) Klinefelter's Syndrome (4) Coarctation of aorta.
r Armspanisshortcomparedtoheightinpatientswith:(1)Shortlimbeddwarfism(2) Cretinism(3)Achondroplasia
69. Ans. is t'i.e., Foreign object being put in the mouth lRef: Nelson lThle Chap. 22.2; AP Ghai Sele p. 58\
o Pica involves repealed or chronic ingestion of non-nutritive substances, which includes plaster, charwal, clay, wool,
ashes, patent & earth. :
o More common associated with autism :
r Family disorganisation
r Poor supervision
r Psychologic Neglect
o Geophagia (eating of earth) is associated with pregnancy and some culture.
ADOLESCENT
70. Ans. is 'a'i.e., 10-19 years lRef : O.P. Ghai 8th/e p. 63 6 Vh/e p. 42]
o Adolescence is usually the period l0 to 20 yr.
71. Ans. is'H i.e., l0 years lRef: See above explanation)
72. Ans. is'd i.e., Appearance of pubic hair and Axillary hair lRef: Nelson l},h/e p. 61]
e Thelarche -+ Pubarche -+ Peak growth velocity -+ Menarche
r Thelarche (development of breast buds) is first visible sign of puberty.
o Pubarche / Adrenarche (development of axillary and pubic hair) is the second sign. Itoccurs about 6-12 months
after thelarche
73. Ans. is'b' i.e., Thelarchy fRef: O.P. Ghai 8,h/e p. 6j dt 7/e p. ag|l
r In girls, the first visible sign of puberty is the appearance of breast buds (Thelarche), between 8-12 years of
age.
o In boys the first visible sign of puberty is testicular enlargement, beginning as early as 9lz yr.
74. Ans. is 'a' i.e., Breast enlargement lRef: Has been explainedl
75. Ans. is 'd i.e., Thelarchy-Pubarchy-Menarchy fRef: O.P. Ghai 8th/e p. 6j 6 7h/e p. 498; Nelson lSth/e p. 611
76. Ans. is'd i.e., Testicular development - pubic hair - axillaryhair - beard fRef: O.P. Ghai 8th/e p. 63 b Vh/e p.
498; Nelson 18th/e p. 51, 621
o In boys, the first visible sign of puberty and the hallmark of SMR 2 is testicular enlargement.
o The sequence of development of secondary sexual characteristic in boys is -
Testicular-enlargement -> Penis enlargement -+ Pubic hair growth -+ Peak growth velocity -+ Axillary hair -+ facial
hair.
77. Ans. is 'd' i.e., |ust before commincement of menarche [Rel Nelson lgth/e p. 60-621
Mensus typically appears around the peak in height velocity -Nelson
Menarche usually occurs afier peak velocity has been attained and as the growthrate begins to decline.
78. Ans. is t'i.e., Hormone related breast enlargement in girls
Thelarche
o Definition :- Begining of secondary (Post natal) breast development at onset of puberty in girls.
r Tanner stage2 breast development
r Usually after 8 years of age
r Because ofrising level ofestradiol
o Breast development during puberty in male termed as gynaecomastia not thelarche.
79. Ans. is 'b' i.e., Tanner stage II fRef: Ghai 7h/e p. 4971
81. Ans. is'd i.e., In the first year of life lRef: O.P, Ghai 8th/e p. 9, 10 6 7h/e p. 7)
o ln the early postnatal period velocity of growth is high duringthefirstfew months,
82. Ans. is'd i.e., Zndyear fRef: O,P, Ghai 8th/e p. 10 lt 7h/e p. 4l
o The brain enlarges rapidly during the latter months of fetal life and early months of postnatal life.
o At birth, the head size is about 65 to 70 percent of the expected head size in adults.
o It reaches 90 percent ofthe adult head size bythe age of2 years.
83. Ans. is'b'i.e., 5-7 years fRef: O.P. Ghai 8th/e p, 10-11 b Vh/e p. 4)
r The growth of lymphoid tissue is most notable during mid-childhood.
o Children between 4 and 8 years of age often have hlpertrophied tonsils and large lymph nodes, which is infact a sign
of lymphoid hyperplasia.
81. Ans. is'd i.e., In the first year of life lRef: O.P, Ghai 8th/e p. 9, 10 & Vh/e p. fl
o In the early postnatal period velocity of growth is high duringthefirstfew months,
82. Ans. is '{ i.e.,Zndyear- fRef: O.P. Ghai 8th/e p. 10 dr 7tu/e p. a)
o The brain enlarges rapidly during the latter months of fetal life and early months of postnatal life.
o At birth, the head size is about 65 to 70 percent of the expected head size in adults.
o It reaches 90 percent of the adult head size by the age of 2 years.
83. Ans. is'b'i.e., 5-7 years fRef: O,P, Ghai 9th/e p. 10-11 dt 7h/e p. 4l
r The growth of lymphoid tissue is most notable during mid-childhood.
o Children between 4 and 8 years of age often have hypertrophied tonsils and large lymph nodes, which is infact a sign
of lymphoid hlperplasia.
85. Ans. is ? i.e., 4year lRef: O.P. Ghai $th/e p. 13 & Vh/e p. 6)
86. Ans. is t' i.e., 5 lRef: Child ilevelopment: Birth to adolesence, Dr Rajesh Dixit, 2006 ed. p. 38; Health, Safety
andNutritionfor the young child, Lynn R Marotz, p. 261
87. Ans. is 'b"i.e., 6 months of age lRef: O.P. Ghai $th/e p. 13 b 7h/e p. 6; Meharban Singfi 3d/e p. 521
r At 6 month of age head circumference is between 40.0-43.5cm.
88. Ans. is t' i.e., 9-12 months [Rel O.P. Ghai 8th/e p. 1j 6 7h/e p. 6; Meharban Singh 3d/e p. 52]
o The circumference of chest is about 3 cm less than head circumference at birth.
o The circumference of head and chest are almost same by the age of 9 months to I year.
r Thereafter the chest circumference exceeds the head circumference.
93, Ans. is 'H i.e., 4years lRef: Nelson 18th/e p. 49; O,P, Ghai 9th/e p, 49)
r A child hops on one foot by 4 years and skips by 5 years.
o As this child can not hop, the age of this child is less than 4 years.
94, Ans. is 'b' i.e., 6 months lRef: O,P. Ghai 9th/e p, 49 dr Vh/e p, 27; Nelson 18th/e p, 46, 47)
o A child can transfer objects from one hand to the other by 5-7 months.
95. Ans. is'b' i.e., 7 months IRe{Nelson 18th/e p. 49; O.P. Ghai lth/e p. 49-501
96. Ans. is'b' i.e., 10-20 words lRef: O.P. Ghai 8th/e p. 53 6 Vh/e p. 301
97. Ans. is t' i.e., 18 months fRef: O.P. Ghai 8th/e p, 53 & Vh/e p. 28)
98. Ans. is'd' i.e., 28 weeks fRef: Nelson 18th/e p, 45; O,P, Ghai 8th/e p. 521
o A child bounces actively, leans forward on hands in sitting position and prefers mother by the age of 7 months (28
weeks).
:t:tr:.:,:,.:.:t.
99. Ans. is'-o" i.e., 7 months fRef: Nelson 18n/e p. 45; O.P. Ghai Sn/e p. SA, 527
r A normal infant sits leaning forward on his hands and babbles by 7 months.
o An infant transfer the object from one hand to other by 5-7 months.
101. Ans. is'l i.e., Lower central {Ref: Nelson 18e/e p. 47, 731
,O2. Ans. is "c' i.e.,2.5 {Ref: Nelson 18n/e p. 47, 737
r Between 20-30 months all milk (primary) teeth are erupted.
103. Ans. is't i"e., Separation anxiety {Ref : Nelson 1*/e p. 1171
o Separation anxiety disorder is characterized by unrealistic and persistent worries of possible harm befalling the
affected child or his or her primary caregivers, reluctance to go to school or sleep without being hear the parents
persistent avoidance of being alone, nightmares involving themes of separation numerous somatic symptoms and
complaints of subjective distress.
104. Ans. is't i.e., Disproportionate dwarfisrn [Rel o.P. Ghai Bth/e p. 519 & Th/e p. 1g]
Note - Patient has short stature with short limbs.
105. Ans" is'C i.e., Temper tantrum lRef : O.P. Ghai 9e/e p. 5S & 7/e p. 371
o Temper tantrum reaches its peak point durin$ second and third year of life and gradually subsides in between 3 to 6
years as the child learns to control his negativism and complies to the requests ofothers.
rrr
b{&JY'KXYXON
o Surveillance of growth and development is an important component of the routine anticipatory care of children'
o The main purpose of growth surrveillance is to identifu those children who are not growing normally.
r 8070 of the median weight for age of the reference is cut-off point below which children should b,e<6isideted
malnourished. I
/
r Low weight for age (underweight) is a combined indicator to reflect both acute and chronic mhlnutrition(ArMs
07).
B:ut it cannot diferentiate acute from chronic malnutrition. \
2) Height for age
r Height for age is a stable measuremeni of growth as opposed to body weight.
r Low height for age (stunting or dwarfism) reflects chronic (past) malnutrltionat,zArrMs,7).
r The cut-offpoint commonly taken for the diagnosis of stunting is 90% of the united states NCHS height for age.
CLASSIFICATION OF MALNUTRITION
Gomez classification
o It is based on weight retardation (not on height retardation)Gr ost,
o The child on the basis of his/her weight is compared with a'normal'child
of the same age.
o The'normal'reference child is the 50th centile of the Boston slsnflqyflsLroa).
Weight of child
Weight for age (o/o) :
x 100
Weight of normol child of same
Interpretation of indicators
Itola] >95
" tfrilily:iniiraitiid:'il:".-:.:
Moderately impaired 80 - 87.5
<80
o Protein energy malnutrition (PEM) is a spectrum of conditions ranging from mild undernutrition ot extreme forms of
malnutrition, i.e. Marasmus and Kwashiorkor.
r Most of the child suffer from mild to moderate nutritional deficit and extreme forms (marasmus and kwashiorkor)
account only for a small proportion of cases of malnutrition.
Marasmus
rs).
o It is due to prolong deficiency of calories and proteins(Ar Thus there is exessive catabolism of adipose tissue and
muscle proteinarrs).
o It is characterized by gross wasting of muscle and subcutaneous tissues resulting in emaciation and marked
stunting:NEBr). There is no edema. Body weight is less then 6070 of expected.
o Fat in adipose tissues is severely depleted. However the buccal pad of fat is preserved till the malnutrition becomes
extreme because a higher proportion of saturated fatty acids is stored there and the saturated fat is the last to be
depleted.
o Skin is dry, scaly and inelastic with wrinkles. The hair is hlpopigmented. Abdomen is distended due to wasting and
hypotonia of abdominal wall muscles. i
o The child is alert but irritable.
o Child may show voracious appetite(NEEl /'pmer 11)
. .
3) Hair changes: Thin, dry and brittle hair; hypopigmented, flag sign{rcrre) (alternate bands of hypo-and hyper-
Pigmentaion{errr);.
4) Infections: Diarrhoea, respiratory and skin infections.
5) Impaired (decreased) appetiteal 13).
Itffif,hi(,r*or
Sar€frl1us
Pmmiflent
bore*
&6ffsasa
lt $ub.ule,r6o&6
fat
Fo$t w{ufld
Complications of pEM
A) Changes in body composition: Increased total body water,
Reduced BMR, decreased insulin levels(Alrlfs 0s, DpG 0e),
increased cortisol and growth hormone, decreased activity
of sodium pump, reduced Bp and stroke volume/cardiac
output, decreased renal blood flow and GFR, poikilothermia,
and reduced IgA levsls{aroa.).
B) Acute complications (Mnemonic-sHIELDED) : sugar deficiency (hypoglycem
iao,cr 06,0s)); Hypothe rmiaecr 06, os).
Infection & septic shock; Electrolyte imbalance (hypokale miao,G'06,05),hlpomagnes
, iurror ou, orl; DEhydration;
and Deficiency of iron, vitamins and other micronutrients. There
may be megaloblastic anemia, which responds
well to folic acid and vitamin B,, supplemelf4fl61arer).
Treatment
r Treatment is done in three stages :-
A) First stage: Dehydration and infections are dealt dtringfirst 24-4Shoursby rehydration and antibiotic therapies.
B) Second stage : Dnring next 7- 10 days patient is given a diet of 75 callkglday along with antibiotics, to maintain
protein and energy need.
C) Third stage : This is aimed at restoring patient's protein and fat contents by providing diet of 175-2OO kcalikg/
day4nrvts
ss' 'u se)
in severe malnutrition and 1 50 kcal/kg/day in moderate malnutrition.
r Iron should be started when child is gaining weight once stabilization phase is over("").
a) Scuny
b) Rickets
c) Kwashiorkor
:.1. ,.
'
:Au*iri*&1leii.&ranhiorkor. . ., ::
. b) 'MarasrRus ',:
' 6) ,l(6i6sliiorkor.
r d):' Iv[3lfln syqdrome ']: ,I ' 'l
o Breast feeding should be initiated within 30 minutes of a normal vaginal delivery and within 4 hours of delivery by
04' PGI ee).
caesarian sectionAl
r WHO recommends 'exclusivebreastfeeding'for the first six months of life(NEEr AilMs06), i.e. during first 6 months only
breast milk is given and nothing else (even water). Wealring should start by 6 months of age when complementary
food should be started in addition to breast milkarq4).
r Breast feeding should be continued with semisolid and solid foods upto two yearsatoa).
t Human breast milk is the best source of nutrition for infant with following benefits :-
1) Superiornutrition(Pcr08)
A) Carbohydrate
r Lactose is in a high concentration in breast milk which helps
in the absorption of calcium and enhances
the growth of Iactobacilli in the intestine.
B) Protein
r The protein content of breast milk is low which causes lower
solute load on the kidney. Most of the protein
is whey proteins (lactalbumin and lactoglobulin), which can
be digested easily (In contrast cow milk
contains more casein).
r Breast milk contains the ideal ratio of the amino acids cystine,
taurine and methionine to support
development of central and peripheral nervous system.
C) Fats
r Breast milk is rich in polyunsaturated fatty acids, necessary for the myelination of the nervous system
and brain growth.
r Active lipase in the breast milk promotes digestion of fats and provides
FFA. The pattern of fats facilitates
absorption of calcium.
D) Minerals
r Breast milk protects against neonatal hlpocalcemia and tetany
due to ideal calcium phosphorus ratio (2: 1)
and better calcium absorption.
r Iron of breast milk is very well absorbed -> breast feeding prevents against iron deficiency
anemia.
r Breast milk also prevents deflciencies of vitamin A, c, D, E and zinc.
r Breast milk has a water content of 88% and hence a breaslfed baby does not require
additional water in
thefirst 6 months of lift even in summer months.
r Breast milk has a low mineral and sodium content -> low osmolality presents
a low solute load to the kidney.
,\ Lower risk of infection(Pcros)
r The breast milk is clean and uncontaminated with several anti-infective factors -+
protect the baby from infection
and diarrhea.
3) Protection from allergy (atopy) {lctoa;
: Low protein contents of breast milk along with a higher concentration of secretory IgA decreases the absorption
of protein macromolecules -+ less chances of allergy and asthma.
4) Emotional bonding
r Breast feeding promotes close physical and emotional bonds
between the mother and the babv.
5) Others
r Breast feeding lowers the risk of ovarian and breast cancer
in mother.
r Breastfed babies have a higher IQ and have less chances ofdeveloping
hypertension, obesity, coronary artery
disease and diabetes in their adulthood.
I The other diseases which are less common in breastfed babies include
inflammatory bowel disease, Hodgkins
lymphoma, necrotizing enterocoritis and sudden infant death syndrome.
r Breast feeding protects against evening colical e8, AIIMIe6).
r Breast milk contains docosahexaenoic acid(ArMsrI'06), required
for the growth of nervous system(izMsir,06).
Anti-infective effect of breast milk
o Breast milk provides protection against infection because
of the following facts -
.
I The breast milk is clean and uncontaminated@cr 0s).
3. Lower pH of the stool of breastfed infants contributes to the favorable intestinal Jlora -+ more bifidobacteria
and lactobacilli, fewer E. coli(Pcr 08) .
e6) e6).
o There may be neonatal jaundice('{[Ms and golden colour stool(Ar e&
'{[Ms
2. Transitional milk
r Is secreted during the following two weelcs (after clostrum).
r The immunoglobulin and protein content decreases while the fat and sugar content increases.
3.Mature milk
r Follows transitional milk.
r It is thin and watery but contains all the nutrients essential for optimal growth of the body.
o According to feed the breast milk is divided into -
1. Fore milk
t lt is watery and is rich in protein, suga6 vitamins, minerals and water that satisfy the baby's thirst.
2.Hindmilk
r Comes towards the end of feed
: Rich in fat content(comed 07)
and provides more energy, and satisfies the baby's hunger.
r The milk of mother who delivers prematurely differs from the milk of a mother who delivers at term -
Preterm milk
r Contains more protein S, sodium, iron, immunoglobins and calories as they are needed by the preterm baby.
RICKETS
I craniotabes is the softening of skull bones, which may be present in normal newborn,
in pre-
especially
mature'ItismostlyseeninJccipital andparietal bonl;.rt'*uyuisobeseen
inricketspcteT),osteogenesis
imperfecta,Pcrez', congenital syphiti5recrc;; and hydrocephflus.
rl
B) Systemicmanifestations
o These are growth retardationect 03) ' apathy, listlessness, irritability; hlpotonia; ligament laxity; and tetany,
convulsions and laryngeal stridor when there is hypocalcemia.
a)."'RiCkets:, ,' ,
b) Osteogenesis imperfecta
, 1
16) ,Congenital syphilis ::
d) All of,lhe above
Followingdeformityis seen ln -
a)Scurly ' . ,
c) Keratomalacia
d) None
Serum calcium
Causes : i) Deficiency of vitamin Dro^/8,5/ i) Primaryhypophosphatemia Vitamin D dependent
r Dietary(rNe4 uPe5) rickets (x-linked), type llro,v8,5)
r Lack of sunlight ii) Fanconi syndromes(D,va?5,
r Congenital r Cystinosis
ii) Malabsorption of vitamin D r Tyrosinosis
iii) Liver disease r Lowe syndrome
iv) Anticonvulsant therapy iii) Proximal renal tubular
v) Renal osteodystrophy@nars1 aciGlOSiSrDrvsr5,
vi) Vitamin D dependent rickets type I
iv) Deficiency ofphosphate or
malabsorption
r vit D enhances absorption of Ca*2 from gut, So its deficiency results in decreased absorption.
r Initially serum calcium level is maintained because of increased activity of parathyroid
gland in response to
calcium deficit' After sometimes' even the compensatory increase
in parathormone cannot sustain normal
calcium level --> J calcium.
r Parathormone also enhances renal excretion of phosphat e + phosphaturia@cr -+ J 06)
serum phosphate.
r Because of unavailability of calcium and phosphate, bone mineralization is decrease -+
compensatory increase
in osteoblastic activity -) Increase alkaline phosphatase.
r So, there is :-
i) Normal to decreased calcium
ii) Decreased phosphass(euoe'ee) (except in renal osteodystrophy,
where phosphate level is increased because
kidney is not able to excrete calcium).
iil) Increased parathormone
iv) Increased alkaline phosphatase@Gl 06, ee)
2. Hlpophosphatemic Rickets
r This is due to deficiency of phosph ate -) Decreased Tthosphate,
t Calcium level is normal.
r As there is no calcium deficiency, there is no compensatory hyperparathyroidism
-+ Normal parathormone.
: Due to unavailabilityof phosphate, mineralization of bone is decreased
and there is increase in compensatory
osteoblastic activity + I Alkaline phosphatase.
r
Serum alkaline phosphatase is a consistent marker and is raised in
all types of rickets(.ares).
Radiological signs of rickets
o Earliest radiological changes are seen around the wrist, i.e,
at lower end ofradius dt ulna,
o Later on, similar changes may also be seen around knee, elbow
& ankle.
o X,ray findings are - ./
b) Bone dysplasia
c) Rickets
d) None
Treatment of rickets
r There are two startgies for administration of vitamin D -
A) Startgy 1 (stoss regimen)
r 6 lac IU (15,000 pg or 15 mg) Vit D3 is administered every 2 weekly.
r At every follow up monitoring is done by X-rays and blood investigations.
r Once healing is started, children are further put on 400 IU br 10 pg of vitamin D, per daI.
B) Startgy 2
r 2,000 - 5,000 IU (50 - 125 pg) of vit D, is given every day for 4-6 weeks.
SCURVY
o Scurr,yis due to deficiency of vitamin C. Vitamin C is required for normal collagen synthesis. Thereforemanifestations
of scurvy are mainly due to defective collagen synthesis :-
I) Defective osteoid productional 10' NrMs eB) .
ii) Deranged capillary function predisposingfor bleeding e.g. subperiosteal bleeding@cl00), gingival bleeding{rcroor.
111) Defective endochondral ossification causing epiphyseal separation@Gr 0o) and brittleness of bone.
iv) Defective dentition and poor wound healing.
e, D y...............e
to m elaph ys ea I w i d e n i n g Due to epiphyseal separation
o Non-tender
r Rounded
a) Scurvy'
b) Rickets
c) Keratomalacia
d) None
a) Sgurvy
b) Rickets
c) Keratomalacia
d) None
Given,X.rg is.diagnoetiiof'-,
a) Rickets
b) Osteomalacia
c) Scurrry
d) None
Laboratory diagnosis
Leukocyte vitamine C
o Leukocyte concentration of vitamin 'C' is a better indicator of body store,
it may be deficient even in the absence
of clinical signs of deficiency' It is estimated by buffy coat PreParation@Gles).
Plasmavitamin C
early vitamin C deficiency'
o plasmi dscorbic and levels vary widely and cannot be relied upon to detect
Urinaryvitamin C
excretion of the vitamin after a test dose
o Saturation of the tissues with vitamin c can be estimated frorir the urinary
of ascorbic acid. Excretion of 80% of the test dose in the urine
within 3-5 hr after parenteral administration is
80% of test dose is excreted'
considered to be normal. In vitamin c deficiency, less than
VITAMIN'A'
MISCELLANEOUS
Hypervitaminosis-D
o The sign and symptoms of vitamin D intoxications are secondry to hypercalcemia which
is caused by -
i) Excessive bone resorption (major cause) -+ Vit D causes bone resoryfiion@Gl06) .
ii) Increased calcium absorption
r Manifestations are i-
1' GIT -+ NauseaattMss6'PGI 7e),
vomiting, onsvsxciqLrtuss6'PGr7e),poor feeding, constipation, abdomifal pain
and pancreatitis.
2. CVS -+ Hlpertension, arrhyhmias and decreased eT interval.
3. CNS -+ Lethargy, hypotonia, confusion, psychosis, disorientation, depression, hallucinations & coma.
4. Kidney -+ PolyuriaatrMss6'PGr7e),hypernatremia, dehydration, nephrolithiasis and nephrocalcinosis.
5. Metastatic calcificationAltMss6'PGI7e).
Hypervitaminosis-A
o Excess of vitamin A can lead to ruptute of lysosomal membrane.
o Acute manifestations -+ Signs and symptoms are due to raised intracranial tension (pseudotumor cerebri or benign
intracranialhypertension6"t)) + headache, nausea, vomiting, dror,r,siness, bulging fontanelles, diplopia, papilledema
and cranial nerve palsies.
o Chronic intoxication -) Anorexia, weight loss, painful extremities, dry itchy desquamating skin, alopecia, coarsening
bone abnormalities and bony swellinglPct
1s), 06)
of hair, hepatospleno megaly4l .
Zinc deficiency
e Important clinical features of zinc deficiency are :-
L. Dwarfism (growth retardation)(Pct 0s)
7. Decreased immunocomPetance
r Dose for treatment of zinc deficiency is 10 mg/d.ay for 14 days for infant 2-6 months of age and 20 mg/day for 14
Acrodermatitis enteroPathica
o AcrodermatitisenteropathicaisarareautosomalrecessivearMsir)disordercausedbyaninabilitytoabsorbsufficient
Zincfromthe diet.
o Initial signs and symptoms occur during the first few months of life often after weaningfrom breast to Cow's milk.
| ::i::r:r;:,1ij .:r:: ji
r !--.r,,;.::. -:r:t
.r:r;!.
r.i:.r;r:r:-:j:.
,1,e.Hap,.:rpn,1 z Nitrition
* Other important features of Kwashiorkor: Hepatomegaly (fatty infiltration), flag sign on hair, flaky paint dermatosis, hypoalbumine-
mia, apathy, poor appetite, low insulin.
o Flaky pain dermatosis is characteristic of : Kwashiorkor.
o Not seen in Kwashiorkor :Vocarious appetite (it is a feature of marasmus), altertness (there is lethargy).
* I lmportant features of Marasmus : No edema, vocarious appetlte, no skin or hair,changes, no hepatomegaly;'active child,
nolmal
.a[buminandinsu[in,musclewastingandweakness.
. Most affected antibody in
PEtVt : lgAl
*Cal.bric.suppIementationrequiredinseverePEM:175.200.kcal/kg/day
,. ...:.
r Exclusive breast feeding is till : 6 months.
* Breastfeeding shoutd be initiated: Within 30 minutes,of normal vaginal delivery and'within 4 hours of delivery.by iae*rianiaitionr
o Most important protective component of breast milk against infection : lgA.
* Fatty acid in breast milk which is required for normaf g;owth of brain ; Docosahexaenoeic acid. :. :]:. ' 1
r' . I :., . :
':
* PABA in breast milk provides protection against : plasmodium.
* -, Exctusive breast fee:d:ing may.cause deficiency,of : Vitamin.Bl2, Vitami.n (, Vitamin D and fluoride ,.:.: ,.
..
c Exclusive breast feed ing can cause : Hemorrhagic d isease of newborn (d ue to deficiency of vita min K), prolongation of physiologica I
jaundice, golden colour stool.
o Not seen in exclusive breast feeding : Evening colic (breast feeding protects against evening colic). :.
.x.Main.protein.inCowtmilk:Casein..,...]
o Human milk contains more (than Cow's milk) : Lactbse, antibodies, lactoferrin.
* Cowtmilkcontains'moie(thanhumanmil'ki:iProtein;saks(sodium;chloride,potassium),fat,minerals(calcium,phosphate). .i,,
o Percentage of lactose in human milk:7.0o/o(7 gm/100 ml).
a Fore-milk is rich- in : Protein, sugar. vitamins, minerals,water. :
. Most prominently affected in Rickets : Growth plate (physis), i.e. defective mineralization of growth plate.
*,. lmportantfeaturesofrickets:Thickening&wideningof..physi5,cupping/flarlng&ftayingofmetaphysis,wideningofepiphysis.
* Earliest manifestation of Rickets : Craniotabes.
. lmportant features of rickets : Craniotabes, delayed closure of anterior fontanel, caput quadratum (hot cross-bunn skull), rachitic
' rosa$ genu valgus, bowing of tibia, double malfeoli
sign, windswept deformity, widening of wrlst, gror44h.retardation, pai*fry.
* Windswept deformiiy in children is seen in : Rickets (most common cause), physeal osteochondromatosis, herediatary epiphyseal
dysplasia.
..::.,:' I
* lmportant lab findings in vitamin D dependent rickets : Normal or slightly decreased serum calcium and phosphate, raised serum
alkaline phosphatase, increase PTH,irlcreased serum bicarbonate.
lmportant labfindings in hypophosphatimic Rickets. ormalselum calcium, decreased run:l
ahosphate;jn$eased,seru.m atkaline'
a Primary defect in scurvy : Decreased osteoid (protein matrix) formation due to defect in collagen synthesis.
rl lmportant features of scurvy : Subperiosteal & gingival bleeding, generalized tendeinesi. pseudoparalysis, scorbutic rosary.
& Pseudoparalysis in an infant suggests : Scurvy.
c r'seuoopaiatysis is also seen in r septic arthritis, osteomyelitis,:congenital syphilis. , , '
a
e
a
a
a
a
a
a
a
a
a
a
a
a
a
III
QUESTIOT{S
N UTRITIONAL STATUS INDICATORS 10" Frotein requirement for 2 year otd child @er dayl
(CET luly 15 Pauern)
I. Deficit in weight for height in a 3 years old child a) 10 gm b) 15 gm
indicates- eET luly 15 pattern) c) 20 gm d) 25gm
a) Acute malnutrition 11. The amount ofcalories required at I year ofage are-
b) Chronic malnutrition (Ar e6)
c) Concomittant acute and chronic a) 900 K callday b) 1000 K call
d) Under weight duy
2. Best indicator for nutritional status for a child is - c) 1200 K callday d) 1400 Kcallday
(AIIMS May 10, Nov 06) 12. The normal calorie requirement for a 5 year old
a) Mid arm circumference child is- (PGt e3)
b) Head circumference a) 800 calories b) 1000 calories
c) Rate ofincrease ofheight and weight c) 1500 calories d) 2000 calories
d) Chest circumference
3. Acute malnutrition is manifested by - @Gr Nov t4) PROTEIN ENERGY MALNUTRITION
a) Weight for age
b) Weight for height
c) Age for height
13. In marasmus wasting is due to - (All Inriia Dec15 pattern)
a) Prolong dietery deficiency ofcalories
d) Brocas index b) Prolong dietery deficiency ofprotein
c) Ponderal index c) Excess catabolism of fat & muscle mass to provide
4. Which of the following is the besr indicator of long energy
tenn nutritional status - (CET Nov. 15 pattern) d) All of above
a) Mid arm circumference t4. Kwashiorkar is diagnosed in growth retarded chil-
b) Height for age dren along with- (NEET Dec.12 pattern)
c) Weight for age a) Edema and mental changes
d) Weight for height b) Hypopigmentation and anemia
5" Common to both acute and chronic malnutrition c) Edema and hypopigmentation
is- (AIIMS May 07) d) hepatomegaly and anemia
a) Weight for age b) Weight for height 15. Which of the following is seen in Marasrnus and not
c) Height for age d) BMr in Kwashiorkor - (All India Dec. 15 pattern)
6. Weight of child is 70% of normal - according to IAp a) Vocarious appetite
classification, categorised in - (AlltrutiaDec15 pauern) b) Fatty change in liver
a) Mild b) Moderate c) Hlpoalbuminemia
c) Severe d) Normal d) Edema
7. A 2 year old child has a weight of 6.4 kg. and has L6. Kwashiorkar is characterised by all of the following
vitamin A deficiency,What is the grade of malnutri- features except - (AI s9)
tion in this child - (AIIMS 87) a) Edema
a) First degree b) Second degree b) Patchy depigmentation of hair
c) Third degree d) Fourth degree c) Fatty liver
R The following statement about Gomez classification d) Fatty infiltration ofpancreas
is false - (Ar 08) t/. All are seen in lVlarasmus except -
a) Based on height retardation (All India Dec.14 Pattern)
b) Based on 50tl'centile Boston standards a) Hepatomegaly b) Muscle wasting
c) Between 75 a:nd 89% implies mild malnutrition c) Voracious appetite d) Weight loss
d) This classification has prognostic value for
hospitalization of children
18. Not Seen in Iftuaqhiorkar - (All rndia Dec15 pattern)
a) Apathy
9. \{aterlow elassifieation of malnutrition in ehild b) Flaky paint dermatosis
takes into account ? (CET lune 14 Pattern) c) Baggy paint appearance
a) Weight for height (wasting) d) Increased tra4saminase
b) Height for age (stunting) 19. Not seen in kwashiorkor- (Alt India Dec.t3 pauern)
c) Weight for height (wasting) and height for age a) Apathy
(stunting)
b) Flaky paint dermatosis
c) Poor appetite d) Increased albumin
d) Percent ofreference weight for age
20. All of the following conditions are obseryed inMt- d) 24
rasmus, except - (AllMS May 0s, DPG 09)
31. The current recommendation for breast feeding is
a) Hepatomegaly b) Muscle wasting that - (Ar 04)
c) Low insulin levels d) Extreme weakness a) Exclusive breast feeding should be continued till
21. l5 months old child feeding on cow milk with water 6 month of age followed by supplementation with
wih severe wasting and bipedal edema with poor additional foods
appetite - (CET luly 15 Pattern) b) Exclusive breast feeding should be continued till
a) Kwashiorkar b) Marasmus 4 month of age followed by supplementation with
c) Both d) None additional foods
22. In Kwashiorkor, which immunoglobulin is most c) Colostorum is the most suitable food for a new
afiected- (At 94) born baby but it is best avoided in first two days
a) IgD b) IgA d) The baby should be allowed to breast feed till one
c) IgE d) IgM year of age
23, A child is sufiering from severe PEM. Calories to be 32. The protective efiects of breast milk are known to be
given per kg of body weight to regain weight- associated with - (Ar 0s, DPG 09)
(AIIMS lune 99) a) IgM antibodies b) Lysozyme
a) 200 Kcal b) 150 Kcal c) Mast cells d) IgA antibodies
c) 400 Kcal d) 100 Kcal JJ. The important fatty acid present in trreast milk
24. Caloric supplementation required for a severeh which is important for gronth is - (AIIMS Nor, 1 1, Nov 06)
malnourished child @erkg-body weight) is - (Ar ee) a) Docosahexaenoeicacid
a) 100 callkg b) 125 callkg b) Palmitic acid
c) 150 callkg d) t75 callkg c) Linoleic acid
25. Ideal time to start Iron theapy in a marasmic child d) Linolenic acid
with fever and hemoglobin 7 gm%o is - 34. What is deficient in exclusively breast fed baby -
(All India Dec15 Pattern) (AIIMS Feb 97)
a) Immedietly a) Vitamin B b) Vitamin A
b) At discharge c) Vitamin C d) Proteins
c) When fever goes down 35. Exclusive milk ingestion can manifest as- (ArrMS s7)
d) At any time a) Scurr,y b) Beri-Beri
25, Flaky paint appearance of skin is seen in- c) Phryenoderma d) Night blindness
(NEET Dec.12 Pattern) 36. Which of the following will occur in an exclusively
a) Dermatitis b) Pellagra breast fed baby - (AIIMS Sep e6)
c) Marasmus d) Kwashiorkor a) Jaundice b) Scurry
27 . All of the following are characteristic features of c) Tetany d) Eczema
Kwashiorkar, except - (AIIMS May 0j) 37. Exclusive breast feeding may be associated with all
a) High blood osmolarity of the following except - (Ar e8, ArrMS 96)
b) Hypoalbuminemia a) Hemolysis due to Vit-K deficiency
c) Edema b) Evening colic
d) Fatty liver c) Golden colour stool
28. Severe acute malnutrition (Sav), true in manage- d) Prolongation ofphysiological jaundice
ment - (CET Nov 15 Pattern) 38. Breast feeding contraindication - (CET luty 15 pattern)
a) SAM with severe edema should be hospitalised a) Hep A
b) SAM wifh good appetite should be hospitalised b) Hep B
c) SAM with poor appetite should be treated in OPD c) CMV
d) Decision of transfer from in patient to out patient d) Active untreated T.B.
care depends upon specific mid-Upper arm
39. True about cow's milk are all except-
circumference value
(AIIMS May 10, May 07)
a) Cow's milk contains 80% whey protein not casein
BREAST FEEDING & BREAST MILK b) Cow milk has less carbohydrate than mothers
milk
29. Exclusive breast feeding is at least till- c) Has mo(e K* and Na* than infant formula feeds
(CET Nov.14 Pattern) d) milk
Has more protein than breast
a) 4 month b) 6 month 40. Percentage of lactose in human milk is -
c) 8 month d) 10 month (All India Dec.14 Pattern)
30. Breast feeding should begin ... hours after delivery- a) 7.2 gm b) 4.s gm
a)2 b)4 c) 8.0 gm d) 6.7 gm
ti
41. Compared with Cow's milk, mothers milkhas more- 50. True about nutritional rickets - (PGI May u)
(Ar 07) a) Craniotabes
a) Lactose b) vit D b) Multiple #
c) Proteins d) Fats c) Widening of wrist
42. Hind milk is richer in - (Comed 07) d) J Phosphate in serum
a) Carbohydrate b) protein e) GroMh retardation
c) Fat d) Minerals 51. Rickets in infant present as all except- (AtrMS May07)
43, Breast milk rtorage in a refrigeratcr io upto - a) Cranitabes
(CET Nol',.14 Pattern) b) Widened Fontanel
a) 4 hrs b) 8 hrs c) Rachitic Rosary
c) 12 hours d) 24 hrs d) Bow legs
44. Breast milk at room temperature stored for- 52- All of the following are seen in Rickets except-
(NEET Dec.12 Pattern) (AIIMS May 0j)
a) 4 hrs b) 8 hrs a) Bow legs b) Gunstock deformity
c) 12 hrs d) 24 hrs c) Pot belly d) Craniotabes
53. Most common cause of genu valgum in children is -
RICKETS a) Osteoarthritis b) Rickets
c) Paget disease d) Rheumatoidarthritis
45. Basic pathology in rickets - (AIl rndia Dec.t3 pauern) 54. Windsweptdeformityis,seen ilo,- 1Nz,ar oec.12 pattern)
a) Defective bone matrix formation a) Scurly b) Rickets
b) Defect in mineralization c) Achondroplasia d) Osteoporosis
c) Defect in osteoid formation
55. Causes of hypophosphatearic rickets - Nn -
d) All of the above
(CET luly 15 Pattern)
46. Deficient mineralisation in epiphysical growth carti- a) Vit D deficiency
lage is seen in - (Ar ee) b) CRF
a) Rickets b) Osteomalacia c) X-linkedhypophosphatemicrickets
c) Scurly d) Hyperparathyroidism d) Fanconi syndrome
47- A 2-year-old troy has vltamia D reeistant rickets. His 56. Vit-D deficiency Rickets is Characterised by -
investigations renealcd s€rum Calcium- 9 n $ dl"
@GI Nov 14)
Phosphate- 2.4 rugJ dl, alkaline phosphataoe- I 04 1
a) t ed forehead sweating
IU, nornral intact parathyroid horraone aad tricar- b) Characteristically Jed Car*
bonate 22 mfi.q/L.1&'hich of the fo0owiag is the rnost
c) Anterior fontanel widened
probable diagnosis - NEET Dec.l2 Pattern, AIIA.{S
d) ted alk. phosphatase
May{M,02)
57. il,arlier manif€statioa of Riekets is -
a) Distal renal tubular acidosis
(All lndia Dec.14 Pattern)
b) Hlpophosphatemic rickets
c) Vitamin D dependent rickets a) Craniotabes b) Rachitic rosary
d) Hypoparathyroidism c) Harrison groove d) Pigeon chest
58. Craniotabes is seen in following except- (pGt Dec 97)
48. A old boy has vitamin D refractory rickets.
2 year
Investigations show serum calcium 9 mg/dl. phos-
a) Rickets
phate2.4mg dl, alkaline phosphate 1040 tU. para-
b) Syphilis
thyroid hormone and bicarbonate levels are normal.
c) Osteogenesis imperfecta
the most probable fiagnosis is -
d) Thalassemia
(ArrMS Nov 02, 00)
a) Distal renal tubular acidosis 59" Splayiag aud Cupping of the metaphysis is seea
b) Hlpophosphatemic rickets. in - (CETNov.l4pattern)
c) Vitamin D dependent rickets a) tuckets b) Scurry
d) Proximal renal tubular acidosiS-.. c) Paget's disease d) Lead poisoning
49- A l0 year old boyhas a fracture of femur. Biochem- Rickety rosary seen in all except - (PGI Dec 97)
ical evaluation revealed Hb lf .5 gm/dl and ESR lS a) Rickets b) Scuny
mm lst hr. Serum calcium 12.8 mg/dl, serun phos, \ c) Chondrodystrophy d) Slphilis
phorus 2.3 mg/dl,, alkaline phosphate 28 KA units 61. Costochondral junction swelling are seen in-
and blood urea 32 mC/dI. Which of the following is (JIPMER 87)
the most probable fiagnosis in his case- (At 04) a) Scurvy b) Rickets
a) Nutritional rickets c) Chondrodystrophy d) Alloftheabove
b) Renal rickets 62" How to acsess Vit" D tfuerapyin Rickete is -
c) Hyperparathyroidism (All India Dec15 Pattern)
d) Skeletal dysplasia a) Sr calcium b) Sr. alkaline phosphatase
I
: \-rav wrist d) Sr. phosphatase 73. The vitamin A eupplement administered in 'Pre-
vention $. nurtntiana;l blindness in children pro-
SCURVY gra;mmc" contain - (Al0s, AIIMS Nov 0s)
a) 25,000IU/ml b) I Lakh ILr/ml
!f Primary metabolic bonc disorder in sflrrvy i$ - (AI 10) c) 3 Lakh IU/ml d) IU/ml
5 Lakh
a r Decreased mineralization 74. 2 year old boy of weight 12 kg with vitamin A defi-
b r Decreased osteoid matrix formation ciency what is oral dose of vitamin A -
. ) Increased bone resorption (All India Decl5 Pattern)
d) Decreased bone mass with normal mineralization a) 50,000 I.U. b) 1 lakh LU.
and osteoid formation c) l.5lakh I.U. d) 2lakh I.U.
b4. A six month old infant fedtatilly on cow's milk has
been brought with bl€€ding spots, anaeffiia,fcver MISCEttANEOUS
and generalised tenderness. On examinetian, there
were swelling in both the lower extremities and the 75. Allare features afYit. D intoxicatiofl,except-
blood count was normal. The most likely diagnosis (PGr 79, AilMS 86)
ts- (PGt e6)
a) Nausea and vomiting
a) Arthritis b) Poliomyelities b) Muscular weakness
c) Osteomyelities d) Scurr,y c) Anorexia
65. Pseudoparalysis in an infantis suggeetive of.- (Pqoa) d) Oliguria
a) Acute Rheumatic fever e) Metastaticcalcification
b) Vitamin 86 deflciency 76. Hypewit*minosis of which of the followingwill
c) Vitamin E deficiency cause bony abnormalities - (PGI Dec 06)
d) Vitamin C deficiency a) VitA b) VitD
6. l{inberger sign is present in - (PGt 2K) c) Vit C d) Vit E
a) Rickets b) Scurly e) Vit K
c) Secondary syphilis d) Tubercuiosis 77. Hypervitaminosis A causes - (All tndia Dects Pauern)
67. Deficiency of vit. C in infant is best estimated by Vit a) Benign cranial hlpertension
C level in - (CET lune 14 Pattern) b) Craniotabes
a) Plasma c) Liver damage
b) Urinary excretion d) All of above
c) Buffy coat estimation 78. A child with alopecia, hyperpigmentation psoriatic
d) Adrenal cortical Vit. C estimation dermatitis in genitals & mouth and hypogonadism is
68. Boy who refuses to eat fruit cornes with knee swell- likely to be sufiering from - (AI e8)
ing and hematoma, deficiency of which vitamin is a) Cu defeciency b) Iron deficiency
suspected ? (CET Nov. 12 Pattern)
c) Zn deficiency d) Mg deficiency
a) Vitamin C b) Vitamin D
79. Zincdeficiencycauses - (PGlDeclj)
c) Vitamin E d) Vitamin B,
a) Sexual infant ilism b) Loss of libido
Niacin
c) Essential fatty acids c) Vitamin A d)Essential fatty acid
d) Pyridoxine
t02. Toad skin is seen in deficiency of vitamin -
90. Para amino benzoic acid of breast milk prevent the a)A b) B,
infection of - (up 07) c)D d) Biotin
a) Plasmodium vivax b) Kleibsella_pneumonia 103. Growth retardation, taste alteration, hepato_spleno_
c) Giardia d) E.coli megly, hypochromic microcytic anemia, loss of hain
91. The substance that has anti infective property direct- hypogonadism in aboyindicate deficiency
ly or indirectly in milk is all except-
of- (Ka,n
]TPMER es) es)
a) Lactoferin b) Lactalbumin a) Selenium b) Copper
c) Lysozyme d) Nucleotides c) Zinc d) Iron
xS4. Deficiency of which element can lead to syndrome of
gro*th failure, anaemia and hlpogonadism - 107, Child ruith frog like position and resietanc€ to move
a Calcium b) Copper (COMED 09) the Imbs - (cMC 01)
; Zinc d) Magnesium a) Scurly
tr,15. -{,bnormalities of copper metabolism are imphcated b) Rickets
in the pathogenesis of all the following except - c) Trauma
(UPSC-t o9) d) Congenital dislocations
a) Wilson's disease 108. Pseudoparalyeis is seen in - (cMC o1)
b) Monkes' Kinky-hair syndrome a) Scurr,y b) Rickets
c) Indian childhood cirrhosis c) Polio d) Osteomalacia
d) Keshan disease 109. Calorie requirement per day of.a childweighing 15
106. Dosage ofYitamin-A forchildrenbetw€en l-3 yeus- kgwouldbe - (MH 1o)
a) 1250 IU b) 1333lU (Manipal0S) a) 1150 kcal b) 1250 kcal
c) 7667 IU d) 2333 rU c) 1450 kcal d) 1550 kcal
I-I
ANSWERS
N UTBITIONAL STATUS I}I DICATOBS
1. Ans. is 'a' i.e., Acute malnutrition [Ref : O.p" Ghai Be/e p. 97 & Zh/e p. 62)
r Wasting (deficit in weight for height) -+ Acute malnutrition.
r Stunting (deficit in height for age) -+ Chronic malnutrition.
o Wasting and stunting -) Acute on chronic malnutrition.
r Underweight (low weight for age) -+ combined indicator to reflect both acute and chronic malnutrition.
) Ans, is 'c' i.e., Rate of increase of height and weight {Ref: o.p. Ghai B&/e p. 13 {t 7n/e p. 6, 6j)
a
t Weight in relation to height is now considered more important than weight alone. Ithelps to determine
whether a
child is within range of normal weight for his height.
3. Ans. is 'V i"e.,Weight for height {Ref : O.p. Ghai *h/e p. 97 & p/e p. 621
o Wasting (deficit in weight for height) usually signifies acute onset malnutrition.
. Stunting (deficit in height for age) usually signinei a chronic.orrr" of rutrrrariai""
o Wasting and stunting --> Acute on chronic malnutrition.
r Underweight {low weight for age) -+ Combined indicator to reflect both acute and chronic malnutrition.
4. Ans. is 'b' i.e., Height for age {Ref : o.p. Ghai d'/e p. 101 6 Th/e p. 62; park lgh/e p. aja)
r
Stunting (deficit in height for age) generally points towards a chronic course of malnutrition. O.p. Ghai
5. Ans. is 'i i,e., Weight tot age{Ref : hdian academy of
-
3d/e p. 12n
Ttediatui{s
r Weight for height is decreased in both acute as well as chronic malnutrition. However, it cannot
distinguish between
acute and chronic malnutrition.
r Therefore, weight for age is a common indicator to reflect both acute and chronic malnutrition.
However, it is not the
best indicator for this (as weight for age cannot differentiate acute from chronic malnutrition).
r Best indicator for this purpose( to differentiate acute from chronic malnutrition) is the
simuitaneous measurement of
'weight for height (wasting)' and 'height for age' (stunting)'which is
useful to understand the dynamics of malnurrition,
distinguishing between current ( acute) malnutrition and long term (chronic)malnutrition.
_l
Normal > BOa/o Normal
t: ,,-J=::,,
II
, 6] 70. Moderate
51 -60 Severe
-'..:..,'tlt.it;
IV < 50 V"ry r"u"r""
7" Ans. is 'c' i.e", Third degree {Ref : O.p. Ghai Be/e p. 97 6 7"/e p- 64}
r Normal expected weight at 2 years Df age is 12 kg.
r This child has a weight of 6.4 kg, i.e.53.30/o of the expected.
e So, this child is having grade III (51-610/o of expected weight) malnutrition.
8. Ans. is 'a' i.e., Based on height retardation fRef.: Park lSth/e p. 463; Op Ghai 8tu/e p. 991
o It is based on weight retardation (not on height retardation,)
9. Ans. is'c'ie.,\Seightfarheight(wastinglandheightf*r*ge(stunting)lRef:A.P,Ghai*thlep.62-64;Nelsan
1*/e p. s9!
o Waterlow's classification is based on stunting (height for age) and wasting (weight for height).
10. Ans. is 'c' i,e,,2fr WlRef: Gbai 7h/e p. 5&|
7-9 year 41 9m
ll. Ans. is t'i.e., 1200 K cal/day lRef : PSM Park lgth/ep. 502)
lnfancy
0-6 months 118
7-12 months 108 ] K.Cal/kg/day
,:ehilirr.elL:tit..t..
t3. Ans. is id' i.e., All of above lRef: Ghai 7h/e p. 67|
o Marasmus is due to prolong deficiency of calories and protein. There is excessive catabolism of fat and muscle pro{in.
14. Ans. is '* i.e., Ederna and mental changes lRef : A. P. Ghai *th/e p- 99-]AA & Thle p. 671
r Classical triad of kwashiorkor is markedly retarded growth, psychomotor (mental) changes and edema.
15. Ans. is '{ i,e., Vocarious appetite lRef: O.P. Ghai *e/e p. gg-$0 d, 7h/e p. 6d; IAp p. }251
:Rd..eover.*r , '.
Mortality
16. Ans. is 't i.e., Fatty Infiltration of Pan creas {Re! O. P. Ghai 8th/e p. 99-100 & Vh/e p. 67)
17, Ans. is 'a' i.e., *trepatomegaily lRef: A. p" Ghai 8th/e p. 99 & Vhle p. 6Zl
r Hepatomegaly is seen in kwashiorkor (not in marasmus).
18. Ans. is'c' i.e., Baggy paint appearanee fRef: Gh*i Vh/e p. 6Z)
r Baggy Paint appearamce -- refer to loose skin of buttock hanging down.
t Seen in Marasmus
r Flaky paint appearance :- Refer to hyperpigmentation, depigmentation, desquemation which may be confluent seen
in kwashiorkar.
r Apathy, increase liver enzyme is also seen in kwashiorkar.
20- Ans. is 'a & c'i.e", Hepatornegaly & Low insulin levels {Ref : O.P. Ghai */e p. 99 & 6n/e p. 104, 105, t06l
r Hepatomegaly is not seen in marasmus and insulin level is normal.
21. Ans. is 'a' i.e., Klvashiorkar {Ref Ghai Bth/e p. 99-100; Th/e p. 6\
r Odema with muscle wasting is seen in Kwashiorkor.
22. Ans. is 'H i.e., lgL[Ref: O. P. Ghai 6,h/e p. 1071
In malnourished subiects, secretory IgA is generally reduced, Therefore infections tend to be severe and recovery
delayed. - Ghai 6th/e p. 107
23. Aas. is '* i.e.,200 Kcal {Rel API Medicine 6th/e p. 1145, O.p. Ghai Btu/e p. 103-104 & 7n/e p. 7jl
Energy requirements for -
l. Severe protein energy malnutrition -) 175 - 200 Kcal/kg/day
2. Moderate protein energy malnutrition -) 150 Kcal/kg/day.
t About 8-10o/o of total calories should be obtained from proteins ofhigher biological ualue.
24. Ans. is'd'i.e., 175 CallKg{Ref: O.P. Ghai te/e p. 103-104 6 Vh/e p. 731
?< Ans. is'c' i.e., When fever goes down [Rel Ghai Vh/e p. 68] '\
r Iron at 3 mg/kg per day should be started when child gaining weight once stabilisationlhasejsiyer.
zo. Ans. is 'd' i.e., Ift,vashiorkor {Ref : A.P. Ghai S,h/e p" 100 dr Vh/e p. 6ZJ
27. Ans. is 'f i.e., High blood osmolarity tRef O. p. Ghai Bn/e p. gg-100 {z fl/e p. 671
*d
28" Ans" is i.e", SAM with $ey€re Adema should be hospitalised leef TJpdates on the management a! savere acute
malnutrition infants nnd children, WHA protocol p. 361
c Children who are identified as having severe acute malnutrition shouldfirst be assessed with afull clinical examination to
confirm whether they have medical complications and whether they haye an appetite. Children who have appetite (pass the
appetite test) and are clinically well and alert should be treated as outpatients. Children who haye medical complications,
severe oedema (+++), or poor appetite (fail the oppetite test), or present with one or more Integrated Management of
Childhood Illness (IMCI) danger signs should, be treated as inpatients.
t Children with severe acute malnutrition who are admitted to hospital can be transferred to outpatient care when their medical
complications, including oedema, are resolving and they have a good appetite, and are clinically well and alert. The decision
to transfer children from inpatient to outpatient care should be determined by their clinical condition and not on the basis
of specific anthropometric outcomes such as a specific mid-upper arm circumference or weight-for-height/length.
29. Ans. is'b'i.e., 6 months fRef. O. P. Ghai 8th/e p. 150 b Vh/e p. 60)
c The WHO recommends exclusive breast feeding for the first six months of life and then breast feeding up to two
years or more.
30. Ans. is 'd i.e., 2 hours lRef, O, P, Ghai 9'h/e p. 150)
o Breast feeding should be initiated within i0 min. of a normal vaginal delivery.
o Breast feeding should be initiated within 4 hrs of delivery by caesarian section.
31. Ans. is 'a' i.e., Exclusive breast Feeding should be continued till 6 month of age followed by supplementation
with additional foods lRel O.P. Ghai 9th/e p. $a & Vh/e p, 601
o The baby should be given exclusive breast feeding not even water for first six months of life.
o Breast feeding should be given, whenever baby feels hungry (DEMAND FEEDING).
r Complementary foods (other foods in addition to breast milk) should be started after six months of age.
o Breast feeding should be continued with semisolid and solid foods upto two years of age and beyond.
32. Ans. is'd'i.e., IgA antibodies [Rel Nelson 18th/e p. 215; O,P. Ghai 8th/e p" 151 6 6th/e p. 971
Although antibodies and Lysozyme, both are important for protective effects of breast milk, antibodies play the
major role. Out of IgM and IgA antibodies, breast milk is especially rich in secretory IgA which is the single best
answer here.
33. Ans. is 'a' i.e. Docosahexaenoeis acid lRef: C.P.D.T. 18th/e p. 286; Park 20th/e p. 4631
o Up to 5-l0o/o of fatty acids in human milk are poly'unsaturated. Most of these are linoleic acid wrth smaller amounts
of linolenic acid.
o Linoleic acid -+ gives rise to Arachdonic acid
o Linolenic acid -+ gives rise to Docosahexaenoeic acid
o Docosahexaenoeic acid is found in human milk and brain lipids and is required for the development of our nervous
system and visual abilitie.s during the first six months of life.
o Lack of sufEcient Docosahexaenoeic acid may be associated wlth impaired mental and visual functioning as well as
attention defi cit hlperactivity disorder.
34. Ans. is'a' i.e., Vitamin B lRef: A. P. Ghai 6th/e p. 149, 158; Nelson 18th/e p. 215; Cloherty 4th/e p. 1131
o Deficiency of VitaminBnrtaf occur in exclusive breastfed infants of mother who is on strictvegetarian diet.
Remember following important facts -
o Milks from the mother whose diet is sufficient and properly balanced will supply all the necessary nutrients except
o The iron content of human milk is low but most normal term infants have sufficient iron stores for the first 4-6
months. Human milk iron is well absorbed. Nonetheless, by 6 months the breast-fed infant's diet should be
supplemented with iron fortifled complementary foods.
o The Vitamin K content of human milk is low and may cause hemorrhigic disease qf newborn.
37. Ans. is'-o" i.e., Evening colic [Ref Nekon 18h/e p. 215)
c Breast feeding protects against evening colic.
c Evening colic may be seen as a manifestation of allergy to cow's milk, but not with - Nelson 18th/e 215
breast milk.
o Haemorrhage due to vit K ileficiency may be seen. Breast milk contains very little Vit K - Dutta 4th/e p. 515
Hypoprothrombinemia, may therefore occur along with defeciency of other vit K dependent coagulation factors.
(VII, IX, X). this predisposes to haemorrhagic disease in new borns.
r There is strong association between exclusive breast feeding and neonatal jaundice. It is presumed to be due to
inhibitory substance in the breast milk, that intefere with bilirubin conjugation e.g. pregananediol and free fatty acids.
t Golden colour stool may be seen.
38. Ans, is *,* i,e,, Active untreat€d auberculosi$ {Ref: ctoherty - manual of Newatot-ogyJ
Contraindication of Breast feeding
1) Galactosemia
2) Active untreated tuberculosis - only in initial period
3) HIV positive mother - especially in developed country.
4) Some medication
39. Ans. is 'd i.e., Cow's milk contaia 80% whey protein not casein fRef: Nutrition and child develolrment, Fliz
beth F/e p. 18; Park 2ff/e p. $l
r Whey protein constitutes 80% of the protein in human milk, while the main protein in cow's milk is casein.
Comparison of human milk and cow's milk
Bacterial contamination
'40/o' .'::
Saturation oJ fatty acids Too much saturated
Linoleic acid (essential) Enough for qoryi"g Uraifr$ Notenough. , '
Cholesterol l
Notenough '":
Minerals {mg)
Calcium 350 (coirect amount) 1;400 (too fiuch)
Phosphate 150{correct amount) 900 (too inuch) :
tf,iiil': .:-::":,., 5in6X,,irrrounr b,ut well-absortred Smali aryouht pborly' absorbed
(enough) (not enough)
About option'C'
o Cow's milk has more K* and Na* than infant formula' CPDT 18th/e 302
-
10. Ans. is 'a' i.e., 7.2Vo lReJ. O. P. Ghai 6tt'le p. 97, 147, 149; Park 2$'t'le p. 46i, 5451
o It is 7.0 o/o.
41. Ans. is 'a' i.e., Lactose lRef. Park 20th/e p. 4631
12. Ans. is t' i.e., Fat [Rel O. P. Ghai 9n/e p. 15j 6 Vh/e p. 1251
Hind milk
r Comes towards the end of feed
t infat content and provides more energy, and satisfies the baby's hunger.
Rich
-13. Ans. is U'i.e., 24 hrs [R{: O. P. Ghai }'h/e p. 155 d" Thle p. }27)
Breast milk
o Canbestoredatroomtemperature -+ ForS-l0hours
e In a refrigerator -+ For 24hours
c In a freezer :) -200' for 3 months
44. Ans. is 'H i.e., I hrs [R{: O.P" Ghai }tt'le p. }55 d'Vhle p. 12fi
RICKETS
45. Ans. is'bn i"e., Defect in mineralization lRsf A' P" Ghai 7h/e p. 82i
r Inricketsosteoid(proteinmatrix)isformednormallybutmineralizationofthisosteoiddoesnotoccuri'e.thereis
defective mineralization.
o Rickets is a syndrome of diverse etiology characterizedby defective mineralization of bone and epiphyseal cartilage
(growth plate) of growing bones.
46. Ans. is 'a' i.e., Rickets lRef : O.P. Ghai 9'h/e p. 113 (t 7h/e p. 821
47" Ans. is'b'i.e., Hyphosphaternic rickets [Ref 0. P. Ghai 8'hle p. 11j, ]15 & 7h/e p.83; Nelsor 17'/e p. 2342]
tAilSQpfresphii*ifgi;fq1lv''..:']::r:
1::r.Ni":,-'l-i','"' ]' '1:- ; f. .:; ,:':' N, :
..::, N: :ir
\+
\i vI r'' ''.r+. :l
,:r,. t,.i: ',,
N
r' 'i'\ r.
Nutrit!onal rickets
Nutritional rickets -
c\r
J J
I
I t N
::d;tritbniai:ta {dtLq11t','r,.,.,':,,,,f.:,-:':"':'
: ::. j.:l::'1,.:l:':: ,.r:: . t., .,t,
-,:1
48. Ans. is 'b, i.e., Hypophosphatemic rickets lRel O.P. Ghai 8'h/e p. 113, 115 dt Vh/e p. 831
r In the patient :-
r Serum Ca2* -) Normal (Normal value -> 9-10 mg/dl)
r Serum POr2* -+ Decrease (N -+ 3-4.5 mgidl)
r Alkaline phosphatase -) increase (N + 30-120 IU or 5-15 KA
r Serum parathormone + Normal (X _+ to_ss units)
)
r Serum bicarbonate leyel _+ Normal (N _+ ZZ_ZS units)
o it is clear that it is a case of Hypophospheternic rickets.
So
c Proximal Renal tubular acidosis ulto .u,.r..,
hlpophosphetemic Rickets but the bicarbonate
in a case of proximal renal iubular acidosis. level will be reduced
r Distal renal tubular acidosis causes vit D. dependent rickets
so it is easily ruled out.
49. Ans. is t'i.e., Hyperparathyroidism
[Ref: Nelson lVh/e p. 2345]
'ff:lr#];.ji:tJi;ttt"" just looking at calciurn value. Amongst
the given options onry hyperparathyroidism
50. Ans. is 'a' i.e., Craniotabes, t, i.e., Widening of wrist, .d, i.e., JpOA, ,e, i.e.,
Ghai 9th/e p' 113 & vh/e
Growth retardation [Ref : O, p,
p' 82; welson lvh/e p. 186; Forfar and Arniel's peiatrics
r craniotabes, widening of wrist and growth retardation
6th/e p, d2 sstl
occur in rickeis.
o Serum phosphate is low
5t. Ans. is 'd' i.e., Bow legs laey o. p. Ghai Bth/e p. 113 & vh/e p. 82)
' otT:.T:;::i'ff.t;:::"formed when the chil{ starts bearing weight. rherefore
deformities of tegs are unusuat
q,)
Ans. is 'b'i.e., Gustock deformity {Ael O. p. Ghai gth/e
p. it3 6 Th/e p. 821
c Gunstock deformity is seen in malunited supraconrlylar
fracture of humerus.
Note -
r Dont get confuse between option'a'and answer.ofprevious
question. In this question the age of the chilcl
been mentioned. Bow legs can occur, once has not
the child starts ;"'il;;
53. Ans. is 'b'i.e., Rickets [ne! O.e Ghai 7/e p. 82; Maheshwari
3d/e p. 275)
r Genu valgum (also known as knock knee) is
a condition where knees are abnormally
abnormaliy divergent. approximated and ankles are
c It is caused due to softening of bones or damage
to laterar Femorar epiphysis
Out of given options -
o Most common cause in children is Rickets.
o Other diseases given in option are seen in eiderly.
61. Ans, is 'd' i.e., All of the above lRef : See above explanationf
62. Ans. is t' i.e., X-ray wrist lRef: Ghai 7/e p. 83)
r In nutritional rickets either single dose Vit. D. 6 iakh l/m or 60,000 IV daily for 10 days.
r It shows evidence of radiological healing within 4 weeks of therapy.
r Reduction in serum alkaline phosphatase and resolution of clinical sign occur slowly.
o Ifno healing - repeat dose.
o If no healing can be demonstrated with 2 mega dose of Vitamin-D, then labelled as refractory rickets.
SCURVY
63. Ans. is 'b' i.e., Decreased osteoid matrix fRef: O.P. Ghai 8th/e p. 120 6 Vh/e p. 82-911
o Coliagen is a component of osteoid (protein matrix).
o Collagen synthesis is deficient in scur\T; therefore, osteoid formation is defective.
e On the other hand, in rickets osteoid formation is normal, but mineralization (Calcification) of osteoid is defective.
64. Ans. is 'd' i.e., Scurvy lRef : O. P. Ghai 8th/e p. 120 6 Vh/e p. 911
o Exclusive feeding on Cow's milk in a 6 months infant with anemia, bleeding, fever and generalized tenderness suggest
the diagnosis of scurr,y.
r Cow's milk does not contain sufficient amount of Vitamin C. On the other hand breast milk contains suffrcient
Vitamin C.
65. Ans. is t'i.e., Vit C deficiency lRef : O. P. Ghai 8th/e p. 120 6 Vh/e p. 91]
Pseudoparalysis
o A voluntary restriction of motion because of pain, incordination or other cause, but not due to actual muscular
paralysis.
Causes of pseudoparalysis
o Scurry (vitamin C def,ciency) o Osteomyelitis
o Septic (arthritis) o Congenital syphilis
67. Ans. is 'c' i.e., Bufly coat estimation l&ef : Nelson lse/e p. 252)
o Leukocyte concentration of vitamin 'C' is a better indicator of body store, it may be deficient even in the absence of
clinical signs of defi ciency.
. It is estimatedby buffy coat prqvaal
68. Ans. is 'l i.e., Yitamin C [Ref: Nelson 18*/e p. 252)
o The history is suggestive of bleeding disorder and the vitamin most likely associated is Vit. C and disease is scurry.
The other hint in questions is that the boy doesrt't eat fruits. Fruits are rich sources of Vitamin C.
o Vitamin C deficiency causes scur\y.
VITAMIN A
69. Ans. is 'b' i.e., Yitamind. {Ref : O. P. Ghai {/e p. uq & 7/e p. 79; Park 1*/e p. 48sl
o Vitamin A is necessary for integrity of epithbiQ!$ides that resist invasion by pathogens.
o Vitamin A has some role in immune response.
70. Ans. is t' i.e., Anterior segment of eye is initially involved lRef : O. P. Ghai 8'h/e p. 111 6 Vh/e p. 791
o Night-biindness is the earliest symptom, which is due to inability to regenerate rhodopsin. Thvl pasterior segment is
involvecl initialiy (rhodopsin is present in ret,inaand retina
is a part of posterior segment of eye).
o Infections, poor growth and rarery hydrocephrus
occur in vitamin A deficiency.
71. Ans' is 'a' i'e" Bitot spot; 'H i.e., Xerophthalmia & 'c' i.e.,
Night blindness {Ref : o, p. Ghai gth/e p. 1 I I 6 Vh /e
p.7e1
Xerophthalmia (Dry eye)
o It is a syndrome due to def,ciency of vitamin A.
o it has foilowing stages :
l. Night blindness : Eailiest acular symptom 4. Corneql xerasis
2. Caniuctival xerasis : Eailiest ocular sign 5. Keratomalacia & corneal ulcers
3. Bitot's spot
72. Ans. is t'i.e., 300 microgram lRef O. p Ghai Bth/e p. 111 6 Vh/e p. Z9)
Daily dose of vitamin in
o Infants 300-400 microgram
o Children 400-600 microgram
o Adolescen[s 750 microgram
73. Ans' is 'H i'e" I Lakh IUlmt fRef. IAP ln/e p. 417; Nutrition & child Development KE Elezabeth
3d/e p. 941
o According to vitamin A prophyiaxis programme
children between 9 rnonths and 5 years are given 9
megadoses of
vitamin a concentrate at 6 month interval.
o The first tlvo doses are integrated with measles vaccination
and DpT Ist Booster.
o For infant the dose is I ml equivalent to I lakh IU and
in chjldren it is 2 ml i.e. 2lakh IU.
74. Ans. is 'd'i.e., 2 lakh I.IJ. [Re! Ghai Tt/e p.SA]
o For treatment of vitamin A deficiency, oral vitamin
A is given at a dose of 50000 IU, 100000 lu and 200000 IU in
children <6 months, 6-12 months and > 1 year, respectivell'.
The same dose is repeated next day and 4 weeks later.
MISCETLANEOUS
i.e.,20 mg of iron and 100 microgram folic acid Nutrition & chitd development by K.E. Elizabeth
83. Ans. is 'l fRef:
3'd\ep.111,1121
o National nutritional anemia prophylaxis programme is based on daily administration of Iron & folic acid tablets to
maintain rural child health.
r For anemia prophylaxis FOLIFER tablets with 20 mg elemental iron and 100 microgram folic acid are given to children
for 3 months.
o For treatment upto 6 mg/kg elemental iron should be given for 3 months.
84" Ans. is 'd i.e.,I-2 rmEqItr{g $te}: Nets*n t9'h/e ch. 52.7}
g5. i.e., Early supplementation of solids in infants & t' i.e., Immunisation to the chil dlRef : O.P-
Ans. is
.b, Ghai
8'hle P. 108-109 dr 7h/e P. 76-771
PEM can be prevented in children by -
i) Exclusive breast feeding for first 6 months.
ii) Supplementary food after the age of 6 months'
iii) Sup;lementary food should be-complementary, so that the deficiency of a limiting amino acid is compensated bv'
a amino acid in other food.
iv) Immunization of vaccine preventable diseases'
v) Restriction of feeding in fever & diarrhea should be discouraged. \
vi) Adequate time between two pregnancies.
\)
g6. Ans. is'b'i.e., condition seen in the displaced child lRef : www.popline.orgl
r The name kwashiorkof comes from the Ga language of Accra, Ghana, and is used to describe the disease of the
displaced baby when the next one is born.
87. Ans. is t' i.e., Edema fRef: A.P. Ghai 6th/e p.I01l
gg. Ans. is t' i.e., The child loses edema and starts gaining weight [Rel: OP Ghai 9'h/e p. ru7 d" 7h/e p. 751
89. Ans. is 1f i.e., Pyridoxine fRef: Ghai 6tule p. 105, 12j, 1251
90. Ans. is'a'i.e., Plasmodium vivax [Ref O.P. Ghai 6'h/e p' 9fl
91. Ans. is 'b' i.e., Lactalbumin & t'i.e., Nucleotides lRef A.P. Ghai 8'h/e p. 151 & 6'h/e p. 147-148; SPM Park
17*le P. 373 dr 2ffh/e P. 462, 4637
92. Ans. is'H i.e., Serum iron estimation [Ref: O.P. Ghai 6h/e p. 3A] dr Thle p. 3aAl
o By the age of 6 months the breast-fed infant's diet should be supplemented with iron fortified complementary foods
because iron in breast milk is sufficient upto the age of 6 months'
o The baby in question has been exclusively breast fed upto I year, so he has developed iron deficiency anemia.
94. Ans. is t' i.e., 5-6 months lRef : Park 19h/e p. 4221
o Breast milk is maximum at 5-6 months of lactation --> 730 ml/day'
e It is minimum at 37-38 rnpnths of lactation ) 345 mllday'
)
\ _--,
95. Ans. is'b'i.e., CMV
[Ref Nelson lgth/e p. 215]
o Breast milk transmits (with
definitive_evidence) : (l)
o Breast milk can rarery transmit HIV (2) CMV
: (1) HTLV - tFpe 1 (2) Rubelra virus (3) HBV (4) HSV
96, Ans.is 'i i,e,,Lactose [Ref O.p, Ghai
r premature mirk
Vh/e p. t2S d" 6th/e
15g] p,
contains ress ractose in comparison
to term miik.
97. Ans is t' i.e., 7 gm [Ref Ghai 6th/e p.
97, 142, 149; park 20th/e p. 463, S4S]
98. Ans. is t'i.e., Saddle nose
[Ref Nelson t4h/e p. 186; Op Ghai
o Saddle nose
gtu/e p. 113)
is not seen in rickets_
rrr
Q',, t[ A P':T'r.,,,E:r':'rR
NEWffi#Rh$ TNFANY
NORMAL NEWBORN
o From birth to under four weeks of age (< 28 days), the infant is called newborn (neonate) and that petiod.is called
neonatal period@EBr).
1. Milia@cro& e8)
r White dots on nose and face due to distended sebaceous glands. These diseappear spontaneously.
2. Erytherna toxi6sln(rcroa' o2' e5)
r Erythematous papules on trunk & face. They appear on 2"d & 3'd day and disappear
spontaneously.
Stork bites
r Pinkish gray capillary hemangiomas on the nape of neck, upper eyelids, forehead
& nose. These disappear
spontaneously.
5. Peeling of skin
r More frequent in post-teim infonts, but can also occur in term infants.
6. Subconjuctival hemorrhages @Gr 02' s8)
r Disappear spontaneously.
7. Breast engorgment
r Due to transplacentally acquired maternal hormones. It is seen on 3d or 4s day.
r*-'
EPstein pearl@Gro8'02)
r Epithelial inclusion cysts, which appear as whitish spots. These are of two t,?es -
i) Palatal + On hard p{rte or on either side of median raphe.
ii) Prepucial --> At the rip of prepuce at 6'O'clock position.
Cnl:P.r:E,(
Skin changes in newborn that disapper spontaneously :MiliafctoB), erythema tox'cum(P6r08), mongolian spots(P6i '8'), stroke
bite, pustular melanosis, peeling of skin, and Harlequin color change(Pci "r.
o A new born loses upto 1 0o/o of his body weight in first few days and regiins his birth weight by age of 10 days.
a " The number, colour and consistency of stools may vary greatly in the same infant and between infants of similar age. The
color of the stoot has little signifrcance except for the presence of blood or absence of bilirubin products;'
Larynx of a neonate is at higher position (thon adults) which allows infdnt to use nasal airway to breath while suck-
ingqttMslO,
PRIMITIVE REFLEXES
o A number of primitive neonatal reflexes can be elicited in healthy term neonate.
o These disappear as the child grows -+ These reflexes are inhibited by frontal lobes as child grows.
o Absence of reflex responses indicates d),sfunction of central or peripheral motor function.
pcl D).
c Abnormal persistence of neoruatal reflexes is pathognomonic of central motor lesions@Pc 0e'
AtMsaT)
v) Assymetrictonic neck reflelAtaT
I Moro',sreflexdevelopsby28thrveekofgestationanddisappearsat6mottthsofags{dnus'7,e5Ar07),andneverrea\rytssr.r(1'ct
e8)
' Persistence of Moro's reJlex beyond 6 manths is ahnormararrMs 07)
.
: a) Parachute reflex.
b) Sucking,re{lex
c) Tonicneikreflex
d) Moro's,reflex
HYPOTHERMIA
o Birthweightisthesinglemastimportantdeterminantafchancesofsurvival,growthanddevelopmentafaninfant{tt
'3). Birth weight should ideally be measured within lst haur of birth. Average birth weight in lndia is 2.7- 2.9 kg (2.8
kg){Nntrt.
s Most common causes of low birth weight (LBW) in India is maternal malnutrition. Maternal nutrition has linear relation
with birth weight.
o Following terms are reiated to birth weight and maturity of a neonate at birth :-
1) Lowbirthweight
r Anyneonatelveighing/essthan2500gm(2.5kg1r*uu':'GMCETq7']'G103)atbirthirrespectiveofgestationalage(WHO
definition). But some lndian scientists consider LBW as < 2ftyleouctrozl.
2) Very low birth weight
r Any neonate weighing less than 1500 gm (1.5 kg) at birth irrespective ofgestational age.
3) Extremely low birth weight
rAny neonate weighing less than 1000 gm (1 kgy*uu't at birth irrespective of gestational age.
4) Appropriate for gestational age (appropriate for date)
r Neonate with birth weight between 10th to 90th percentile.
5) Small for gestational age (small for date)
r Neonate with birth weight less than 10th percentile(Pct00). These are the baby cailed as intrauterine growth
retardation (IUGR).
6) Largefor gestational age (largefor date)
r Neonate with birth weight more than 90th percentile.
7) Tertn neonate (termbaby)
r Neonate born between 37 and < 42 weeks (259-293 days), irrespective of birth weight.
8) Preterm baby
r Neonate born before 37 weeksql 01) (< 259 days), irrespective of birth weight.
9) Post-termbaby
r Neonate born at or after 42 weeks (> 294 days), irrespective of birth weight.
Causes of intrauterine growth retardation (smal! for date)
r Important causes of IUGR are :-
1) Maternal malnutrition: Most important cause.
2) Substance/drug intake: Smoking and tabacco(NEEr' AttMS 87), alcohol$EEr' AIIMS 87), propranolol\IlMs 87) "
3) Maternalfacfors: Short stature mother, primi or grand multipara, yound mother (< 20 years),lowpre-pregnancy
weight.
4) Maternal illness/diseases : Anemia, CRF$'rr), heart disease, malaria, pre-eclampsia, hlpertension.
5) Placentalfacfors: Abruptio placenta, excessive infarct, single umblical artery.
6) Fetal factors : First born babies, genetic/chromosomal aberrations, twin/multiple pregnancies, intrauterine
infection@at) .
RESPIRATORY DISTRESS
o The principle features ofrespiratory distress in a neonate are :-
1) Taclrypnea (fast breathing): Fast breathing is defined as :-
l) Child less than 2 months of age + > 60 breaths per miflute?Gto4)
ii) Child aged 2 months upto 12 months -+ > 50 breaths per minute
iil) Child aged 12 months upto 5 years ) > 40 breaths per minute
5) CYanosis(DNB12'PGI04)
Apnea
o Apnea malr !s defined as -
i) Cessation of respiration for 20 seconds with or without bradycardia and cyanosis(Ar 13' NEEI' DNB 12)
.
or
ii) Cessation of respiration for less than 20 seconds if it is associated with bradycardia or cyanosisGr 13' Nnnr' DNB 12)
.
i.
h
ti
I
. Apnea is more common in preterm infants.
c Apnea of prematurity ocatrs in preterm neonates in 2nd to 5th day of life and is because of immaturity of
developing brain.
o Important causes of neonatal apnea are : Hypoglycemia@Grqg),metabolic acidosis ,hypothermia@G108) andpretnaturity@er
oB)
.
r Pneumonia.
t Transient tachypnea of newboyn(etess.
r Persistent pulmonary hypertension
o Congenital malformation -+ TER Diaphragmatic hernia(Pclo3' 0r), lobar emphysema, pulmonary hlpoplasia.
r Upper airway obustruction -+ choanal atresia, vocal cord palasy, lingual thyroid.
r Pulmonary hemorrhage
Causes of respiratory distress with mediastinal shift in neonates
r Diaphragmatic hernia
r Congenital lobar emphysema
o Congenital mediastinal mass
o Pneumothorax
o Congenital cystic adenomatoid malformation
Clinical maiifestations
r Respiratory distress within lst hour with tachlpnea, retraction, grunting and cyanosis.
r Overdistention of the chest.
Complications
r Respiratory distress sl,ndrome r Pneumothorax r Persistent pulmonary hlpertension
b) Transient tachypnea
'trc)l,.+keola;1protf.;i,*dsis'.',1:,,,,1.' "'',, ',',, .,r,
Clinical features
o CDH may present as
l. Soon (within 6 hrs) after birth (most of the cases)
or
2. After neonaral period (small group)
l) Soonafterbirth
t Respiratory distress is a cardinal sign@Nn o -> presents as tachypnea, grunting@rva re, chest
retraction,
cyanosis.
t Scaphoid abdomen@NB ls)
r Increased chest wall diameter
r Bowel sounds may be heard in the chest with decreased breath sound.
r Cardiac impulse is displaced away from the side of hernia.
2) Afterneonatalperiod
: Vomiting as a result of intestinal obstruction
r Mild respiratory symptoms
r
occasionally, incarceration of the intestine will proceed to ischemia
with sepsis and shock.
o Most common cause of death in CDH is pulmonary
complications(ArrnseL) (pulmonary hypoplasia{ArruseB)
and pul-
monary hypertension).
Diagnosis
o Prenatal ultrasound can diagnose CDH between 16 and
14 wk.
o After delivery chest X-ray and nasal gastric tube is all that
is usually required to confirm the diagnosis.
Prognosis
o Two most important prognostic
facto.rs are pulmonary hypertension(AilMs il, 0s,At oe) and pulmonary hypoplasiailrrMs
"). Other prognostic factors are : Gestational age at detectionailMs 11Ar lt),associated
anomalies, size of 11,
d.efect{ArrMs
AI11)
aldside of defect (right side has poor prognosis). Timing of surgery is not Ar
a prognostic factor*nus 11, 11).
Management
e cDH is no longer considered as surgical emergency child
is first resuscitated and stabilized before surgery.
,,,*
't
Dlttercnlial diagnosir
r Pulmonary sequestration.
o Pleuropericardial cysf |tt Ms s7 ).
r Cystoid adenomatoid malformation.
iv) In severe case whiteout lunglenus n' t0, PGr e7, Keruta e4)
Prenatal diagnosis of HIUID
r Prenatal diagnosis of HMD can be made by -
1) Lecithin / sphingomyelin (L/S) ratio in amnioticfluid @EEr)
2) Shake test
r Amniotic fluid or gastric aspirate is mixed with absolute alcohol and shaken for 15 seconds and
allowed to settle' copious bubbles are formed in the presence
of adequate surfactant indicating extent of lung
maturity.
Treatmentof HMD
r Neonate should be managed in NICU (neonatal intensive care
unit).
o Oxygen should be given ,
Mild distress _+ Without ventilator
Moderate distressqllMs 10' 0e) -) Continuous positive airway pressure (CpApltenus n, os1
olnjectionbetamethasone (l2mglmevery24hours(Nnnr)JFor2doses)ispreferred.Dexamethasone(6mglmevery
12 hours for 4 doses) i.s an alternative. Beside reducing HMD risk, corticosteroids also reduces mortalfiy(AlrMsee) and
v entri cular h emorrhage(
ut us sa) .
incidence of int er
Supplement 28 days) and Supplement O, (for 28 days) and Supplement O, {for 28 days) and
> 32 weeks
r Breathingroomairby56days r <300/oQrby56dayspostnatal positive pressure (PPV) by
psstnatalageoratdischarge ageoratdischarge(whichev- 56 days postnatal age or at
GA at birth
(whichevercomesfirst). ercomesfirst). whichever comes
l::i,:"tn"
=qR. tp,u,a."=q{gffi::;SlFiiiiti;i: ::.:iii:.j'r:, .::::i:...::i::.,j.,,,...rr,..ii#L't?i,t;.i:i,il:;,.::.-:iii': :ir!
RESUSCIT4T|ON OF NEWBORN
1. Clearance of meconium
2. Active breathing or crying
3. Good muscle tone (flexed posture and active movement of baby).
4. Pink color (look at tougue and lips)
5. Term gestation (deliverybetween3T-42 weeks of pregnancy).
r Ifall signs are positive no active resuscitation is required.
r Ifany ofthe 5 signs is absent, baby requires resuscitation.
r The baby should be placed under the heat source (radiant warmer) and subjected to a set ofintervention known as
initial steps.
4. Freeflowofoxygen
r Ifthe baby continues to be depressed, provide free flow of oxygen using a facemask.
o After providing initial steps, the baby should be evaluated for three signs -
1. Respiration
2. Heart rate (HR)
3. Color
r If baby has good breathing, HR >100 and pink color, he should be given supportive care.
o If the baby is not breathing well or HR <100 then bag and maskventilation is needed.
o After the infant has received 30 seconds of ventilation with 100% oxygen by bag and mask, evaluation of heart rate
should be done -
HR >100 -+ Discontinue ventilation if spontaneous respiration is presenl(ersz).
a Forchildren,uncuffedandstroightblade(,4//M599]endotra.n;;l*b"
a
";rt* ;;;l,lli;on,o,
ofpremature
a l:::::"j:1,::l
birth l"j_,1"_1l.,l"sutation
In cases of asphyxia, corticosteroidsr,renotuseclhtos).
,,,,6,pcles,
warmed
vvqlrrreu rrtLuu..u'5'
incubators.
a Bagandmaskventilationiscontraindicatedin:Diophragmtatichernia(AtMsoa,ss),Tracheo-esophagealfistulorucscoz),and
meco nium aspi roti on sy n d rom e4il.vs 8s).
Important druqs used for neonatal resuscitation are epinephrine
(adrenaling){A/75,, normal saline or
naloxone/4i,5) and sodabicarbonate#i rir. ringer lactate,
Dose of adrenaline inneonatal resuscitation : 0.1
to 0.3 mg/kg diluted l n. :l o,oggurrr
APGAR Scoring
o APGAR Score is a quantitative method for assessing infants respiratory,
circulatory and neurological status
. Respiratory efforl
:l*i
o Color ofthe bodytAttMseT) (Ap-
pearance) Blue or pale Body pink extremities blue pink
Flaiiid
o Reflex stimulation (Grimace)
or putting catheter in nose No response GrimaCerrr,5l Cries, coughs or sneezes
l) Strongrespiratory effortGIIMSoe)
2) Good muscle toneGIIMSos)
3) Heart rate greater than 700aIIMS0s)
r The vigrous child does not require any tracheal suctioning and the
initial steps of resuscitation are provided,
usual
i'e', provide warmith, positioning, suctioning of mouth and nose (not tracheal
suctioning), Dry, stimulate and
02 if necessary.
B) Non-vigrous newborn
r If any of the above three signs is present, the newborn is classified as non-vigrous.
: For non-vigrous child, the initial steps are modified: -
i) Place the baby under radiant warmer and postpone suctioning to prevent stimulation of posterior
pharyngeal wall that can cause bradycardia.
ii) Residual meconium in the mouth and posterior pharynx should be removed
by suctioning under direct
vision using a laryngoscope.
iil) The trachea should then be intubated and mechonium suctioned
from the lower airway. Tracheal
suctioning is best done by applying suction directly to the endotracheal
tube.
r After providing initial steps, the further management is same as with resucitation for other conditions.
a For chi ld ren, u n cuffed a nd stra ight blade^rMs ss) enclotr achea l tu be is used.
a lncubators used for thermal regulation of premature neonates are convectio
nut13.06,pctsa) warmed incubators.
a ln cases ofbirth asph;n<ia, corticosteroidsare not asedal0s).
f Bagandmaskveniilaiioniscontraindicatedi; riiopnrng^oticherniaulMsM,se),Trocheo-esophagealfistutatuescoz),and
mecon i u m aspi rotion sy n d rome(At tns 8st.
lmportant drugs used for neonataf resuscitation are epinephrine
{adrenaline)(,4r,5.r, normal saline or ringer lactate,
6616;qpgFr rs,r and sodabicaylgn31g(er ;s).
Dose of adrenaline inneonatal resuscitation : 0.1 to 0.3 mg/kg
diluted l :l o,ooo(Ntr).
APGAR Scoring
r APGAR Score is a quantitative method for assessing infants respiratory,
circulatory and neurological status :
. Respiratory
iii.;:#;*irefforttil"*ai j\rr,.r.;
None
;,,,*,,,,;4,;
Slow irregular
i:,=,'r1?itf.ii-,.1-'r...;1"
Good, crying
> 100
t Color ofthe boayroiisin lg;-
pearance) Blue or pale Body pink extremities blue Pink
.-,rt*:i:t:::.j -:rr*r::=i:.: a.: -.... ..
o ii.:::r.:1::::1-1
c lf the Apgar scote remains below 3 at later times such as 10, 15 or 30 mintues, there is a risk that the child will suffer
longer-term neurological damage. There is also a small but significant increase of the risk of cerebral palsy.
r However, the purpose of the Apgar test is to determine quickly whether a newborn needs immediate medical care; it
was not designed to make long-term predicitions on a child's healthallMs 11) .
Lort.thest .,,,
Xiphoid:retraction .,. Na!-l'flaring G'i*nt. ,:.
retra(tion.
Nong None None None
,:t :.:1 , Lag oqin$pirqliqh :': Jnii'tti.bte .r.:.,i. Just visible Minimal :Stetho5c0peonly
2 See- saw Marked Marked Marked Naked ear
Nil
0 < 60/min Nil Normal None
' \.\
:',,. .:r';;;',,,11.,14
Au,sc with',,.'
:,,r.-1 ,,.1'l :60.80/m.in ',.[n'rgorn air :Mild:?::',: ,.
stethoslo:pe
Mild,. .1.: :,::.':.
Audible with
2 >80/ min ln >4Oo/o O, Marked? Moderate
naked ear
A) UnC,onjugated hyperbilirubinemia
* Conjugated hyperbilirubinemia is seen when -
1) lncreasedproductionofbilirubinfromhemoglobin,Sothatthecapacityoflivertoconjugatebilirubinisoverwhelmed
by increased production, e.g. -
t Hemotytic on"^iotn"''tto7t -+ Hereditory spherocytosis, G6PD deficiencyulittsaT).
o lneffective erythropoiesis - + Thalassemia, Pernicious anemia.
2) Reduced hepatic uptake of bilirubin from bilirubin - albumin complex + Drugs,
3) lmpaired hepatic conjugation, e.g.
i) -) Liver of a neonate is functionally immature (, UDPG transferase)
Physiologicol joundice4ilMs0T)
ii) Breastmilkiqundiceottusair-+ Pregananedial in breast milk interferes with bilirubin conjugation.
iii) Geneticdeficiencyof UDPGtransferase-+ Crigter-Nojjatsyndrome\'ls,NEETDNBl3,Pctosa6Aufsot),Gilbertsyndrome(At
I 3, NEEI DN| | 3, pct 0g. 06, AIIMS O I )
ii) lmpaired bile flow --> Obstructive jaundice(AttMsol), primary biliary cirrhosis, Neonotal cholestosis, e.g. Extrahepotic
biliaryatresia(At13)/neonateidiopathichepatitis,Choledocolgyst(PctM,sclerosingcholangitis, Carolidiseose,Metobolic
(Tyrosinemia, Wolman disease, Nieman pick disease, Galactosemia, Fructosemia).
Physiological jaundice
r Most neonates develop visible jaundice due to elevation of unconjugated bilirubin concentration during their
first week. This common condition is called physiological jaundice.
r This pattern of hyperbilirubinemia has been classified into two functionally distinct periods -
1. Phase one
r Last for 5 days in term infant with peak bilirubin levels to 12 mg/dl.
r Last for 7 days in preterm infrnt with peak bilirubin levels to 15 mg/dl.
2. Phase two
r 'Ihere is decline to about 2 mgldl, which iasts for 2 weeks after rvhich adult values are attained.
Criteria for physiological jaundke
. Clinicaljaundice appears after 24hours ofage'PCI03'.
'.'. Total bilirubin rises by less than Smg/dl per day (no sudden rise)@etos).
;llt Peak bilirubin occurs at i-5 days of age, with a total bilirubin of no more than 15 mg/dl
it t Clinical jaundice is resolyed by I weeks in term infants and 2 weeks in preterm infants(eet ost,
Congenital hyperbilirubinemias
r Important congential hlperbilirubinemias are :-
1) IJnconjugatedhyperbilirubinemia (ilefective conjugation): Gilbert syndromeql 13'NEETDNa n'PGIoe'06'AIIM\01'%),
Crigler Najiar Synilrome (type I dt II)(u t:' Nrnr'
DNB ls' PGr 0e' 06' AIIMS 01' e3)
,
Gilbertsyndrome
e7) 13' NEEI' DNB 13' PGI
e Gilbert syndrome rs an autosomal dominantattMs congeflital unconjugated hyperbilirubinemiaat
09, 06, 02, 4ttMs 0 L 97, 93).
c Allhepaticbiochemicaltestsandliverhistologyarenormal\ttMseT),butinsomepatientsincreasedlipofuscinpigment
may occur.
ls' AttMS e7),
e There is mild increase in unconjugate bilirubin(/r thus kernicterus does not occur.
e Basic defects are: - \
l) Decreased hepatic uptake of bilirubin.
ii) Decreased activity of UDPG transferaseql
ls).
ii) Total bilirubin rises by less than Smg/dl per day (no sudden rise)(ecr 03)
.
ili) Peak bilirubin occurs at i-5 days of age, with a total bilirubin of no more than 15 mg/dl
iv) Clinical jaundice is resolved by 1 weeks in term infants and 2 weeks in preterm infants@ct ost
.
Breast milkiaundice
o There is strong association between exclusive breastfeeding and neonatal jaundice.
o A few babies who remain on exclusive breast feed develop jaundice in the seconil week of life and continue well
into the third month. This is called breastmilkiaundice.
o A bilirubin level of over 20 mg/dl may be attained. (It is presumed to be due to inhibitory substances in the
breastmilk that interfere with bilirubin conjugation e.g. pregananediol and free fatty acids).
o Temporary interruption of breastmilk feeds will ilramatically reduce the serum levels of bilirubin and there may
be slight increase in bilirubin when breast feeding is resumed, but it never reaches the previous levels.
Congenital hyperbilirubinemias
o Important congential hyperbilirubinemias are :-
l) (Jnconjugated hyperbilirubinemia (defective conjugation) t Gilbert syndrome6"i'NEEI'DNB 13'PGt0e'06'AilMS01'e3),
ts' Nnnr' DNB 13' PGI 0e' 06' AIIMI 0t' e3)
Crigler Najiar Syndrome (type I dt IISGT .
2) Conjugated hyperbilirubinemia : Rotor syndrotneat 13' NEEr' DNB 13' PGt 0e' 06' AIIMS 01' e3)
, Dubin f ohnson syndrome-
Gilhert syndrome
e7) 13' NEET' DNB 13' PGI
e Gilbert syndrome is atr autosomal dominan{or/Ms congenital unconjugated lryperbilirubinemiaAl
09,06,02, ArlMS 01,97,93)
.
e Allhepaticbiochemicaltestsandliverhistologyarenor*o1{utusez),butinsomepatientsincreasedlipofuscinpigment
may occur.
1s' ArrMseT),
o There is mild increase in unconjugate bilirubin(Ar thus kernicterus does not occur.
t Basic defects are: -
l) Decreased hepatic uptake of bilirubin.
ii) Decreased activity of UDPG transferaseql
ts).
Rotor syndrome
o Rotor syndrome is a type of congenital conjugated hyperbilirubinemiaut n, NEEI, AnMs 07).
o It is autosomal recessiye.
r It is due to decreasedbiliary excretion ofconjugatedbilirubinand
also due to decrease hepatic uptake & storage of
bilirubin.
o Differentiating features of rotor syndrome (from DIS) -
i) Liver is not pigmented and liver histology is normal(pcr02).
ii) coproporphlrine I is increased in urine but total coproporphyrine level
is also increased.
iii) Gall bladder is visualized
iv) There is no reflux ofconjugated BSp.
Kernicterus
r Kernicterus or bilirubin encephalopathy, is a condition caused
by bilirubin toxicity to the basal ganglion(Aree) and
various brainstem nuclei.
e It is mainly caused by unconjugated bilirubinal 12) as unconjugated bilirubin
can cross blood brain barrier.
Unconjugated bilirubin level of more than 20 mgl dltl't tst increases
the risk of kernicterus.
o Clinicaily, kernicterus is described in 3 phases, which may
progress over 24 hours to 7 days :-
l. Phase I -s poor suck, lethargy, hypotonia{o, ,i), depressed sensorium.
2. Phase II -) Fever, hypertonia progressing to opisthotonus(,Arrs).
3. Phase III -+ High pitched cry, conulsions, death.
o Long term survivors demonstrate choreoathetoid cerebral
palsyLl 13),
upward gaze palsyar 13),
sensorineural
hearing lo ss( AI 3) andmental retariation.
1
3) Acidosis, 4r ,o','"""-"o' l
4) Increased FFA (secondary to hypoglycemia, Oisllace bilirubin from its binding
starvation or hypothermia)Gr t'tt /I site on albumin
5) Asphyxiqal ta)
6) Hyperosmolarity\tt4 )t
Make neurones more susceptible lo
7) Prematurity{At u) I
toxic effec1 ofunconjugate bilirubin
8) Infection J
IREATM ENT OF HYPERBILIRUBINEMIA
11-14
34 12-14 17-19
2001-2so0 g
10-12
,F.hii,fe&rii1y.
24 - 48hrs >15 >20
48,-72hrs:,. ,)18 >25
> 72 hrs{AEMs ee)
> 20@aM3se)
>25
NEONATAT HYPOGLYCEMIA
I
n;;;;';;i,*;*i
Neonate of diabetic rnother
r Neonates of diabetic mother have following probiems :-
1) Hyp o gly cemi aGI
t[s 06' I'Gr 07 ) (non-ketotic) (ArrMs e8' Ar e5r.
6) Polyclthemia.
3) Hyperbilirubinemia\iltts06'PGt07)' 8) CardiomegalY.
:*E-.i.ri:
Cardiac malformations
c Ventricular or atrial septal defect
a Double-outlet right ventricle
o TransPosition of great vessels
* Coarctation ofthe Aorta.
c Truncus arteriosus
Congenital anomolies other than <ardiovascular system
* Neurat tubl fl2fg6l5tearazt
o Situs inversus
e HydronePhrosis
c Double ureter
s Renal agenesis and.DYsPlasia
r HoloprosencePhalY
MISCELLANEOUS
Ferinatal asPhYxia
(hlpoxia) and/or a lack of perfusion
o perinatal asphlxia is an insult to the fetus or newborn due to lack of oxygen
(ischemia). Effects of perinatal asphyxia are :-
l) CNS : Hlpoxic ischmeic encephaiopathy, infarction, cerbral edema, seizures\"Mso'), hypotonia ot hypertonia
(generalized, involving all muscles simultaneouslyallMs03)), altereil sensorium(^"Mso')'
2) CVS : Myocardial ischemia, tricuspid insufficiency' hypotension'
3) Pulmonary : Pulmonary hypertension, pulmonary hemorrhage' RDS'
4) Renal: Acute tubular or cortical necrosis '
5) Adrenal : Adrenal hemorrhage'
6) Metabolic: SIADH, Hyponatremia, Hypoglycemia, Hypocalcemia, Myoglobinuria'
7) Integument : Subcutaneous fat necrosis'
8) HematologY: DIC.
g) Gastrointestinal : Perforation, ulceration with hemorrhage, Necrosis.
CneprsR. 3 Hewbornlnfant. .-..r. 1,,. .,,,.. ;: .. '
Hydrops fetalis
r Hydrops fetalis (fetal hydrops) is a serious fetal condition
characterized by abnormal accumulation of
more fetal compartments, including ascites, pleural effusion,
fluid in 2 or
pericardial effusion and skin edema.
o Important causes of hydrops are :_
1) Immune: Rh incompatability.
2) Non-immune: Twin-Twin transfusion, chorangioma ofplacenta, congenitalheartblockrcone(t0e),
0e)' cystichygroln4@omert
mediastinal teratoma, congenital infections (TORCH)
and. congenital ,ephrosi5ao-"aos).
Microcephaly
e Microcephaly is defined as a head circumference (occipitofrontal
circumference) that meastnes more than three
standard deviation below the meAn@NB 12) for age and sex.
r Important causes of microcephaly are :_
A) Primary (genetic)
i) Isolated: Autosomal recessive, autosomar dominant,
x-rinkbd.
ii) syndrome: Down syndrome (trisomy 21), Edward
syndrome (trisomy lg), patau syndrome (trisomy
cri-du-chat syndrome.
l3),
B) Secondary
i) Structurar defects: Neurar tube defects (anencephary,
encephalocele).
ii) Metabolic disorders: RhenylketonuriaarMse4),citrullinemia,
methylmalonic aciduria.
iii) congenital infections i RubeilqLrrMss4), cMy,HS{ toxoplasmosis, syphiris, varicelra.
iv) Teratogens: Alcohol, tobacco, cocaine, heroin.
v) others: Maternal diabetes, maternal phenylketonuria,
hypothy,oidism, hlpopituitrism, adrenal insufficiency.
C ria p t,g R :,s.:' N€nt.Or
(i) Commonlyby toxoplasmosis and CMV and (ii) Less commoniy by HSV and rubella.
o Hydrocephalus with intracerebral calcificationin a neonate with history of 'spiramycin' treatment of mother in
pregnancy suggest the diagnosis of congenital toxoplasmosis(AlrMs 11' At 0e) .
a) Macrocaphaly
b) Microcephaly
c) Dolchocaphaly
d) Plagiocephaly
Macrocephaly
o Macrocephaly is defined as an occitrtito frontal circumference greater than two standard (SD) above the mean@I
is) for age and sex (Note : Microcephaly is three standard deviation below the mean).
r Important causes are :-
l) Syndromes : Fragile-X syndrome, and neurocutaneous syndromes (Neurofibromatosis), tuberous scierosis, Sturge-
Weber.
ii) Increased CSF : Hydrocephalus, choroid plexus papillom6l{Atss).
111) Bone disease: Achondropiasia, osteogenesis imperfecta, osteopetrosis.
iv) Others: AV malformation, intracranial hemorrhage (subdural, epidural, subarachnoid), Thalassemia major,
, hlpervitaminosis-A, lead poisoning, pseudotumor cerebri, galactosemia, Canavan's leukodystrophy(AflMs08).
a) Microcephaly
b) Macrocephaly
c) Plagiocephaly
d) Dolichocephaly
Fetalalcohol syndrome \
r High level of alcohol ingestion in pregnancy can cause damage to fetus, known a s fetal alcohol syndrome. The harmful
effects may be due to alcohol itself or due to one of its breakdown products.
r Some evidence suggests that alcclhol may impair placental transfer of essential amino acids and zinc, both necessary
for protein synthesis, which may account for IUGR.
r Characterististics of fetal alcohol syndrome include : -
1) I(JGRarIMsoe) 5) Facial abnormalities
Cnaptrn' 3''Newborn Infant
2) MicrocePhalyGrrMsoe) 6) Minor joint anomalies
3) Congenital heart defects (ASD, V51l/utus ont
7) Hlperkinetic movements
4) MentalretardationattMsoe)
Note: Ihe fefus in ichthyosis appears grostesque and the appearance is called horleguin fefus. But, it is different from Harlequin color change.
Cephalohennatoma
o Cepholhematoma is a subperiosteal hemorrhage usually involving parietal and temporal bones. It appears within
12-24 hours. It is more common in forceps delivery, vaccum extraction and prolonged labor. It is soft and fluctuant
swelling with well defined margins.
o A cepholhematoma crossing the midline indicates underlying fracture of the skuli -+
fracture is linear not clepressed.
a It disappears between 2 week to 3 months(uPsceT).
a) Macrocephaly
b) Microcephaly
c) Cephalohematoma
d) None rr
murmur.
o Not a finding in a normal newborn : Central cyanosis (there is peripheral cyanosis).
s Newborn babies are able to breath and suck at the same time because of : High position of larynx.
x Reflexes pre*enf qf &rth :rRootinglsucking/swallowing reflexes, crossed extensor, moro! reflex, Assymelrlc tonic neckrefiex, graspreflex.
a Reflexes appear after birth: Symmetric tonic neck reflex, parachute reflex, landau reflex.
x' Parachute reflex disappsars af : Never iit remains throughout:life). . ,
* Persistence of moro's reflex is abnormal beyond the age of :6 month (morot reflex disappears at 6 months).
*',Refle*wltichfieve.r.recppears:Morosreflex .' , , ', ' .,
& Persistence of moro's reflex beyond 6 months indicates: Dysfunction of CNS (e.g. brain damage).
* unilatera! morob re{lex is seen in Erb's patly {Cu-Cu damage}, spastic hemiplegia,tracture of humerus or'clavicle, shoulderdislocation.
r
& Jaundice appearing within 24 hours of birth: Erythroblastosis fetalis (most common cause), infections, G6pD deficiency, hereditary
spherocytosis.
& PeripheralsmeqrofneonatewithABahemolyticdiseaseshows:Microspherocyte5.
& Drug which inqeases the risk of kernicterus in a child with hyperbitirubinemia : Sulfonamide.
* Not a late feature of kernicterus: Hypotonia (it is an early feature).
@ lmportant late features of kernikterus: Choreoathetosis, sensorineural deafness, upward gaze palsy,
mental retardation.
& Kernicterus is due to:High unconjugated bilirubin (not conjugated bilirubin).
@ Drugs used in treatment of hyperbilirubinemia/kernicterus: Barbiturates, metalloporphyrins (tin, zinc).
* Mechonism mainly resposnsible for reduction of bilirubin by phototherapy:5tructural isomerization.
@ Bronz-baby syndrome is due to: Phototherapy
* A child with hyperbilirubinemia, parameters measured should be:Total bilirubin and direct (conjugated) bilirubin.
& Not a cause of neonatal hypoglycemia: post-terminfant
@ lmportant causes of neonatal hypoglycemia: Prematurity,
RDS, maternal diabetes, asphp<ia, erythroblastosis (Rh incompatibility).
& Symptomatic neonatal hypoglycema should be managed by: IOyo dextrose.
& lmportant complications of neonate of diabetic mother: Hyperbilirubinemia, hypocalcemia, hypomagnesemia, polycythemia,
HMD,
TTN, CHD.
@ Not a complication of neonate of diabetic mother:Hyperglycamia (there is hypoglycemia).
@ Most specific fetal malformation in neonate of diabetic mother:Caudal regression syndrome.
& Type of hypoglycemia in neonate of diabetic mother: Nonketotic hypoglycemia.
& Most common cause of seizures in neonates of diabetic mother : Hypog lycemia (most common) followed by hypocalcemia.
& Maximum concentration of dextrose that can be given to neonate through periphera! lines:12.5o/o.
& Neonatal hyperglycemia is defined as: Blood glucose > 1 25mg/dl orlplasma glucose > 1 5gmg/dl.
& Neonatal hypogtycemia is defined as:Blood glocose < 4omgld l; or seru m g lucose < 35 mgldl between -3
1 hou rs of life, serum glucose
< 40 mg/dl between 3-24 hours of life, serum g*ucose < 45 mg/dl after 24 hours of life.
& Hypogtycemia in infant> 2 month o/d: Serum glucose < 54 mg/dl.
& Resolution of physiological umbilical hernia occurs at:1Oth week of gestation.
& lmportant drug causing neonatal respiratory depression: Opioids (morphine).
& Tests used to differentiate maternal from fetal btood : Alkali denaturation {Apt. test), and acid denaturation (kleihouer
betke) test.
& Causesofvomitinganfirstdayoflife:Aerophagy;esophagealatresia,faultyfeedingtechnique, amnioticfluidgastritts.
@ Best way to monitor neanate's breathing and apnea in incubator for preterm nonventilated baby : lmpedence technique.
a lnflation pressure required for first'inflation in a neonate : 25-40 cm H for > 1 .5 seconds.
,o
Organs palpable in a normal neonate: Liver, kidney and spleen.
& Common rashes in a newborn: Erythema toxicum (most common), acne neonatorum, transient pustular melanosis.
& M.C cause of respiratory distress in preterm neonate: Hyaline membrane disease.
& MC cause of respiratory distress in term or post-term neonate: Meconium aspiration syndrome.
& Heart rate in a normal neonate: l ZO-l40 per minute.
I Respiratory rate in a normal neonate:35-4ber miiute.
& Best method for transport of newborn with maintainance of temperature: Kangaroo Mother Care (KMC).
xxx
QUESTIONS
7. New born babies are able to breathe and suck at the a) Shivering
same time due to - (AIIMS Nov 10) b) Breakdown of brownfat with adrenaline secretion
a) Wide short tongue b) Short soft palate c) Universal flexion like a fetus
c) High larynx d) Short pharynx d) Cutaneous vasoconstriction
18. Following features may be seen in cold injury of
PRIMITIVE RELFEXES neonates except - (Ar ee)
a) Bradycardia
8. Which of the following reflexes is not present at b) Uncontrolled shivering
birth- (AilMS May 07, At 07) c) Scleroma
a) Asymmetric Tonic Neck Reflex d) Metabolic acidosis
b) Morot Reflex
c) Symmetric tonic neck reflex LOW BIRTH WEIGHT
d) Crossed extensor reflex
9. Swallowing breathing reflex - not seen in fetus for - 19. Small for date baby is - (All India Dec. 11 Pattern)
(All lndia Dec15 Pattern) a) < 10 percentile for the gestational age
a) 14 weeks b) < 50 percentile for gestational age
b) 12 weeks c) < 2000 gm
c) 16 weeks d) < 2500 gm
d) Appear in all above period '
20" Extremely low birth weight baby-
10. Persistant Moro's reflex at 6-7 months indicates - t' (All India Dec.lj Pattern)
(PGI 02, DPG oe) a) < 2.5 kg b) <2kg
a) Normal child b) Brain damage c) < 1.5 kg d) <lkg
c) Hungry child d) Irritable child ,1 IUGR is caused by all except - (NEET Dec.12 Pattern)
1I. Parachute reflex disappear at- (All lndia Dec.13 Pattern) a) Diabetes b) Alcohol
.r;.,;. .,t ::.:
''
:iii{dit
smokrng
c) Smoking
cJ d)
Chronic renal failure c) 36
22. d) 72
For a term small for date baby, true is _ (ArrMS May 9s)
31. Most commoa cause of sepsis in Indiawithin 2
a) No nipple nodule
b) No palmar/plantar crease
months- (AIIMS Nov 09)
a) H influenza
c) Weight less than lOth percentile b) E.coli
d) Hperbilirubinemia
c) Coaguiase positive staph aureus
23. All of the fr:Ilnwing are features of prernaturity in a d) Group B streptococcus
neonate, except - (All India Dec. 15 Pattern) 32.
A 7 day old iafant develops syrnptoms of neoaatal
a) No creases on sole
septicemia. Most likely cause is _ (Ar
b) Abundantlanugo s8)
a) Local nursery environment
c) Thick ear cartilage
d) Empty scrotum
b) Infection through umblical cord
c) Exclusivelybreast fed baby
24. A premature infant is more likelythan a full term d) Infection by GIT bacteria
infant to - (AilMS 80, pG Bs) JJ. Most corn:aon caus€ of Ne{rnatal sepsis in hospital
a) Suffer fromjaundice ofhepatic origin
in India is ^
b) Maintain in normal body temperature in a cold @rrMS May 07)
environment
a) Escherichia coli
a) HMD
40. \{hich of the following d*es not indicates respirato* b) Diphragmatic hernia
neonate? (CETNou' 12Pattern) c) Pneumothorax
ry distress in
a) Wheeze d) Meconium aspiration syndrome
b) Grunt 48. A new born baby has been referred to the casualty as
c) Retraction a case of congenital diaphragmatic hernia. The first
d) Tachypnea clinical intervention is to - @IIMS May 03)
b) Meconium aspiration
a) Glucose
c) Neonatal pulmonary alveolar prciteinosis
b) Dexamethasone
d) Diffuse herpes simplex infection
c) Calcium gluconate
d) Normal saiine
RESUSCITATION
82. Grimace with APGAR score - (All rndia Dec15 pattern)
a)0 b)1
74. Meconium aspiration is done for
c)2 d)3
3 times but no
breathing occurs. Next step in resuscitation would 83. Which is not a component of APGAR Score -
be- (At e7) (All India Dec.14 Pattern)
a) Chest compression a) Colour ofthe body
b) Orinhalation $
b) Muscle tone
c) Bag & mask intubation c) Heart ratelminutes
d) Trikling of sole d) Respiratory rate per minute
75. A 3 hours old neonate with apnea is on bag and 84. Which of the following is not true about newborn
mask ventilation for last 30 seconds, now showing assessment - (AIIMSNov 11)
spontaneous breathing with heart rate 110/min. The a) APGAR at7 minindicates neonatal mortality
next step should be - (Ar e2)
depression
b) APGAR at 1 min, indicators for neonatal
Cnaprnn 3 Newborn lnfant
b) Gilbert's syndrome
c) Not required any treatment
c) Criggler Najjar syndrome I d) All oTabove
d) Criggler Najjar syndrome 2
98. True about criggler najjar type-Il syndrome is -
(All India Dec. t4 Pattern)
90. A child has bilirubin of 4 mg. Conjugated bilirutrin
a) Diglucuronide deficiency
and alkaline phosphatase are normal, trile salts and
b) Dominant trait
trile in urine are atlsent. However urobilinogen in
urine is raised. What is the likely diagnosis -
c) Kernicterus is seen
d) Phenobarbitone not useful
@IIMSNov0l)
a) obstructivejaundice 99. A case of jaundince with 50% direct bilirubin, other
b) Rotor's syndrome LFTs normal. Diagnosis is - (ArrMS Nov 0e)
c) Biliary cholestasis a) Rotor syndrome
d) Hemolytic jaundice b) Gilbert syndrome
91. A 5-years old male child presentgwith episodic
c) Glucuronyl transferase deficiency
d) Primary biliary cirrhosis
anaemia and jaundice since birth. He is least likely
to have which of the following - (AIIMS Nov 11) 100. Unconjugated hyperbilirubinemia is seen in -
a) Hereditary spherocltosis (All India Dec.13 pattern)
b) Sickle cell anemia a) Rotor syndrome
c) PNH b) Dubin-fohnson syndrome
d) G-6-PD deficiency c) Biliary atresia
d) Crigler-Najjar syndrome
92. |aundice at birth or within 24 hours of birth is com-
monly due to - (Ar e5)
101. Causes of conjugated hyperbilirubinemia is -
a) Erythroblastosis (NEET Dec.12 pattern)
c) Birth asphyxia a) 25 mm of Hg
d) Intraventricularhemorrhage b) 25 cm of HrO
c) 25 cm of Hg
d) 25 mm of HrO
MISCELLANEOUS
131. Vomiting on the first day of baby's life may be
122, Kangaroo mother care-True is - (All India Dec15 pattern)
causedbyallofthefollowingexcept - (Ate7)
IIN
T
ANSWERS
NORMAL NEWBORN
L Ans. is 'c' i,e,,28 days of life fRef: O.P, Gkai }th/e p. 124 6 7h/e p. 96]
o From birth to under four weeks ofage (< 28 days), the infant is called neonate.
2. Ans, is 'c' i.e., Central cyanosis lRef : O.P. Ghai 6th/e p. 145 & Vhle p. 11jl
r There is peripheral cyanosis (not central cyanosis).
o Length is approximately 50 cm and the attitude of body is in flexion (not extension).
4. Ans. is 'c' i.e., No specific therapy fRef: O.P. Ghai 6thle p. 1471
r Menstural-like bleeding (vaginal bleeding) may occur from the third to seventh day of life.
o This is attributed withdrawl of maternal hormones after birth.
o The bleeding would subside after 2-3 days and no therapy is required.
5. Ans. is t' i.e., Lumbosacral area; 'd' i.e., Leg & t' i.e., Thigh lRef: Netson l8'k/e p. 26621
o Mongolian spots are blue or slate - gray macular lesions which occur most commonly in pre-sacral area (mainly in
lower back dt buttoclcs) but may be found over the posterior thighs, legs, and shoulders.
6. Ans. is'c'i.e., Leaving it alone [Ref: O.P. Ghai 6'h/e p. 146, 147]
o Hymenal tags around margins of hymen is normal finding.
7. Ans. is t' i.e., High larynx lRef : Gray's 40th/e p. 584; Andrew Gr*yson p. 821
o The infant larynx differs markedly from its adult counterpart. Although it is about one - third adult size, it is
proportionately larger. Its lumen is short and funnel - shaped and disproportionately narrower than that of adult. It
lies higher in the neck than the adult larynx. At rest, the upper border ofthe infant epiglottis is at the level ofthe
second or third cervical vertebra; when the larynx is elevated, it reaches the level ofthe first cervical vertebra. This
high position enables an infant to use its nasal airway to breath while sucking.
PRIMITIVE REFLEXES
8. Ans. is t' i"e., Symmetric Tonic neck reflexes lRef : Nelson 18'h/e p. 2$9; A.P. Ghai 8'h/e p. 142 {z
7h/e p. 114; Meharban singh 3'd/e p. 71; Chedda 3'd/e p. 31)
A. Reflexes present at birth
1. Rooting, sucking & swallowing reflexes 4. Crossed extensor
2. Moro reflex 5. Assymmetric tonic neck reflex
3rfalmar grasp (grasp reflex)
B. Reflexesappearafterbirth
1. Symmetric tonic neck -+ appears at 4-6 months
2. Parachute reflex -) appears at 8-9 months
3. Landau reflex -> appears at 10 months
Absent
Abnormal persistence
'l +
Dysfunction of CNS or pNS
Dysfunction of CI\S
13. ,dns" is'b'i,e., Cr-Cu[Ref: o,p. Ghai 6thle p. 146; Nelson lg,h/e p. 2439, z2l)
o Unilateral Moro,s reflex is seen
in :_
t E-rbspalsy (Cs-Cu) damage
t Fracture of humerus or clavicle.
I Spastic hemiplegia
t Shoulder dislocation
o Exaggerated Moro,s reflex is
seen in _ cerebral damage.
HYPOTHERMIA
t7. Ans. is 'a'i.e., ShiveringfRef: O.p. @tai gth/e p. l4j 6 Vh/e p. t t5]
"Always remember that newborn
cannot produce heat by shivering),
xs' Ans. is'b'i.e., Uncontrolled shivering fRef: o.p. Ghai B,h/e p. 143 6 vh/e p. 118]
"N e o n at e s Re sp o n d b y N on- shiv er ing thr mo gene sis',.
19. Ans. is 'd i.e., < tr 0 percentile for gestational age lRef o.p. Ghai 6th/e p, 136 d, Th/e p. 1291
o Appropriate for gestational age (appropriate for date)
Babies with birth weight ranging between 10th to 90th percentile on such a chart are considered
appropriate for date.
o Small for gestational age (small for date)
Babies with birth weight less than 10th percentile are categorized as small for dates.
r Large for gestational age (large for date)
Babies with birth weight more than 90th percentile are categorized as large for date.
21, Ans. is 'a'i.e., Diabetes [Ref O.p" Ghai B,h/e p. 155 6 f,/e p. 1281
o In DM, there is large for date baby (not small for date : IUGR). Other three are causes
of IUGR.
)) Ans. is t' i.e., weight less than l0th percentile [Ref o.p. Ghai 8'h/e p. 138-140 6 Thle p. 109]
o First let me differentiate the following three terms
i) Low birth weight neonates
ii) Preterm infant (Premature infant)
iii) Small for gestational age (small for date)
i) Lowbirth weight
r
Any neonate weighing less than 2500 gms at birth irrespective of the gestational age.
ii) Preterm infant (premature infant)
r Any neonate born before 37 weeks of gestation irrespective of the birth weight.
r Because birth weight is a function of gestation, a preterm baby is expected to have less weight.
iii) Small for date (IUGR)
r Babies with a birth weight less than 10 percentile for that gestational age. These may be preterm (born before
37th week) or term (born between 37 to 42 weeks).
o So, both preterm infant and small for date neonate have low birth weight.
pI='ooo*too=r.o
(s0)'
32-34 weeks
tr4week;l
J
I nititate b r eas t fe edin g
I
V
Observe iJ
1. Positioning and attachment are good.
2. Able to suck effectively and long enough
(about 10-15 min)
J
Observe i/
l. Accepting well without
spilling/coughing
H
2. Able to accept adequate amount
I
+
Start feed by OG/NG tube
spoon/paladai feeding I
Y
Observe if
1. Vomiting / abdominal
distension occurs
l7&-..k.1
2. The prefeed aspirate exceed
>25%o of feed volume
I
Gastric tube feeding
Coming to question
o Best answer of this question is feeding by spoon or paladia. However these are not provided in options.
o Amongst the given options orogastric tube is the answer of choice.
30. Ans. is 'd' i.e., 72 hours 7/e p. t36l
fRef: Ghai
o Early onset neonalal sepsis occurs within 72 hours of life.
31. Ans. is 'b' i.e., E.coli [Rel A.F. Ghai |th/e p. 163 6 7h/e p. 136; Care of the new born 6th/e, Meharban Singhl
New born sepsis can be classified into early onset sepsis-occurring within 72 hours and late onset sepsis occuring after
,/2 hours-
Early onset sepsis -
r It is caused by organisms prevalent in the genital tract or in the labor room and maternity operation theatre.
o In the west it is mostly caused by group B streptococcus and E.coli.
o In our country it is mostly due to gram negative organisms-E.coli, klebsiella and enterobactor sp.
r
Majority of the neonates with early onset sepsis manifest as respiratory distress due to intrauterine pneumonia.
Late onset Septicemia :
o Late onset septicemia is acquired as nosocomial infection from the nursery or lying in ward.
o The onset is delayed for 48-72 hours after birth.
r In most cases symptoms appear by the end of first week or during second week of life.
o About two third cases of late onset septicemia are caused by gram negative bacilli, Klebsiella pneumonea, entero
bacteria, E.Coli, pseudomonas aeruginosa, alkaligenese fecalis, salmonella tyhimurium, proteus, citrobacter and
serratia.
32. Ans. is 'a' i.e., Local nursery environment [R4 O.p, Ghai gth/e p. 163 & Th/e p. 1361
. Late onset sepsis is caused by organisms of the external environment of home or hospital and the infection is
transmitted most frequently by the hands of the care-provider.
33. Ans" is 'b' i.e., Klebsiella lR ef : OP Ghai 8th/e p. 163 dz Vh/e p. 1i6; Meherbsan Singfi 6th/e p. 209 and lournal of past-
graduate medicine (IPGM)I
t Most common cause of neonatal sepsis in hospitals in India is -+ Klebsiella
t Most common cause of neonatal sepsis in hospitals across the world is -+ E. coli
o Most common cause of overall neonatal sepsis -+ Group B streptococci
34. Ans. is 'a' i.e., Genital tract lR.ef: Nelson lBth/e ch. lB3l
. Gram positive CAMP positive coccus is group B streptococcus (Str. agalactiae), the most common cause of neonatal
r mepingitis.
------...:tt"habitat in human hosts is female genital tract and rectum.
35. Ans. is 'H i.e., Neutrophilia lRef: O.P. Ghai 8th/e p. 164 & Thle p. 137; Nelson t6h/e p. 54Bl
:1!=eti:tr:ie$as.slra[s-ai1
inflammatory response ERS is lncreased
36. Ans. is 'a' i.e., Group B streptoco ccifRef: O,p. Ghai 8th/e p. 163 6 Vh/e p. 1j6)
J/. Ans. is '-o" i.e., Streptococcus agalactiae [Rel O.P. Ghnl Sth/e p. 16j 6 Vh/e p. 136; Nelsan lrth/e p. Z4\
38. Ans. is 'b' i"e., E. coli [Rel Nelson l|th/e p. 747]
r E. coli & streptococcus agalactie (group B streptococci) are the two most common cause of neonatal sepsis and
meningitis.
39' Ans. is'c'i.e., Ampicilrin and Gentamicin
[Rl o.p. Ghai Bth/e p. 171 6 p/e p. r38;]
r Antibiotic therapy for neonatar pneumonia incrudes ampicillin prus gentamycin.
RESPIRATORY DISTRESS
4. Audible grunting
5. Cyanosis
41. Ans. is 'd i.e.,Apnea [Re! O.p. Ghai dth/e p. 169 6 Zh/e p. 116]
e Apnea may be defined as _
i) cessation of respiration for 20 seconds with or without bradycardia
and cyanosis.
49. Ans. is 'H i.e., Put a nasogastric tube {Ref. see previous expranatian}
r Mediastnal deviation, scaphoid abdomen with respirator-y distress suggest the
diagnosis of congenital diaphragmatic
hernia (CDH).
o The resuscitation of CDH patient consist of :
a) Stabilization by mechanical ventilation with 100% 02.
b) Nasogastric suction
r This child has already been intubated.
r Now nasogastric suction should be done to aspirate swallowed air and to prevent
distension of the herniated bowel
which would further compress the lung.
I
Method to confirm tracheal intubation
l. Tests which suggest tracheal placement (not confirmatory)
r Symmetrical Bilateral chest movements when reservoir bag is squeezed.
r Equal breath sounds over lung fields when reservoir bag is squeezed-
r Absence of gurgle over lung fields when reservoir bag is squeezed.
r Misting of the tube (water vapour deposition) during expiration.
: Feeling of correct lung compliance and refilling of bag during expiration.
2. ConfirmatorY tests
r Capnography -+ Measures end tidal CO2 in expired gas.
r Esophageal detector device.
o None of these method has been mentioned in the options of this question.
r Amongst the given options, best course of action is to remove the tube and reattempt intubation : -
"If there is any doubt about tube placement the tube should be removed" --- Lee'
r Here "removal of tube and reattempting intubatiori' is not provided amongst the option.
o The next best stept is to decompress the distended stomach by nasogastric tube insertion.
So, the same question has three different answers depending on the options provided :-
1) Confirm the position of ET tube (not by chest x-ray) -+ Best answer
ii) Removal of the tube and reattempting intubation -+ If previous one is not provided as an option.
111) Nasogastric tube insertion -+ lf previous two are not provided in option.
Note : In previous three explanations I have explained the management protocol of CDH in which intubation has
already been used. But you should keep in mind that nasogastric suction should be the flrst procedure except
in
Apnea, cyanosis and respiratory desease, where intubation is preferred initially.
53. Ans is'-o- i.e., Delay in emergent surgery fRef: Nelson 18th/e p. 748; Fundamentals of pediatric Surgery p.
535,5361
r Timing of surgical repair has gradually shifted from an emergency repair, to a policy of stabilization using a variety
ofventilatory strategies prior to operation.
o Current recommenJation is to adopt a conservative approach and delay surgical repair of the CDH until the infant
stablizes from a hemodynamic and respiratory point of view'
"If there is any doubt about tube placement the tube should be removed" --- Lee.
Signs of CDH
(Scaphoid abdomen, mediastinal shift)
lmmediate ET lntubation
Surgery as required
52. Ans. is t'i.e., Nasogastric fube inserti onfRef: See above explanation)
r Here "removal of tube and reattempting intubation" is not provided amongst the option.
o The next best stept is to decompress the distended stomach by nasogastric tube insertion.
So, the same question has three diferent answers depending on the options provided :-
1) Confirm the position of ET tube (not by chest x-ray) -+ Best answer
ii) Remoyal of the tube and reattempting intubation -+ lf previous one is not provided as an option.
111) Nasogastric tube insertion -+ If previous two are not provided in option.
Note : In previous three explanations I have explained the management protocol of CDH in which intubation has
already been used. But you should keep in mind that nasogastric suction should be the first procedure except in
Apnea, cyanosis and respiratory desease, where intubation is preferred initially.
53. Ans is '-o- i.e., Delay in emergent surgery lRef: Nelson 18th/e p. 748; Fundnmentals of pediatric Surgery p.
535, 5361
r Timing of surgical repair has gradually shifted from an emergency repair, to a policy of stabilization using a variety
ofventilatory strategies prior to operation.
r Current recommendation is to adopt a conservative approach and delay surgical repair of the CDH until the infant
stablizes from a hemodynamic and respiratory point of view.
.1!$*aa*,!itq',
r These factors are :-
i) Pulmonary hypoplasia (most important)
ii) Pulmonary hlpertension (2nd most important)
B) Secondary or relative predictors (diagnostic/clinicai)
a These poor prognostic factors are:
a) Antinatal
i) Detection at an early gestational age (< 24 wks)
ii) Associatedextradiaphragmatic congenital anomalies
iii) Liver herniation into thorax (Liver above diaphragm)
v) Stomach herniationinto thorax (Stomach above diaphragm)
vi) Presence of poiyhydraminios
vii) Small lung to head circumference ratio (LHR ratio)
viii) Small fetal abdominal circumference (< than 5th percentile)
b) Postnatal
i) Early age (< 6 hours) ofpresentation
ii) PO, and PCO, unresponsive to ventilation
iii) Need for extracorporeal membrane oxJgenation (ECMO)
c) Side ofdefect
i) Right sided defect
54. Ans. is'a'i.e. Pulmonary hlryertension IRel Sabistan 18th/e p. 20731
"Compression of the lung results in pulmonary hypoplasia involving both lungs, with the ipsilateral lung being the
most affected. In addition to the abnormal airway development, the pulmonary yasculature is distinctly abnormal in
that the medial muscular thickness of the arterioles is excessive and extremely sensitive to the multiple local and
systemic factors known to trigger vasospasm. Thus, the two main factors that affect morbidity and mortality are
p ulm o n ar y hy p opla si a and p ulmon ar y hy p er ten si on, " - S ab i st o n 1 8th / e p 2 0 7 3
55. Ans. is t' i.e., Prematurity lReJ: Nelson !.9't'/o p. 731, 7321
o HMD always occurs in preterm babies often less than 34 weeks of gestation.
55. Ans. is t' i.e., }IMD lRef : O.P. Ghai 9th/e p. 169 & 7h/e p. 143; Nelsan tVth/e p. 7jtr)
o Surfactant deficiency (decreased production and secretion) is the primary cause o/RDS.
57. Ans. is'a' i.e., In ttre flrst 6 hours of life lRef : A,P. Ghai 9th/e p. 169 6 Vh/e p. 1.43; Nelson IBth/e p. 7321
c Respiratory distress occurs within the first 6 hours of life.
58" Ans. is 'b' i"e., Hyaline membrane disease [Ref: A.P. Ghai ?th/e p. 169 6 Vh/e p. ]43; Nelson lYthle p. Z3l, Zj2l
Respiratory distress in a preterm infant and X-rays showing ground glass appearance with air bronchogram suggest
the diagnosis of neonatal respiratory distress syndrome (RDS) also called hyaline membrane disease.
"Hyaline membrane disease is the commonest couse of respiratory distress in a preterm neonate". Ghai
-
About other options
o Meconium aspiration sl, rdrome usually occurs in full-term or post-term newborn.
o ARDS is adult respiratory distress syndrome.
59. Ans. is 'a' i.e", Flyaline membrane disease {Ref: Ghai Vh/e p. l4jl
60. Ans. is 'b' i.e., Air bronchogram on chest x-ray {Ref : Nelson 18th/e p, 7fi; aP Ghai Bth/e p. 169 6 Vh/e p. 143)
The chest x-ray of an infant with RDS is characterized by atelectasis, air bronchograms, and a diffuse reticular-
granular pattern commonly referred to as 'ground glass'i The chest x-ray may progress to a complete "white out"
with severe disease.
About other options
r Antenatal corticosteroids are given in pre-term (pre-mature) pregnancies not in term pregnancies. Further, antenatal
corticosteroids are given to prevent RDS (HMD) -> after antenatal corticosteroids administration, risk of HMD is
reduced.
. Respiratory distress occurs within first 6 hours.
r HMD occurs in pre-term neonate.
a1. Ams, ic i,*., LIS uafi*r {Ref : {},ff" {itr*i Vtt'lt. y, l{t* ,*. Vt'le p, t4,ll
"d
Prenatal diagnosis o[ HMD can be made bv -
1) Lecithin / sphingomyelin (L/S) ratio in amniotic Jluid -+ LIS ratio > 2 indicates adequate lung maturity.
2) Shake test -+ Amniotic fluid or gastric aspirate is mixed with absolute alcohol and shaken for 15 seconds and
allowed to settle. Copious bubbles are formed in the presence of adequate surfactant indicating extent of lung
maturity.
62, Ans. is t' i.e., Phosphatidyl glycerol estimation is a reliable method of diagnosis [Ref : O"F. Ghai 8th/e p. 169
dz Vh/ep. 143-144)
o In HMD surfactant is reduced and its measurement can be used for diagnosis e.g. in shake test.
r Constituent of surfactant are - dipalmitoyl phosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins
(surfactant proteins -+ SPA, SPB, SPC, SPD) and cholesterol.
63. Ans. is 'd' i.e., Is treated by administrating 100% orygen [Ref : A.P. Ghai 9th/e p. 169 6 Vh/e p. 143-144]
o Premature infants receiving high concentrations ofoxygen may deveiop retrolental fibroplasias. So generally oxygen
tension is kept approximately 90o/o and not 100%.
ff. Ans. is 'd i.e., CPAP lRef: Neonatology by Eval4th/e p. 591
r Specific treatment for HMD is intratracheal surfactant therapy. This therapy requires endbtracheal intubation, which
also may be necessary to achieye adequate ventilation and oxygenation.
o Less premature infants (those > 1kg or > 28-30 weeks gestation) and those with lower O.requirements (FiO2 <
40 - 50%) may respond well to supplemental A, alone or to treatment with nasal continuous positive airway
pressure (CPAP).
65. Ans. is t' i.e., Prevents hlperbilirubinernia lRef : O.P Ghai ?'h/e p. 170 & 7h/e p. 144)
Prevention of HMD
r Prenatal steroids are effective in preventing HMD.
o Steroids acts by enhancing lung maturity.
Benefits
r 50 percent reduction in the incidence of respiratory distress syndrome (RDS)
c 5O percent reduction in the incidence of intraventricular hemorrhage (lVH)
e 40 percent reduction in mortality.
lndications
r All mother at risk of preteim delivery between 24 and 34 weeks of gestation.
r Cases of preterm premature rupture of membrane at less than 32 weeks of gestation
in the absence of overt clinical chorioamnionitis
Contraindicotion
a Clinical chrioamnionitis. (Maternal hypertension and diabetes mellitus are no
contiaindications. Careful monitoring and management of hypertension and hy-
perglycemia should be ensured).
Treatment schedule
r Inj. Betamethasone 12 mg lM evety 24 hours, 2 doses (preferred).
* Inj. Dexamethasone 6 mg tM every '12 hours,4 doses (only if betamethasone can
not be arranged).
Timing of effect
r Optimal effect occurs after 24h of initiating treatment.
c The effect ofone course lasts for 7 days.
uh'
6&,
'&ns.
l$ i,e,, tr? mg eveyy 24 h*qrg {fl,ef : See oLtove cxplanation)
o/. Ans. is 'd i,e,, FRC is snialler than closing yolume lRef : Handbook of pediatric intensive care l"t/e p. 1j8|
"Hyaline membrane disease reduces compliance and causes a fall in FRC (to levels below the normal closing yolume
of the lung)". -- Handbook of pediatric intensive care
o Respiratory distress occurs within.first 6 hours.
o HMD occurs in pre-term neonate.
6t. &l*s. 1s "lt i.*,, X,15 r*tiey {t4.{"{ : t}"t!. ti&a*i ttt,/r p. I {i9 ,$, 7tt'/* yt, I 4 4}
62. Ans. is'c'i.e., Phosphatidyl glycerol estimation is a reliable method of diagnosis [Ref : O.P. Ghai *thle p. 169
dr 7h/e p. 143-1441
r In HMD surfactant is reduced and its measurement can be used for diagnosis e.g. in shake test.
o Constituent of surfactant are - dipalmitoyl phosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins
(surfactant proteins -+ SPA, SPB, SPC, SPD) and cholesterol.
63. Ans. is 'd' i.e., Is treated by administrating 100% oxygen lRef : O.P. Ghai 8th/e p. 169 6 7h/e p. 14i-1441
o Premature infants receiving high concentrations of oxygen may develop retrolental fibroplasias. So generally oxygen
tension is kept approximately 90o/o and not 100%.
64. Ans. is 'a' i.e., CPAP lRef: Neonatology by Eval4th/e p. 591
r Specific treatment for HMD is intratracheal surfactant therapy. This therapy requireq endotracheal intubation, which
also may be necessary to achieve adequate ventilation and oxygenation.
o Less prcmature infants (those > 1 kg or > 28-3A weeks gestation) and those with lower O, requirements (FiO2 <
40 - 50o/o) may respond well to supplemental O, alone or to treatment with nasal continuous positive airway
pressure (CPAP).
65. Ans. is 'c' i.e., Prevents hyperbilirubinemia [Ref : O.P. Ghai 8th/e p. 170 6 Vh/e p. Ma)
Prevention of HMD
r Prenatal steroids are effective in preventing HMD.
r Steroids acts by enhancing lung maturity.
Benefits
e 50 percent reduction in the incidence of respiratory distress syndrome (RDS)
f 50 percent reduction in the incidence of intraventricular hemorrhage (lVH)
I 40 percent reduction in mortality.
lndications
o All mother at risk of preterm delivery between 24 and 34 weeks of gestation.
c Cases of preterm premature rupture of membrane at less than 32 weeks of gestation
in the absence of overt clinical chorioamnionitis
Controindicatio
q Clinical chrioamnionitis. (Maternal hypertension and diabetes mellitus are no
contraindications. Careful monitoring and management of hypertension and hy-
perglycemia should be ensured).
Treatment schedule
e lnj. Betamethasone 12 mg lM every 24 hours, 2 doses (preferred).
. lnj. Dexamethasone 6 mg lM every 12 hours, 4 doses (only if betamethasone can
not be arranged).
Timing of effect
a Optimal effect occurs aftet 24 h of initiating treatment.
a The effectofone course lasts for 7 days.
{:t{x, A&s, ,s
rt:u'
i,*,, n } lug *veyy A4, k*urs lii,.cf' ; See ll;i:,vr tt:flttuttlianl
67. Ans. is 'd i.e., FRC is smaller than closing yolume [Ref : Hand book of pediatric intensiye care l't/e p. 138f
"Hyaline membrane disease reduces compliance and causes a fall in FRC (to leyels below the normal closing yolume
of the lung)" Handbook of pediatric intensive care
--
Ans. is 'b' i.e., Theophylline use [Rel: A.P. Ghai Sthle p. 171 6 Vh/e p. 146; Nelson l1,t,/e p. 737, 73g1
Bronchopulmonary dysptasia {BPD}
o BPD is a resuit of lwng iniury in infants requiring mechanical ventilation and suppiemental crxygen.
e Nlost of the children with BPD are premflture and have hyaline membrane disease. But, BPD can also occur in fultr
term newborns with meconium aspiration or persistent pulmonary hlpertension.
Pathogenesis
o The premature lung makes insufficient ftrnctional surfantant and the antioxidant defence mechanisms are not
sufiiciently mature to protect the lung from the toxic oxygen metabolites generated from oxygen therapy.
Premature newborn
J
lmmature lung (.f surfactant)
.t
Hyaline membrane disease
Jr
Oxygen therapy to newborn
Alveolar collapse T
Generation of toxic oxygen metabolites
(atelectotraiuma)
j J
Oxidant damage to lung because in prernature
Ventiiator induceci
newborn the antioxidant defence mechanisms
overdisiension
(volutrauma) are not sufficiently mature
J
Pulmonary edema, lnflammation & hypercellularity
followed by fibrosis and repair
J
Bronchopulmonary dysplasia
tLl ,1.-:"r-*. ir 'a' i.e", 3{itr{3Y,P'* i.?.':i: \e{s*rt l#'i':* {.-i;,:::ttr ii}i.i1:
SevereG,,3,
Supplement Or(for 28 days) Supplement O, (for 28 days) Supplement O, (for 28 days)
and and and
< 32'wereks GA:at birth, r, 'Br,eatlinE room airat36weeks Breathing with < 307o O, at Breathing > 3oo/o O, and/or
36 week corected',GA of at positive pressure ventilotion
, . . ,
-,:,, ,,,,. ., iwhichever.comes first). ,
discharge (whichever come (PPvltn'r) at 36 weeks
first). corrected GA or at discharge
(whichever come first).
:.
,
..1,'
: 32 weeks GA at birth Breathing room air by 56 days < 30olo O, by 56 days postnatal Breathing > 30o/o O, and/or
postnatal age or at discharge age or at discharge (whichever positive pressure ventilation
(whichever comes fi rst). comes first). (PPV) by 56 days postnatal
age or at discharge (whichever
comes first).
GA : gestational age
r The baby in question falls in category < 32 weeks gestation age at birth.
r Sirryly looking at question, answer seems to be sever BPD as mechnnical ventilation (ptositive pressure ventilatian)
orrX:., in diagnostic criteria of sever BPD.
l::rs iar:luded
e But, this question is not as simpie as it is looking. It is tricky one.
o In baby with > 32 gestation age at birth, we will have to see the respiration at 36 weeks corrected gestational age -
r This ba\ born at 27 weeks of gestati6n and required mechanical ventilation for 4 more weeks, i.e. upto 31 weeks
was
corrected gestational age. After that he maintained at room air. Thus, at 36 weeks corrected gestaional age, baby is
breathing at room air + diagnostic criteria of mild BPD.
:0. Ans is t' i.e., Elective caesarean section lkef. O.P. Ghai */e p. 171 & 7e/e p. 145; Variaus artides af Abs & Gynaej
o In text books, both elective caesarian section and normal preterm or term vaginal delivery have been mentioned as
risk factors for transient tachypnea of newborn.
e But the best answer is caesarian section -
"Delivery by caesarian section and gestational age are the risk factors for TTN". Articles Obs & Gvnae
-
7 L. Ans. is 'c' i.e., Prominent horizontal fissures lRef : A.P. Ghai */e p. l7I & 7/e p. 146; Nek*n 18*le p" 741]
r The lungs are generally clear withoui rales or rhonchi and chest roentgenogram shows
t Prominent pulmonary vascular markings - Overaeration
t Fluid lines in the fissure : Flat diaphragms
- Prominent inter lobar fissure s Occasionally pleural Jluid.
72. Ans" is t' i"e., Interlobar fissure effusion lRef : O"F" Gk*i */e p. 171 {z Tele p. 146; Nekar' 1*/e p. 741}
73. Ans. is t' i"e., Neonatal pulrnonary alveolar proteinosis f&ef : Nekon 18"1e p" 1821!
"Respriratory distress in an infant along with a positive family history of similaily affected newborn infants
strongly suggests, pulmonary alveolar proteinosis".
RESUSCTTATION _ _ __
74. Ans. is 'd' i.e., Trikling of sole lRef: A.P. Gb*i */e p. 128 & flle p. 98-99]
r After suctioning, the baby should be dried by using pre-warmed linen to prevent heat loss.
r A brief tactile stimulation in the form of flicking the soles or rubbing the back may be provided in case of non-
establishment of good respiratory efforts.
75. Ans. is "d i.e., Discontinue ventilation [Re, O.P" Ghai 8*/e p. 127 {r */e p- 99
}{.A"TEB
er5{"tsctTATION
i.e., Triklicg of sole lkef: A"p' *hai p' & Ple p' 9s-991
74. Ans. is ? Sele 12s
usjng pre-warmtd
r After suctioning, tnJbaUy shoul<i be dried-bJ
"i:-1-1"- Y;t^t:::,t]::l:i:
RTSUSCITATION
74. Ans. is lf i.e-, Trikling of sote [Ref A'P' Ghai */e p" 12s e f
p' 9s-991
le
o Clearance of meconium
o Active breathing or crying
o Good muscle tone Routine care
o Color -+ Pink
o Term gestation
lnitial steps
o Provide warmth
o Positioning
o Good muscle tone
o Clear airways + suctioning
o Dry stimulate -+ flicking sole or rubbing back
r Orif necessary
I
Supportive care
HR>100&Pink
Apnea or
HR < 100
Ongoing care
HR>100&Pink
76- Ans is'b' i.e., Ist mouth suctioning done & 'c' i.e.,Max. length of nasal suctioning is upto 3 cm and mouth
suctioning is upto 5 cmlRef: A.P. Ghai 8th/e p. 128 6 Vh/e p. 98-994ganual of neonatatiare p" 68, 3S5l
Suctioning during resuscitation "
L
j] ]. ]: i,:,]i,..,,ji....-:11:..,i i,i. '',: ]v
-8. Ans. is '* i.e., Check pulses lRef: O.P. Ghai 8'h/e p. 126 & Vh/e p. 1001
o After airway has been opened and two rescue breath! provided, determine the need for chest compression. For
this check the pulse in carotid (in children) or branchial artery (in infants).
r If the pulse is not palpable or heart rate is <60/min, begin chest compression.
-9. Ans. is 'c' i.e., Diaphragmatic hernia lRet O.P. Ghai 9th/e p. 129 (t Vh/e p. 100, 1537
r In diaphragmatic hernia, the abdominal contents herniating into thoracic cavity have already comprornised venti-
lation.
r Giving bag and mask ventilation to this patient will worsen the condition of the patient as air will also enter in the
stomach and further compress the lungs.
o Indications of Bag and Maskventilation.
t Bag and mask ventilation is indicated if even after tactile stimulation.
a) Theinfantis apneic or gasPing
b) Respiration is spontaneous but heart rate is below 100 beats/minute.
Remember
Bag and mask ventilation causes abdominal distention as air or oxygen not only enters the lung, but also escapes
into the stomach via esophagus. Distended stomach presses on the diaphragm and compromises ventilation. Therefore
if ventilation continues for more than two minutes, an orogastric tube should be inserted and left open to decompress
the abdomen.
80. Ans. is t' i.e., Convcetion [Ref : 0.P. Gksi $tt'le p. 128 & 7h/e p. 117)
"Conyection warmed incubators are being routinely used for thermal regulation of the premature neonate's ambient
air" - Ghai 6'h/e 154
81. Ans. is 'b- i.e., Dexamethasone ["&e/ This is an extraet of the book PAEDIATRICS pOR DACTORS; Frank Shann
and John Vince; http://www.develapmentgateway.com.au/health/paed,iatrics/PaediatricsFarDoctors-pg236-2 2"pdfl
'Corticosteroids should not be used' - Paediatrics for doctors - Frankshann 6 /ohn Vince
Management Protocol
The management protocol of babies with asphlxia:
1. Oxygen. In the absence of continuous oxygen saturation monitoring, it is reasonable to give nasopharyngeal
oxygen (0.5 litre/min) untii the baby recovers. If monitoring is available, oxygen is given as appropriate.
2. Thermal control. Baby's body temperature should be kept in the normal range of 36.5-37.20C (sometimes the babies
become hlperpyrexic).
3. Correction of shock, If peripheral perfusion is poor, it is reasonable to give 20 ml/kg of normal saline initially. If
perfusion remains poor, the use of dopamine should be considered.
4. Fluid balance. Give IV fluids at 213 maintenance. Use 107o dextrose"
5. Monitor blood glucose with dextrostix and do not let it fall below 2.2 r4mol (explains gJucose administration)
6. Prevent/control convulsions. In less severely affected babies, phenobarbitone should be given when there is
anyrspicion of actual or impending convulsions (phenobarbitone loadid! dose 20 mg/kg IM or 10mg/kg slowly
IV then 5 mg/kg daily orally).
T.Treath)tpocalcaemiaif it occurs (or more practically, if the babyhas uncontrollable fitting with anormal dextrostix).
(explains calcium gluconate administration )
Notes
l.Corticosteroids should not be used, and although many paediatricians use mannitol, there is no evidence for its
effectiveness.
2. Babies with severe asphlxia may appear to settie relatively quickly after the resuscitation - but there is likely to be
a deterioratiorr after 6-12 hours or so as cerebral oedema develops.
84. Acs is ?' i-e., APGAR at 7 rnia iadicates neonatal mortality depression
[Re! Avery,s pediatrics]
I Later times APGAR score (after 5 minutes) indicates about long term
neurological damage (not neonatal mortality)
lnterpretation of APGAR Score
t The test is generally done at one andfive minutes afier birth, and
may be repeated later if the score is and remains
low. Scores 3 and below are generally regarded as critically low, 4 to
6 fairly low; and 7 to 10 generally normal.
a A low score on the one-minute test may show that the nei,onate
requires medical attention (e.g. resuscitation)but
is not necessarily an indication that there wiil be long-term problems, particulariy
if there is an improvement by the
stage of the five-minute test- lf the Apgar score remains below
3 at liter times such as 10, 15 or 30 mintues, there
is a risk that the child will suffer longer-term neurological damage.
There is also a small but significant increase of
the risk of cerebral palsy. However, the purpose of the Apgar test i
to determine quickly whether a newborn needs
immediate medical care; it was not designed to make long-term predicitions
on a childl health.
CO2 transport across placenta
r
Coz is cleared by placenta by simple diffusion. Co, is produced abundantly
in the fetus, and the pCo2 of fetal blood
is higher than maternal blood. co, therefore diffuses from fetal blood,
through the placenta, into the maternal
circulation, and is disposed by expiration from mother,s iung.
Anaerobic metabolism causes acidemia due to lactate (lactic acid) production
o Anoxic perfusion causes an increase in glucose consumption
which is more than two fold higher than that seen in
the oxygenated perfusion, resulting finally in placental uptake of glucose
not only from the maternal but also from
the fetal circulation.
t
Lactate production i-s increased during the anoxic peifusion,whiie
the final tissue energy value lies between the
values observed for fresh tissue and for the oxygenated perfusion.
The shift to anerobic ietabolism shown by pla-
cental tissue in anoxic conditions enables continued functioning ofthe
tissue over the 2-h perfusion period but it
appear that under anoxic conditions the tissue may incur u, .rr".gy
debt not observed in oxygenated perfusions.
85. Ans. is 'c' i.e.,5 {Ref : Meharban Singh 6a/e p. 2621
Qri Ans, is 'rj' i.e., &Yl qlt *kl*v* {Re t Netsc}y, xgtr/e p. l{}{}}
o Drug used during neonatal resuscitation : (l) Epinephrine/Adrenalin, (2)
l/S or RL, (3) Naloxoneand (a) Sodium-by-
carbonate. Dose of Adrenaiin 0.1 - 0.3 ml/kg of l: 10,000.
Ans" is k't"c", *"1-*"3 rcL/kgira l:3*,{}*Xl [fr# {,}.p"
Dose or adrenlaine -
0.1 ml/kg to 0.3 ml/kg diluted (1:10,000)
:
Routs (1) Intravenous (umbilical vein) or
(2) Endotracheal
lndication -
HR < 60/min after 30 sec. of positive pressure ventilation & chest compression
HYPERBILIRUBINEMIA
SS. A*s" is'# i"e.n >15 xxlgld{ {1}-e! &leai Tkle 1t. }'a7}
s9. Ams, is 'a' i-e", K*€err c3xdreme* {R.ef: X$**isrtee's 17r'le Ck 7*b!* a3- 11
90. Ans. is 'd' i.e., Hemolytic jaundice fRef: Chatterjee Shinde 4th/e p. 593; Chanilrasoma 3th/e p. 6j5l
o-Important clues provided in question are'-
1) lncreased total bili.rubin lj
2) Normal."r;,rg"*i btlorut" so' t unconjugated bilirubin
o Amongst the given options, only hemolytic jaundice causes increased unconjugated bilirubin.
o Remaining three cause conjugated hlperbilirubinemia'
91. Ans is t' i.e., PNH tRel Readbelowl
o Causes of )aundice since birth are:-
i) Rhincompatibility(erythroblastosisfetalis)
ii) ABOincompatibility
iii) Congenital infections (TORCH)
iv) Sepsis
v) Concealedhemorrhage
vi) Red cell membrane defect (hereditary sphero-cytosis)
vii) Red cell enzyme defect (G6PD deficiency)
o So, option a & d can cause jaundice si*ce birth. ,
o In sickle cell anemia, affected infants do not develop symptoms in the first few months of life because the hemoglobin
produced by the developing fetus (fetal hemoglobin) protects the red blood celis frcrn sickling. This fetal hernogiobin
disappears after 5 month of age so that by 5 months of age, the sickling of the red blood cells is prominent and symp-
toms begin.
o PNH is manfested in adults.
o So, both PNH and sickle cell anemia does not cause jaundice since birth.
o But among these two I would prefer PNH as the answer because it is manifested in adulthood while the patient in
question is a 5-years old child.
o Sickle cell anemia slrnptoms develop at the age of 5 months and it is one of the cause of jaundice (en.wikipedia.org).
Ans. is 'l i.e., Erythroblastosis [Ref, Nelson l9th/e p. 258)
c Er1'throblastosis fetalis (due to Rh incompatibility) is the most common cause ofjaundice
presenting at birth or within
24 hours oflife.
&ytt;. i:r't3' i,r;,,b?"fu r.taxe*xrzy*aZltzigit,z,{iLr:l: :r,rt trbLt..,, 1..,-!t,tt,rt..,:,}
o laundice of Rh incompatibility appears at birth or within 24 hours.
94. Ans. is nb' i.e., congenital cholangiopathy lRef : o.p. Ghai Bth/e p. 122 6 vh/e p. 1491
This child has unconjugated hyperbilirubinemia, while congenital cholanglopathy causes
conjugated
hlperbilirubinemia.
95" Ans. is 'd'i.e., Novobiocin therapy [Ref: Robbins Vh/e p. 887, 888]
96" Ans. is'a' i.e., lVtrild conjugated hyperbilirubinemialRef. Robbin's vh/e p. BB8; Harrisan lVh/e p. 19291
e Gilbert syndrome is a type of congenital unconjugated hlperbilirubinemia.
x lt is autosomal dominant.
o Hepatic biochemical tests are normal
a There is normal hepatic histology, but in some patients increased lipofuscin pigment may occur.
o There is mild increase in unconjugated bilirubin.
{}'7" |z*y.. tt'ttr'i.t:., l,1l *{ atzazv*. 1}tttl: {,{*lsa.rz t8,t'le t:/t. .1.:i,11 \
o In Gilbert syndrome there is unconjugated (indirect) hyperbilirubinemia due to decreased activity of UDPG
transferase,
o usually no treatment is required. But phenobarbitone can be used to reduce the level ofunconjugated bilirubin.
{}{i. *,y'r*. it't:' s.*",13**s'tt$.**t t *ratt {llLl: {.{*ryisez* tythl*, y l,}:tr|
101" Ans. is od i.e., &,otor syndrome {l?.ef: Nelson lVt'/e Chap" 3521
102" ,4"ns. is 'd' i.e., ,{ltr of atrove [Ref: Gkai 7h/e p. ja4]
o Mildly elevated bilirubin especially indirect and normal liver enzyme seen in hemolytic anemia.
o In above question all causes hemolytic anemia.
KERNICTERUS
103. Ams. is 'd i.e,, No nong term effect &'H i.e., Occurs with bilirubin rnore than 25 mga/o {R.ef: Read belaw}
r Long term survivors demonstrat e choreoathetoid cerebral palsy, upwaril gaze palsy, sensorineural hearirug loss and
mental retardation.
o Kernicterus occurs when bilirubin level is > 20 mg/dl or > 20 mgo/o.
"It is generally believed that unconjugated bilirubin lewl of more than 20 mg/dl may lead to kernicterus"
pediatrics
--Clinical
"Risk of kernicterus increases with bilirubin levels more than 20 mg/dl and this became the conyentional cut-of pointfor
therapeutic intervention in term neonates" Pediatric essentials
--
o Unconjugated bilirubin causes toxicity to basal ganglion and various brainstem nuclei.
o Opisthotonus is seen in phase II of kernicterus.
f 04. Ans. is'd' i.e., Sulfonamides [Rel KDT Sn/e p. 644; Goad.man Gilman 10th/e p. 117fl
The administration of sulfonamides to newborn infants, especially if premature, may lead to the displacement of
Bilirubin from plasma albumin. In newborn infants, free Bilirubin can become deposited in the basal ganglia and
subthalamic nuclei of the brain. causing an encephalopathy called kernicterus. Sulfonamides should not be given
to pregnant women near term because these drugs pass through the placenta and are secreted in milk.
Kernicterus is due to unconjugated hyperbilirubinemia.
TREATMENT OF HYPERBILIRUBINEMIA
lO7. Ans. is 'd i.e., Barbiturate lRef O.P. Ghai 6th/e p. 172, 173 6 Vh/e p. 1501
Barbiturates (Phenobarbitone)
o It is effective only if given to mother before delivery.
o It acts by inducing the conjugation of bilirubin -+ Phenobarbitone is an enzyme inducer.
108. Ans. is t'i.e., Structural isomerization [Ry'; Manual of Neonatal Care Sthle p. 2A8l
o "Structural isomerization is the intramolecular. cyclization of bilirubin to lumirubin. It is the most important
pathway for the lowering of serum bilirubin levek! - Manual of Neonatal Care 5/e, p 208
109. Ans. is 'a' i.e., Phototherapy I Ref : O.P. Ghai thle p:-175 dz 6hle p. 17j)
Bronze baby syndrome -
r It refers to dark grayish brown discoloration of the skin in infants undergoing phototherapy. Almost all infants ob-
served with this slmdrome have had a rnixed type of hlperbilirubinemia with significant elevation of direct reacting
bilirubin and often with other evidence of obstructive liver disease.
o So, this child has : -
i) Conjugatedhlperbilirubinemia
ii) Other LFTs normal
o Amongst the given options, Rotor syndrome and Primary biliary cirrhosis cause conjugated hyperbilirubinemia,
o In Primary biliary cirrhosis, other LFTs are also abnormal, e.g., SGOT and SGPT are raised.
o Now we are left with Rotor syndrome which causes conjugated hlperbilirubinemia. Other LFTs are normal.
na'
XSl" Ams, is i"c., Rotqlr syndreir*e {{lef: Nelsaw 1.7t'/e Chap^ 3521
L&2. Ans" is 'd' i"e", AII mf above {Ref: Gkai Thle p" 3a4)
o Mildly elevated bilirubin especially indirect and normal liver enzyme seen in hemolytic anemia.
o In above question all causes hemolytic anemia.
KERNICTERUS
XS3, Ams. is 'd 2.e., N*r lmng term effect &'b' i.e., Occurs with bilirutrin more tban25 wegak {R.ef: &eadbelaw}
o Long term survivors demonstrat e choreoathetoid cerebral palsy, upward gaze palsy, sensorineural hearing loss and
mental retardation.
r Kernicterus occurs when bilirubin level is > 20 mg/dl or > 20 mgo/o.
"It is generally believed that unconjugated bilirubin level of more than 20 mg/dl may lead to kernicterus"
pediatrics
--Clinical
"Risk of kernicterus increases with bilirubin leuels more than 20 mg/dl and this became the conyentional cut-of point for
therapeutic intervention in term neonates" P ediatr ic es senti als
--
o Unconjugated bilirubin causes toxicity to basal ganglion and various brainstem nuclei.
o Opisthotonus is seen in phase II ofkernicterus.
104. Ans. is 'd' i.e., Sulfonamides [Rel KDT 5'h/e p. 644; Goodman Gilman 10th/e p. 1176]
The administration of sulfonamides to newborn infants, especially if premature, may lead to the displacement of
Bilirubin from plasma albumin. In newborn infants, free Bilirubin can become deposited in the basal ganglia anil
alo be ven
, . .: t.j.l::i::::,rri:'::l:;..:
:,, ::.r,.
i ... : .rl:ii::ii.:i .r ii:ir,i
.,' :.:ii-;. r'r,'ii..:nl,:
. ...t,::t.,:....: ):.-;;r.a.)
nCI0, ,&ns. is 'd' i"e", Crigler-Najjar symdrorne lRef: Nelsow tr9th/e p. 20E4; Ghai 7h/e p. 32Al
101" "&ns. is 'd 1.e., Kotor syndrome {flef: Nelsow tr7t'/e Chap. 3521
1CI2" Ans. is 'd' i"e., ,&ll of above l&ef: Glaai Th/e p. N_<1)
o Mildly elevated bilirubin especially indirect and normal liver enzyme seen in hemolytic anemia.
o In above question all causes hemolytic anemia.
KERNICTERUS
1&3, Ans" is 'd i,e.,lnlo long term effect &'tr' i.e., Occurs with bilirut in more tbax 25 mgYa lRef: Read belawl
o Long term survivors demonstrat e choreoathetoid cerebral palsy, upward gaze palsy, sensorineural hearing loss and
mental retardation.
o Kernicterus occurs when bilirubin level is > 20 mgldl or > 20 mgo/o.
"It is generally believed that unconjugated bilirubin level of more than 20 mg/dl may lead to kernicterus"
pediatrics
--Clinical
"Risk of kernicterus increases with bilirubin levels more than 20 mg/dl and this became the conventional cut-of point for
therapeutic intervention in term neonates" Pediatric essentials
--
o Unconjugated bilirubin causes toxicity to basal ganglion and various brainstem nuclei.
r Opisthotonus is seen in phase II of kernicterus.
104. Ans. is 8' i.e., Sulfonamides [Rel KDT Sth/e p. 644; Goodman Gilman 10th/e p. 11761
The ailministration of sulfonamiiles to newborn infants, especially if premature, may lead to the displacement of
Bilirubin from plasma albumin. In newborn infants, free Bilirubin can become deposited in the basal ganglia and.
subthalamic nuclei of the brain. causing an encephalopathy called kerhicterus. Sulfonamides should not be given
to pregnant women near term because these drugs pass through the placenta and are secreted in milk.
Kernicterus is due to unconjugated hyperbilirubinemia.
lO7. Ans. is'a' i.e., Barbiturate lRef: O.P. Ghai 6h/e p. 172, 173 6 Vhle p. 1501
Barbiturates (Phenobarbitone)
o It is effective only if given to mother before delivery.
o It acts by inducing the conjugation of bilirubin -> Phenobarbitone is an enzyme inducer.
f 08. Ans. is t' i.e., Structural isomerization [Relr Manual of Neonatal Care Sth/e p. 2081
o "structural isomerization is the intramoleculary cyclization of bilirubin to lumirubin. It is the most important
pathway for the lowering of serum bilirubin levekl - Manual of Neonatal Care 5/e, p 208
f 09. Ans. is 'd i.e., Phototherap y I Ref : O.P. Ghai t;nt, p. vs 6 dhle p. 17j)
Bronze baby syndrome -
o It refers to dark grayish brown discoloration of the skin in infants undergoing phototherapy. A1most all infants ob-
served with this syndrome have had a mixed type of hyperbilirubinemia with significant elevation of direct reacting
bilirubin and often with other evidence of obstructive liver disease.
r l0'
Ans' is 'a' i'e', 2omg% [Ref cpDT r*/e Figure(I-3]
Nerson r8h/e p. 7641
o in full term newborn phototherapy is
indicated when total serum bilirubin
birth; (ii) > 18 mg/dl in 48_72hrs. after birth; level is : (i) > l5 mg/dl in24-4ghrs.
and (tii);_';; ;g/dl more than 72 after
hrs. after birth.
111' Ans'isk'i'e.,Exc&amg*tr&lxsfu*ic:aa
isrri e"r; Gia*i8rr*p.:"rs-:z*";;;p ,r'--ri*
' ff:::1ifffl:[1t;ii['fi];Jl,ffi1Tf to weight (< rooo gm) birirubin rever
orthis newborn (13 mgo/o or 13 ms/
rl2' Ans' is h'i.e., Totar and direct bilirubin
[Ref Nelsoa lPh p. 75sl
o Measurement of total and direct bilirubin
will make us available with all the three parameters
bilirubin levels' These will help to classify jau"ai." i.e. direct, indirect, total
into-rtr..lp..ti". type and aid in diagnosis.
Agre
l15' Ans' is'b'i'e., r0% IV Dextrose [Ref, Essence of peditrics (Elsevier, rndia)
4e/e p.44,451
t
symtomatic (Lethargy) Hypoglycemia (<4hmg/dl)
should be managed i,tith 10o/o IV Dextrose,
116" A:rs. is t' i"e." 1$% dextrqls x 4 xallk g,
iRri Nefs*zr iS&le y, l)31
o In seizures, dose of l07o dextrose is 4
ml/kg.
l1?. Ans. is'c'i.e., 12"S A,{IMSi{e*w$taansgr iwl}t **{ - *€9,7ttzg$r*rxziqe{l.Ne*qg$x.nl
{fie_f
r
Dont give > l2'5o/o dextrose infusion through peripheral
line because of risk of thrombophlebitis. (prefer
18. central line)
I Ans. is t' i.e. History of Unconsciousness
r Neonates are susceptible for developing hypoglycemia
during the first 2-4 hours of life.
' is not started wi{r,in ulnhour of brrih about
r0% of normal ,,eor,"t"s are likely to develop
dffi:t"?tfeding
o This hypoglycemia is corrected either
by starting breast-feeding or by administering
glucose.
' ,l#1,i,[:ff:etic
mother is prone ror hipoglv;mia -+ gt,r.o-r.
solution is given #iire child deverops symptoms
of
o In a child with history of hlpoglycemia,
glucose administration is indicated if the
spnptoms of hypoglycemia recur.
Caredal regr€siion:
o Caudal regression syndrome (CRS) is a rare malformative syndrome seen mainly in cases of maternal diabetes with
poor metabolic control.
r This syndrome associates vertebral agenesis of variable level with genito-urinary and digestive malformations.
These abnormalities are related to the impaired development of the mid-posterior axis mesoderm
MISCETTAHEOUS
123. Ans.isnc'i.c.*lOweeksfR.ef:AbdaminolW,altHernias:'Principlesandmanagcm:entbyRabertBmdavip.5g4l
c During development the intestinal loops lie outside the abdominal cavity in the umbilical cord called the physiological
umbilical hernia.
r The loops go back into the abdominal cavity by 10uh week of gestation"
124. ,4ns. is "H i.e., 125 mgldl lRej': Indian Pediatrics 20{t8;45:29-38},
o No established definition of neonatai hlperglycemia and upper safe limit of blood glucose has been determined
o Various researches has suggested
Whole blood glucose > L25 mgldl
Plasma glucose > 150 mg/dl
125" Ans. is
ol i.e.,Morphi*e *
{Ref : Avery's d**ase af newborrc /e p. 442}
e Morphine and other opioids can cause neonatal respiratory depression.
126. Ans is 'a' i.e., Opioids fRef: Cloherty 6h/e p. 220, 237; Auery,s disease of the newborn gth/e p. 4421
127. Ans. is t' i.e., Seizure lRef : o.P. Ghai 8th/e p. 167 6 Vh/e p. l4t; Nelson lgth/e p. 718; CpDT lSth/e p. ill
Clinical features of hypoxic ischemic encephalopathy
r Encephalopathy progress over time -
1) Birth to 12 hours -+ Decreased level of conciousness, poor tone, decreased spontaneous movement, periodic
breathing or apnea, seizures.
2) 12-24 hours ) More seizuers, Apneic spells, jitteriness, weakness.
3) After 24 houts -+ Hypotonia, J conciousness, poor feeding, brainstem signs (oculomotor) and pupillary
disturbances.
128. Ans. is'b' i.e., Differential hypotonia (lower limbs > upper limbs) fRef. a.p. Gbai 8th/e p. 166, 167 6 vh/e p.
139-MA; Nelson 18'h/e p. ZISI
o During asphyxia the infant may remain hypotonic or change
from hypotonia to extreme hypertonia or their tone
may appear normal. These changes are seen simultaneousty and the change in muscle tone
is also of the same degree in
both the limbs.
129 ' Ans' is 'd' i.e., State 6 [Ref : Brazelton TB' The Neonatal intensive care unit network neurobehaviaral scales procedures.
Pediatrics 20a4; I 1 3:641 -67)
r Crying lustily n'ith all limbs moving (child in question), straight away goes in state 6.
."ry-
r 3&" 'A"ns' is i.e., 25 crn of F{r0 fRef: Texthoak af paediatric errxergerxcy nzedicine - peter catner*n, George
felirzek, Ia*
Everitt p. 49; obstetrics: Narmal and prabtew Ttregruarocies by Steven G.Gsbbe, R. Nieb),t p. 4g6llennifer
r Higher inflation pressure of about '25 to 40 cms of Hro and higher inflation time > 1.5 sec. may be required for first
several breaths (=5).
r The volume of first breath is between 30-67 rnl.
o Residual volume after first breath : 4-30 ml (average : 16,20 ml).
o By around 30 minutes most neonate achieve normal FRC.
l3l. Ans is 'a' i.e., Pyloric stenosis fRef: Neanatology by Meharban singh p. loSl
c A large number of normal babies vomit on first day due to irritation of stomach by swallowed
amniotic fluid
o The regurgitation / vomiting in a neonate is due to -+ faulty feeding techniques
or, aerophagy
o Eosophageal atresia may present with vomiting on the first day.
r In hypertrophic pyloric stenosis vomiting characteristically occurs after 2 weeks of age. (2-3weeks).
132. Ans. is H' i.e., Impedence technique lRef : Care of the newbarnby Meharban singh 6h/e p. 30, 2801
r The respiratory monitor based on impednace technique measures changes in the electrical
resistance during breathing.
The electrode is fixed on the chest wall to pick up signals which are displayed as respiratory
rate.
o capnography - It is a simple non invasive method to assess arterial cor.
r It is used to assess the placement of ET tube in esophagus or trachea.
135, Ans. is'c'i.e., < 3SD for age and sex {Ref: Nelsan lgth/e p. 2aA\
I Microcephaly is defined as a head circumference that measures more than three standard deviation
below the mean
for age.
.Cllap.t:Eirii
136. Ans" is t'i"e., Congenital variceltra syndrorne {Ref Nelsan tr811'/e p. 77$7
137, Ans. is t' i.e., Large proportionate body fRef: Nelson 18th/e p. 7811
r Characterististics of fetai alcohol syndrome inciude : -
1) IUGR (not large proportionate body) 4) Mental retardation
2) Microcephaly 5) Minor joint anomalies
3) Congenitalheart defects (ASD, VSD) 6) Hlperkinetic movements
7) Facial abnormalities -+ Short palpebral fissures, epicanthal folds, maxillary hlpoplasia, micrognathia, low set
ears, smooth philthrum, thin smooth upper lip.
138. Ans. is t > d' i.e., Apt test > Kleihauer Betke test [Relr Perinatal transfusion ?ned.icine 2d/e p. 218]
j.*.*=.r*..,
i*g[t4'S-;'
sourc::J::mry. M,ut"lul or neonatll . .
Mut9rnlt
.
How jt,Wolkl :: r : '.,,. fiil6[i6g'1'%-NaOfJ,destigysiduk.llbAibut. Addingnciddestroys adult HbA but noi fetalHbF ,:,.
o Both Apt test and KB test are used to differentiate maternal blood from fetal blood. So, trvo options are correct.
r However, we have to choose one option and according to me Apt test is best here because Apt test is used
specifically for differentiating maternal and fetal blood while KB test is used to quantifli fetomaternal hemorrhage.
140. Ans. is t' i.e., 28 weeks lRef: Meharban Singh S'd/e p. 71)
136" -&ns' isne'i.e,,C<ragemitatrvaricellasy&dr${TelRef:Nels**{*il'lep'77a}
Causes of HYdroPs fetalis
lmmune
c Rh incomPatability
Non-immune
q-thalassemia, G-6PD defi ciencY
o Anemia
, congenitol heort block
c CardiacdYsarrhYthmias Supraventricular tachycardia AF,
hypoplastic left heart'
ednocardial cushion defect, cardiomyopathy,
o Structual cardiac de- Tricuspid insufficiency,
fects premature closure of foramen ovale
* Vascular Chorangiomaofplacenta,Twin.Twintransfusion,umblicalarteryaneurysm,thrombosis
of renal or umblical vein or IVC
syndrome
* Lymphatic Lymphangiect asia, cystic hygroma, Noonan
lvlolcl I lol
Source of samPle Maternal or neonatal
Adding acid destroy!'aduti HbA but'no!fetal'HbF
How it'works.., :' Adding loloNaOH destloys adult HbA but
notfetal HbF
Ouantitative
Assessment tYPe Qualitatlve
Positive neais blood ls af fetal o tigln :'' Reboited'in estimated''ml3of futal,blood..''
Results: .: .:: i:
are correct'
maternal blood from fetal blood' So, two options
r Both Apt test and KB test are used to differentiate
rHowever,wehavetochooseoneoptionandaccordinqtomeApttestisbestherebecauseApttestisused
to quantifli fetomaternal hemorrhage'
and fetal blood while KB test is o..d
specifically for differentiating maternal
ANSWERS OF V
Mehatban Singh S'd/e p' 711
140. Ans. is t'i.e., 28 weeks lRef:
Aas, is'd i.e.,Loes ofweight [Ref: Netson l.*/e p. 220" 22107
r An infant should gain weight progressively, except for the first few days of lifb.
r Liver, spleen and kidney may be palpable ia normal newborn.
Nelson
o Sometimes trachea may be deviated from midline without any significance. --
142. Ans, is'l i.e",Autonomic dysfunction {Ref: Nelson t*/e p. 2262}
o If reflects an imbalance in the autonomic vascular regulatory mechanism.
143" Ans. is '8 i.e",30-40 breathc/minute {Ref : op Ghai &/e p. 145 d? p/e p. 10sl
o Heart rate in neonate -) l2O-l4O per minute.
I Respiratoryrate -+ 35 to 40 per minute.
lM. Anc, is'd i.e,,120-tfilm,-{Ref: O.p, Ghai tr/e p. 145 {r p/e p. 105)
145, Ane" ic 'V Le,,Birthweight below t0* percentile {Ref: Internetl
c lVlicrosomia means small for date baby, i.e. newborn baby with a birth weight less than 10e percentile.
l#. Ans, ie 'd i"e.,Erythcrnatouc papular pustular leeion * {Ref : Dutta #/e p. 446; Gupte S. */e p. 522)
Common neubom raches
r Erlthema toxicurn -> Most common
r Acne neonatorum
r Transient neonatal pustural melanosis.
149, Ane. io'il i,e,,5-7 weeks{Ref A.P" Ghai *le p" 141 6 Zh/e p. fi2; Nelson 18tu/e p. 214)
r It disappears between 2 week to 3 months.
150. Anc. ie 'C i.e., Olset of reepiratory distresc is immediately after birth and it rarely laste beyond 4g hrs
{Ref O"P, Ghai */e p" tz1 & Zh/e p" t46l
151, Ano, ic 'd i.e., cerebral palsy &'U i,e.,rlypoxic lcchemic encephalop *hy {Ref: Internetl
r Normal posture of a full term neonate is flexor posture.
o Extensor postlrre may be seen when there is brain damage as in hlpoxia --> hlpoxic
ischemic encephalopathy and
cerebral palsy.
,52, Anr, ic'* i,e,,Transient tachypnea of newborn fRef: o,p, Ghai gth/e p, l7l & ztu/e p. rufl
I Respiratory distress, which resolves within 24 hours without any respiratory support and fluid in interlobar
fissure
on chest X-ray suggest the diagnosis of TTN.
153. Ane" is 'il i,e,, Any time during pregn fRef: Read below]
^cy
r Fetal growth is affected by maternal nutrition during any trimester in pregnancy.
r Fetal growth is affected even by nutritional status of mother prior to pregnancy.
154. Anc, ie 'H i,e., Bacterial flora fRef: Has been explained]
r Meconium contains -
i) Intestinal epitheliai cells iii) Mucus v) Bile
ii)Lanugo iv) Amniotic fluid vi) Water
155, Ans is '* i.e., Kangarooo Mother Care (KMC) lRef, O.P. Ghai Bth/e p. 14s, 148 6 Vhle p, 121,153; K.N.
Agrawal l,t/e p, 1A4l
"Preferably mother should accompany and baby can be transported in KMC position.
Even father can provide KMC during
transport if mother can not acompany. _ K.N. Agrawal
i.e., cord bilirubin is more than 5 mg;
156. Ans. is .d i.e., cord blood hemoglobin is less than l0 g %;'H
.c,
i.e., History of previous sibling affected [Ref lVelsolr
l*/e p- 77ll
p'
157. Ans. is t'i.e., Cord bilirubin < 5 mll00 ml [Rel: Nelson
18e/e 7711
f 63. Ans. is 1d i.e., Measurment of ct - fetoprotein [Ref : Nelsorc l*le p' 6951
164. Ans. is'C i.e., 60 [Ref: O.P. Ghai }e/e p' 381 & *le p' i52l
Tachypnea
o < 2 months -+ 60 or more RR/min
o 2-12 months ) 50 or more RR/min
o 12-60 months -+ 40 or more RR/min
165. Ans. is'H i.e., 3 hours [Ref Netson 18th/e p' 655]
o Blood glucose reaches its nadir in initial 2-3 hrs' of life'
; A'P' Ghai Sele p' 154 & 7e/e p' 126i
166" Ans. is'b' i.e., Lower areola more visible [Ref
III
P T E'R
CAKffiXffi\{&SCq"-fX"r&K
SYSTEM
FETAL CIRCULATION
o Fetal circulation differs from adult circulation in several ways. Almost all differences are attributable to the fundamental
difference in the site of gas exchange. In the adult gas exchange occurs in the lungs, while in the
fetus placenta
2. Left side
o The left ventricle pumps blood into the ascending aorta for distribution in coronary circulation, head and upper limbs.
llmblical cord contains one umblical vein and two umblical arterieswEEr)
CAKMKffire$CULAK
$YSYKivg
FETAL CIRCULATION
o Fetal circulation differs ffom adult circulation in several ways. Almost all differences are attributable to the fundamental
difference in the site of gas exchange. In the adult gas exchange occurs in the lungs, while in the fetus placenta
provides the exchange ofgases and nutrients.
Course of fetal circulation
A) Blood returing to heart
o Blood oxygenated in the placenta returns by way of the umblical vein@Groz), whichenter the fetus at the umblicus
and course through to join the portal vein.
o The ductus yenous is a bypass shunt between portal vein and IVC.
o Most of the umblical venous blood shunts through the ductus venosus to the IVC.
o Blood from fVC (which carries the blood drained from lower extremities, umblical veins, hepatic veins and renal
veins) enters the right atrium. On reaching the right atrium, about 1/3rd of total inferior vena caval return of
blood enters the left atrium through formen oval. The rest two third mixes with the venous return from SVC
(which carries the blood drained from head, neck and upper limbs) to enter the right ventricles.
2. Left side
' e fhe left ventricle pumps blood into the ascending aorta for distribution in coronary circulation, head and upper limbs.
Umblical cord contains one umblicol vein and two umblical arterieswEEt)
$i a : ; a:)ir: ;.:.:::t a:i:,:..
t::,,:::::::::t: : a::::,.::,
$:P:ff,-f,:.{::
Fetal circulation
I uPPer"-""**l
timus
I I
+-Er*
syc
Pulmonary vein
RA
+LA
T
1t3
2t3
RV*+ * r-v
A
I Heart
i --------+-
I
V
P u I m o n a ry tru n k -------------**
I
I Major
---.-------}Ductus arferrosus----> Descending aorta
r Blood in IVC has more oxygen saturation than blood in SVC as IVC carries the oxygenated blood of
umblical vein.
The left ventricular blood has more oxygen saturation that right ventricular blood because it
carries the blood of IVC,
while blood in right ventricle is a mixture of blood from IVC and SVC. Sq thebrain and coronary circulation
receiye
blood with higher oxygen saturation (through ascending aorta) than the lower half of boflyrtr tst.
r The left ventricular output is approximately half of right ventricular output because volume of
blood reaching in left
atrium is considerably lower than volume of blood reaching in right atrium. Infact right atrium is the major
source of
blood to left atrium.
r Aorta and pulmonary trunk are connected by ductus arteriosis, and pulmonary trunk has pressure slightly
higher or
equal to that of arota + So, blood flows from pulmonary trunk to aorta.
. The pressure in right and left ventricles are equal@r ts).
Down'ssyndrome{trisomy2l} Enidocardlatcushiondefect{Atse){atypeofASD),VSDIOF
Turner syndrome Bicuspidaorticvolve (mostcommon)@NB13),asarctotionof aortq(2d MC)6,tMs08), AS, MVP
ttlaonan syndrome
William syndrome Suprava lv ular AS(il ee, Bra nch P5, hypercalcem ia
Osteogenesis imperfecta AR
B) Environmentalfactors
I Those who have an inherited tendency, develop CHD due to unfavorable environmental factors.
I of these the most well known is high altitude -> There is higher incidence
of pDA and ASD in children born
at a high altitude.
NADA's criteria
o The Assessment of a chird
for the presence or absence of heart disease can be done with the help of some guidelines
suggested by NADA. These guidelines are called NADAs
criteria(At )3, Arrfts e7)
* Systolic murmur, grade lll or more, * Systolic murmur < grade lll
especially with thrill
a Diastolic murmur o Abnormal 2ndheart sound
o Abnormal ECG
& Cyanosis * Abnormal X Ray
& Congestive cardiac failure o Abnormal Bp
NADA's criteria
t The Assessment of a child
for the Ttresence or absence of heart disease can be done with the herp
suggested by NADA, These guidelines are of some guidelines
called NADAs criteria,r 13,AnMse7)
o Right ventricular hlpertrophy causes RAD, and CHDt causing RVH are : -
i) TGA iii) ToF v) Eisenmenger\ syndrome
ti) TAPVR iv) AgPtdttusstl vi) COA (in infants)
PATHOPHYSIOLOGY OF CHDs
[:Ti:J::'::'::.-""-':i:y,']li"'.*":"
the body, and oxygenated brood returning from
rung is pumped
I ruur ro Pu
a cleft in the septal tricuspid leaflet. It is the most common CHD in Down syndrolrrreulls).
r ASD is more common in females than males.
o lmportant syndromes associated with ASD are :-
t Holt - oram syndrome@t1s'PGI0L) t Thrombocytopenia absent radius (TAR) slfldrome(Pctot)
t Down slndromsedot) t Pierre Robin syndrome
t Ellis-van crevald syndromeecl 01 ) s Ehler Danlos syndrome
t Rubinstein - Taybi syndrome t Fetal alcohol syndrome
Hemodynamics of ASD
o There is abnormal connection between left and right atrium, which is due to defect in atrial septum.
r Blood flows from left atrium to right atrium because left atrium has slightly higher pressure than r@t atrium@I e7)
o Increased blood flow through pulmonary circulation -+ Pulmonary plethora that may cause pulmonary
otr.
hYPertensisnrar
o The left atrium is not enlargedal 11' 06)
because it decompresses itself by shunting blood to right atrium at a minor
difference in pressure. The left atrium may enlarge once Eisenmanger's syndrome develops and a reversal of shunt is seen
across the defect.
Clinical manifestations of ASD
r Patients with ASD are generally asymptomatic.
o Mild effort intolerance and respiratory tract infection may occur.
: CHF is rare.
o Infective endocarditis is very rare in ASDNEID.
r Complications usually develop in 4'h decade and include pulmonary hypertension, strokeNEEr), right sided HF and
Eisemmenger's syndrome.
Physical examination
o Parasternal impulse
r Systolic thrill at 2dleft interspace.
o Accentuation of S, due to loud tricuspid component.
o Wide split andfixed S2euoe'AltMsa3).
Chestx-ray in ASD
o Mild to moderate cardiomegaly o Prominent pulmonary artery segement.
c Right atrial and right ventricular enlargement c Relatively small aortic shadow{NBgr)
t Plethoric lungfields. o Normal left atrium@IlMs t' 06, 01)
1
r It is situated inferior to fossa ovalis. It associated with a cleft in the anterior leaflet of mitral valve, with or without
a cleft in the septal tricuspid leaflet. It is the most common CHD in Down syndrome(Arls).
r ASD is more common in females than males.
o Important syndromes associated with ASD are :-
t Holt - otam sYndrome4l 1s'PGIol) t Thrombocytopenia absent radius (TAR) sffld.rome@cl ot)
r Increased blood flow through pulmonary circulation -+ Pulmonary plethora that may cause pulmonary
hYPertension6ror).
o The lefi atrium is not enlarged@I 11' 06)
because it decompresses itself by shunting blood to right atrium at a minor
difference in pressure. The lefi atrium may enlarge once Eisenmanger\ syndrome develops and a reversal of shunt is seen
across the defect.
r Complications usually develop in 4th decade and include pulmonary hypertension, strokeNnnr), right sided HF and
Eisemmengert syndrome.
Physical examination
o Parasternal impulse
r Systolic thrill at 2"d left interspace.
o Accentuation of S, due to loud tricuspid component.
o Wide split andfixed Sr{PeIqe'AIIMSo3).
Chestx-ray in ASD
t Mild to moderate cardiomegaly o Prominent pulmonary artery segement.
t Right atrial and right ventricular enlargement c Relatively small aortic shadow$EB?')
t Plethoriclungfields. o Normal left atrium4ilMs 1' 06' ot )
1
Fluoroscopic examination shows vigorous pulmonary pulsations due to increased pulmonary
blood flow called as ,Hilar dance slgn(et tst or Great Hilar Dance sign,.
Note r Hilar dance sign may be seen in other left-to-right shunts, but it is typically described in
relation to ASD.
o vsD is the most common congenital heart diseaseal se). 'fhere is a communication between two ventricies. VSD mav
be located at :-
i) Membraruous part of interventricular septum (called membranous VSD) : Most commot 6t t3,ArrMssz).
Hemodynamics of VSD
o A vsD results in shunting ofoxygenated blood from left to right because
left ventricle has more pressure than right
-+ Left to right shunt(Arr3).
I Blood flow from Ieft to right ventricle due to high pressure gradient -+ Pansystolic
murmur and systolic thrill(Arr3).
r Because Ieft ventricle starts contracting before Right ventricle, pansystolic murmur starts early -+ Masking
of S,.
o This pressure gradient is maintained throughout the systole pansystolic
murmur lasts long -+ Masking of Sr.
e Towards the end of systole, the declining left ventricular pressure
becomes lower than aortic --> Early closure of Ar.
o Left to right shunt occurs during systole at a time when the right ventricle
is also contracting, therefore left to right
shunt streams to pulmonatY artery more or less directly -+ No volume overload
-+ Rightventricle size remains
normal.
o Increased blood flow through pulmonary valve -+ Pulmonary ej ection
systolic murmur and delay & accentuated pr.
o Early closure of A, and delayed closure of P, cause -+ Widely split s2(Ar,3) (But
this is usually masked by pansvstolic
murmur).
o Larger volume reaches the ieft atrium + Left atrial hypertrophy(eii:r.
c Increased blood flow through mitral valve Accentuated S, (But it is masked
-) by pansystolic murmur) and delayed
diastolic murmur.
o Ejection systolic murmur of pulmonary valve can not be separated from pansystolic
murmur.
a The effect of ejection systolic murmur is a selective transmission of pansystolic
murmur to the upper left
sternal border (pulmonary valve area) --> ln this area ejection characteristic of
this murmur can be recognized
since it does not mask the aortic component of Sr. For the same reason second
heart sound (Sr) can be heard
in the pulmonary area where it is not masked by pansystoric murmur.
a Thepersistenceaffunctionofductttsarteriosus beyond24hoursafterbirthisconsidere|aspDAinterm,eanate,i.e.if
functional closure does not take place in 24 hours afier birth, it is considerecl as pDA.
r The aortic attachment of ductus arteriosus is just distal
to subclavian artery.
o PDA is more cammon infemales than in males(Aros).
Hemodyrramics of pDA
I In PDA blood flows from aorta to pulmonary artery because
aortic pressure is higher than pulmonary artery pressure
-+ Left to right shunt.
e Pressure gradient between aorta and puhnonary artery
is maintained throughout the cardiac cycte (cluring
systole and
diastole) -> continous murmur, i.e., murmur starts in systole
after s, and reaches a peak at s2. It then dimi'ishes
and audible only a part ofdiastole.
r Larger biood volume passes through pulmonary circulation (blood
from right side of heart plus some blood from
aorta) -+ Fulmonary plethora which may cause pulmonary
h1p ertensionKetuta 00 ).
o Increased flow after passing through lung reaches the left
atrium and causes volume overload + Left atrial
dilatation
and hypertrophy.
c Increased blood volume passes from ieIl atrium to left ventricle
through mitral vaive, i.e., increasecl flow through mitral
valve -+ Accentuation of Sl and delayed diastolic
murmur.
System
r Left ventricle recieves larger amount
of blood that results in vorume
overroad -+ Left ventricre enrargement.
'"T:,;'".ff;:il:iffii*".t:#::r;.Tffs;:H":*rticvarvewhichmavcroseevenafterpurmonary
ur r* varves,' -> raradoxical spliting
A, occurs before pr). of Sr, i.e.,
{ occurs after p, (Normally
t left ventricular volume ejected
into the aorta resulrs in diratation
:fli: of the ascending aorta + Aortic ejection
" passes through normal aortic valve -+
Aortic ejecrion systoric murmur (bur
:;:il:JrTr:.Tl;o it is masked by
Clinical manifestations of pDA
c Patient may be asymptomatic
r Symptoms develop early and CHF
may develop at 6 to gth weeks of
e Common symptoms -+ Dysnea age,
on exertion, palpitation and.frequent
chest inf,ections@erataq|).
Signs
o Tachypnea & Thchycardia
o Bounding pulse with wide
pulse pressure (with elevated
systolic and lower diastolic
o Hyperkinetic cardiac impulse pressure).
o Systolic or continuous thrill.
o Accentuated S,
t split of s' (But it may be masked
by continuous murmur since
X;H:.T:, maximum intensity of conrinous
"",U1
o Continous (machinery) murmur -> Murmur starts after
S, and reaches the peak at
audible only during a part of the sr. It then diminishes and is
diastole' Murmur is best heard at second reft
below left clavicle. irntercostal space and is arso
heard
o S, may occur at apex followed
by a delayed diastolic murmur.
Differential diagnosis
o 'Small'Aor topulmonary window
defec{AIIMSll) has symptoms
similaT fs pl)1{.aaus0r). Aortopurmonary
is an abnormar communication window defect
between ascending aort) ana
mati:in, purmonary artery.
Course and comptications of pDA
c spontaneous closure of PDA does
not usually occur infull infants
because pDA in term infonts
abnormality of ductal smooth muscles resultsfo,rm structural
(In premature infants spontaneous
infants results from unresponsiveness crosure may occur because pDA in these
to oxlgen){euus t0, 06, es,Kerata 00).
o Pulmonary vascular pressure
regress slower than normal and
maximum decrease occurs around
at 1-3 weeks). 6-g weeks (normary
o Common complications are _
:
i) ctlp -> MC complication and MC cause of
deathar 13,NEE)).
ii) Infective end.ocayfllslsrNrnr) --y 2nay6 cause
of death.
iii) Aneurysm of pDA _+ Rare and possible rupture in adult life.
iv) Pulmonary hypertension.
v) Pneumonia (6
frequent chest infections)(Kerata00).
vi) Eisenmenger syndromeNEED.
Management of pDA
r NSATDs (most commonly indomethacin)^'ttusoalare
used to induce crosure of pDA,
of prostaglandins,llMs 06) (Prostaglanding as these drugsinhibit synthesis
oot).
are involved in maintainance of patency of
ductus arteriosus@rrMs 04, ss,Ar
o If indomethacin is not successful
and the duc hemodynamically significant,
without division of ductus should surgical ligation{Aros.) yri16 o,
u. p.rro.-'JJ.remains
r Left ventricle recieves larger amount of blood that results
in volume overload -+ Left ventricle enlargement.
o Extra volume passes through aortic area
cause delayed closure of aortic
valve which may close even after pulmonary
valve (normal pulmonaryvalves close
after aortic valves). -+ paradoxical spliting
of Sr, i.e. A, occurs after p, (Normally
A, occurs before pr).
t left ventricular volume ejected into the aorta
results in dilatation of the ascending
Hi: aorta + Aortic ejection
Management of pDA
r NSATDs (most commonly indomethacin)^ilMs06)
are used to induce closure of pDA,
as these d^tgs inhibit synthesis
of prostaglandiflsallMs 06) (Prostaglanding
are involved in maintainance of patency
oo)). of ductus arteriosus'rrMs 04, es, Ar
h.
I
&, fl
fhe X-ray isrsuge*tive- of irhi{h CI{D , .
a) ' ppA,:"' 1.
c) .''TOF ''r .
d) 'TGA,'''
Ans. is,lql i,e;;,PDi!l
TETRALOGY OF FALLOT
r TOF is the commonest cyanotic congenital heart disease@EEr).
o It has four components :-
06' NEEI' PGt 04)
i) VSDaI 13'
o Chest x-ray shows normal heart sizewith oligaemic lungfields. The heart is boot shaped@NB ts) (coeur an sabot)@Elr,
Al0a).'Ihere may be right aortic
arch in 25o/o patients.
o ECG shows right axis deviation, inverted T waye and'P' pulmonale.
i;:9,r,x1gt* :A. ca r di$ 5 cu Ia r sy st e m
Management of TOF
o Management consists of :
A) Medical management : It is mainiy concerned about management of anoxic/cyanotic spells (tat spells)
correction of anemia :-
r Knee chest position r Propranoiol : 0.1 mg/kg/IV
r Humidified oxygen r Vasopressors : Methoxamine IM or IV
r MorphinerPclat) A.l to 0.2 mg/kg subcutaneous inj r Correction of Anaemia.
r Correction of acidosis with sodium bicarbonate TV
w lsoprenaline should be ovoided asitcausesperiphera! pooling of blood@nMsA).
E) Snrrgicalmanagernent:Itconsistsofanastomosingasl,stemicartervwithpuimonaryarterytoincreaseoulmonarr.
biood florv. These shunt are :,
i) Blalock - Taussig shunt -> Subclavian artery - Pulmonary Artery anastomosisur06).
ii) Modifieil Blalock-Taussig shunt: Subclavian-pulmonary artery shunt by Gore-'fer
interposition graft. It is
the most popular procedure at any age@NB 1s).
iii) Pott's shunt -+ Descending Aorta to Pulmonary Artery@rot) (no longer performed).
iv) Waterston's shunl -+ Ascending Aorta to right pulmonary Artery (no longer performed).
Fallot's physiology
c Group of condition presenting with similar feature of TOF.
e These includes -
1) TOFGIi5) 4) Single ventricle with pS
2) TGA with VSD &Psrerisr 5) Corrected TGA with VSD & pS
3) TA(AI ls) 6) Double outlet right ventricle with pS
TRICUSPIS ATRESIA
I ThroughASD
Left atrium
Left ventricle
Pulmonary circulation rhroush *rZ\ hroush aortic vatve
t +- I
Haemodynamics
o The inflow portion of R.V. is hlpoplastic
r The systemic venous blood coming to R.A. exits by way of a patent foramen ovale@EBr) or an ASD.
o A VSD provides communication between L.V and outflow portion of R.V
r The L.V. thus maintains both the systemic and pulmonary circulation.
o The saturation of blood in the pulmonary artery and aorta is identical --> Because unoxygenated blood from right
atrium mixes with oxygenated blood into left atrium.
o The pulmonary blood flow is dependent on size of VSD -+ Smaller the VSD, less the pulmoanry bloodJlow@IlMsss).
Clinical features
o Child is cyanotic from birth@101' AIIMS 00)
.
o Ebstein anomaly consists of downward displacement of an abnormal tricuspid valve into the right ventri-
el, 80)
cle@NB .
c Normally tricuspid valve has three leaflets -+ Anterior, posterior and septal.
r Fixed end ofthese leaflets is attached to valve ring in tricuspid area.
r In Ebstein anomaly, anterior leaflet is attached to valve ring as normal, but the other two leaflets (posterior and septal
are displaced downward and are attached to the wall of left ventricle.
c The portion of right ventricle above he tricuspid valve becomes a part of right atrium -+ atrialized right ventricle.
Hemodynamics
* The tricuspid valve anomaly results in obstruction of blood flow as well as regurgitation of blood from the righ;
ventricle into the right atrium -+ Dilatation and hypertrophy of right atrium@r 15 DNB 12) due to volume overload.
e Blood flows right atrium to left atrium through patent foramen ovale or ASD + Right to left shunt and cyanosis.
Clinical manifestations
o Cyanosis o Fatigue
o Dysnea on exertion o Paroxysmal attacks of tachycardia
Signs
o Cyanosis and clubbing
o Dominant V wave on JVP.
e Systolic thrill at the left sternal border
e S, normal
o S, wides split but variable
c Rightventricular S.
0 Right.atrial 54.
e Systolic murmur due to regurgitation at tricuspid valve.
e Delayed diastolic murmur due to obustruction at tricuspid valve like tricuspid stenosis.
c Both systolic and diastolic murmur produced at the tricuspid valve have scratchy character like pericardial
friction rib.
e Patients with Ebstein anamoly may have accessory conduction pathway causing WPW syndromerA,rs).
r As oxygenated blood is not available for systemic distribution, survival of the patient depends on the
presence of atrial, ventricular or aortopulmonary communication.
B) Physiologically correctedtype
r Right atrium is connected to an inverted morphologically left ventricle and Ieft ventricle is connected to
pulmonary arterY.
r Left atrium is connected to an inverted morphologically right ventricle and right ventricle is connected to
Aorta.
r So, these patients have normal route ofblood flow except for that, the functions ofright and left ventricles
are interchanged due to Position.
r This type of TGA is associated with other anomalies.
: The hemodynamics and clinical features depend on other anomalies because corrected TGA itself has normal
route of blood flow.
Hemodynamicsof TGA
13' PGI ee).
o ln TGA aorta lies anterior and to the right of pulmonary 4rtery6r
o In patients with TGA the oxygenated pulmonary venous blood recirculates in the lungs whereas deoxygenated
systemic venous blood recirculates in the systemic circulation -> Pulmonary artery saturation is always higher than
aortic saturation (opposite to normal person).
o Because oxygenated blood is not available for systemic circulation, survival depends on the mixing available between
the two circulation.
r So, patientswith TGA can be divided into : -
i) TGA with intact ventricular septum.
ii) TGA with VSD.
ii)TGAwithVSD
t Presence of VSp/rctoz'se) of adequate size results in good mixing of blood.
r patients become symptomatic, at 4-8 weeks when fetal pulmonary vasculature regresses maximally -+ CHF
develops at this time.
r The failing left ventricle and large pulmonary blood flow cause increase in Ieft atrial pressure + t back
pressure -> Pulmonary venous hlpertension and pulmonary plethora'
r The presence of a large VSD equalizes the pressure in the two ventricles as well as in two great vessels.
r pulmonary artery carries large flow -+ patients with TGA and large VSD develop pulmonaryvascular obstructive
disease (Eisenmenger physiology) early in life.
eardlouasculsr System
X-rays
e Cardiomegaly
o Plethoric lungfields
o "Egg on Side'(NEEr) appearance -+ right upper fields appear more plethoric
than other areas.
o Absent thymic shadow.
Management of TGA
o when TGA is suspected, an infusion of prostaglanding E,6t tst (Misopro{Alts),
riaprostil) should be iwitiated to
maintain potency af dwctus arteriosus\t 04, Arr/rs 04) to allow mixing of biood.
a Infants who remain severely hypoxic or acidotic clespite PGE infusion I .r:
should undergo atrial septostomy(lr i.e.
artilrcial ASD to allow mixing of blood. Septostomy is successful only upto
the age c;f 6 -12 weeks.
r Arterial Switch Procedure is the definitive swrgico.l
ltrocedure.In this, aorta and pulm,nary artery are divided and
reanastomosed in correct position. Two arterial switch procedures are
:-
i) Iantene arterial switch procedure (surgical treatment of choice)
ii) Mustard and senning procedure.
Hemodynamics of TAPVC
c TAPVC results in the pulmonary venous blood reaching the right atrium which
also receives the systerrtic venous
blood(Ate7).
o This results in volume overload to right atrium -+ Right atrial enlargement.
r I-arger volume of blood reaches the right ventricle + Right ventricle enlargement.
o bloodJlow to the lefi atrium is through patentforamen ovale or ASD(AIe7).
The
o Because there is mixing of unoxygenated blood from systemic circulation and oxygenated blood from pulmonary
circulation in the right atrium -+ The oxygen saturation of blood in pulmonary artery is higher or identical to that
in AortaGIeT).
: ", t'
a l Figqre tof S,appearance (Snowman,sign) is characteristic of TAPVC.
EISENMENGER SYNDROME
development of pulmonary vascular resistance. Initially shunt is from left to right as the systemic vascular pressure
l
is greater than pulmonary vascular pressure. With time pulmonary vascular resistance increases due to change in
pulmonary vessel wail as a result of increased flow in pulmonary vessels. When pulmonary vascular pressure exceeds
the systemic vascular resistance, reversal of shunt into right to left shunt occurs.
t Tltus, development of pulmonary hypertensian can be assurmed to be a sign of impending Eisenmenger's syndrome.
Signs of pulmonary hypertension are : -
1) Loud' P2ttrrrurs 'ot
11i) Parasternalheaye
o The hilar (central) area suggests pulmonary plethora whereas the peripheral lung fields suggest pulmonary oligemia'
ECG
o tught ventricular hlpertrophy with right axis deviation'
e 'P'pulmonale.
COARCTAtrION OF AORTA
andposterior
r Coarctation of aorta (coA) is a constriction of aorta due to sharp indentationinvofuinganterior,lateral
wall of aorta. The medial wall is spared in the narrowing'
arteriasus
o of coarctation@t se) occur just below the origin of left subclavian occur at the arigin of ductus
9go/o
Z) An,,adult'forru in which there is discrete ridge like in{biding of the Aorta just opposite to ciosed ductus arteriosus'
not formed.
o Ifthe constriction is distal to tluctus arteriosus (post ductal or adult type coarctation ofaorta), it causes obstruction
circuiation + This
offlow ofdesending aorta, and parts ofbody that are suppiied by descending aorta, have impaired
stimulates formation of collaterals in fetal life'
This collateral circulation
r Collateral circulation connects the proximai and the distal aspects of the vessels over time.
will develop mainlY from the : -
r Subclavian
r Axiliary
07)
s Internal thoracic@rttts
t Superior and infetior epigastric@uMs 07)
r Intercostal arteries
Hemodynamics after birth
r After birth, ductus arteriosus closes, so that blood flow to descending aorta from right ventricle does not occur and
descending aorta must receive its total supply from left ventricle via ascending aorta.
r But there is obstruction due tc coarctation'
-+ Hypertension
r In preductal coarctation, there are no collaterals -+ Neonates become symptomatic imrnediatly
results in CHF.
r In postductal coarctation, due to Presence ofcollaterals neonates are spared
from developing hypertension & cHF.
r Due to obstruction, there is pressure overioad to ieft ventricle -+ Left ventricular
hypertrophy.
Clinical manifestations of CoA
o Symptoms of coarctation of aorta occurs due to decrease
in blood suppty distai to aortic obstruction.
o If obstruction is distal to left subclavian artery, manifestations
are due to arterial insufficiency to lorver limbs.
t Intermittent claudicationLr ss)
r pain
r Weakness of Leg
a Dyspnea on rurxninglAree)
I weak pulses and iower BP in the lower extremities -+ Delayed
or weak impatpable fetnorals compared to sh.ong
brachialarteries6I10'06,AllMS02).ftis6Irc,06,AIIMS02).
c collatetal circulation develops between precoarctation arterial branches and the post caarctation arteries through
enlarged intercostal and internal mammary arteries.
e This produces radiologicallyvisible erosiotts (notching)
ofundersurface {ir{e; ior) afribs.
. Hypertension -+ Headache, dizziness.
o If the obstruction is proximal to left subclavian artery
-+ Blood supply tr: leli arm (sr,rcoiied by left subclavian)
is interrupted whereas blood supply to right arm is normai
-+ pressure difference in two arms"
Murmur in CoA
r The blood passing through the narrowed aorta --> Midsystolic
nxurrnttrin anterior part of chest, back and spinous
process.
r when lumen becomes seYerly narrowed the blood flow through it, turns into
c coA is associated with bicuspid aortic valve in
a high velocity jet + cantinous murmur.
50-807o of patients. The bicuspid vaive produce aortic
regurgitation
-> Diastolic murmur.
Radiological finding of CoA
1) Abnormal aortic arch is the commonest finding. Site of narrowing may be seen
an indentation. classical ,3,
as
sign or 'double bulge sign' on ieft border of aortic shadow
is formeci (above by down word) : prestenotic dilatation.
coarctation itself (indentation), and poststenotic dilatation.
2) Rib notching is seen on 'inferipr' border of 3'd or 4th rib down
wardslr se, e8). rtis due to enlargement of intercostal
arteries (collateral vessels)alss). Rib notching is seen in adulthood, (not
seen until late childhood).
Causes ofdeath in CoA
o The causes of mortality in co-arctation of aorta are :-
t Hypertension
t Rupture of aorta
t Cerebral haemoruhage(ecr 00)
(due ta aneurysm rupture)
s Aortic dissectiort
t Left ventricular f,ailwrsea oo)
rThus,ostiumprimumASDisatypeofAVSDorendocardialcushiondefect.
ii)CompleteAVSD:Thereisacommonatriventricularjunctionandsinglecommonvahrrlarorifice.
s congestive heo"tt failure is state in which the heart co?1tlot praduce tlte cardiac out required to sustain the
rnetabolic needs o;f tue body, without evoking certain compensatorv meclzanism.
o The most cofilmon cause of CHF in infants -+ Congenital heart
disease(coued0s).
I The rnost c&mmcn cause of CHF in the older children -+ R.heumatic fever(rrri, & rheurnatic heart
disease.
:r'-1 :: .::.li:iii,l:::::i:..=1:ar::l r 1:
a Tachypnea 1S Cardiac enlargement
e Tachycardia * Galtop rhythrn (S3) t Facia'l edem;i :
a Cough * Peripherai cyanosis {t Jugar venous engrogment
o Wheezing * Small volume pulse * Edema of feettNEEt)
6 Rales in chest & Absence of weight gain o Ascites@Gt83) (in older children)
e Hoarse Cry * Ot i!!u rig{eet a1 ttwen ao1'
* PUlmonaryedern6{Pct83)
Treatmant
r Coirrmonly useri drugs for trearment of cI{F in chilclren are :-
1) ACE inhibitors (drug of cltoiee1ipn,0q))
2i Diuretics
3) Beta-blockers.
o lliuretics (especially doop diuretics) are the drug of choice to cantrol pulmonary
eclema antl systemic venous congestion,
RHEUMATIC FEVER
H
As is the case of streptococcal sore throat, acute rheumatic fever most ofien occurs in children, the p*ak age
related incidence is between 5-75 years(co-"doa),
Epidemiological risk factor for rheumatic fever, include lawer standards of living especially cror,vriing, ihe diseasr: ir a.);
1. Corditlsutt&s,0,el) A) Clinical
2, ArthrltiCutnslo,st) i) FevelAtoT)
3. SubcutaneousnoduledAilMs%t ii) ArthralgiarArrsr
4. Chareaatlrls 10) iii) Previous rheumatic fever or rheumatic heort disease(At 07)
t Two major or one major & 2 minor criteria are required in the presence of essential criteria to diagnose ecul*t
rheumaticfever.
Rheumatic carditis
o It is the most common acquired heart disease In 6hildlsn{atrs).
o It is seen in 40-600/o of patients. Usually seen within 3 weeks. It is a pancarditis@Gre8r involving all the three iayers I
Myocardium, endocardium & Pericardium.
o Rheumatic carditis is the only manifestation of acute RF that has the potential to ceuse long term disubility a*d d.c*h.
r The rnost common cause of CHF in the older children -+ Rheumatic feveral ") & rheurnatic heart disease.
a Pulmonaryedemaed$)
Trsatment
r Commonly useci drugs for treatment of CHF in children are :-
1) ACE inhibitors (drug of choicelipns0a))
2) Diuretics
3) Beta-blockers.
s l)ittretics (especialty doop diuretics) are the drug of choice to control pulmonary edema and systemic venous congestion.
RHEUMATIC FEVER
r Rheumatic fever is an acute irnmunologically mediated muitisystem intlammatory disease that occurs few weeks
08).
after an episode of group A streptoco ccal pharyngitis(co'ned
o Lhe disesse is imtnune mediated, not a communicable disease(co,ed98).
the penk age
o As is the case of streptococcal sore throat, acute rheumatic fever most often occurs in children,
related incidence is between 5-75 years$o*"doa) '
o Epidemiological risk factor for rheumatic fever, include lower standards o! living especially crowding,
the disease hai';
populations(conedol) '
been more commofi among socially and economically disadvantaged
o criteria to diagnose Rheumatic fever is Modified fone's criteria.
Criteria for Diagnosis of Rheumatic fever
1. CordlitistAtr[s,o,e4) A) Clinical
2, ArthrltistAttnsla,s4) i| Fevey'Atoz)
3. Subcutaneousnoduleso*Ms%) ii) ArthratgiarAt'5t
iiil. Previoi rheumatic fever or rheumatic heart disease(Atl7)
s ,o)
4. Chorea$:lr,t
5' Erythema marginatum '
;"T::::?tase reactants; teukocytosis, erevated sedimentotion ret*{Atir,s&t
Essential criteria
I Evidence of recent streptococcal infection as indicated by
-
e Two major or one major & 2 minor criteria are required in the presence of essential criteria to diagnase
acntle:
rheumaticfever.
Rheumatic carditis
r It is the most common acquired heart disease in children(Aris)'
o It is seen in 40-600/o of patients. Usually seen within 3 weeks. It is a pancarditis(Pcr
es)
involving ail the three ial''ers )
10-30o/o cases(DNB
r5). Pulmonary valve involvement is unusual(DNB's)'
Arthritis in RF
o It mostfrequentmaior@rst) manifestation (75% of cases)'
is the
period
o ltis migratory polyarthritisx<"tutaes,Pclo3), i.e., several joints are involved in quick succession and each for a brief
of time.
e Anyjointmaybeaffectedbutinvolvementoflargejointssuchasknee,ankle,elbow,andwristiscommon.Smalljoiirts
ofhands and feet are not involved.
r Inflammation of any one joint subside spontaneously within a week and the entire bout of polyarthritis rareiy last
more than 4 weelcs,
o Resolution is complete with no residualioint damage(rNte)'
o A strikingfeature is dtamatic response to salicylates(Pcl88) '
Sydnehamk chorea
o The characteristic picture of chorea is
that if ofien occur in isolation@cr'{ either
unaccompanied by other major
manifestations of RF or after a latent period of
several months, at a time when all other manifestations
subsided. of RF have
o Rapid purposeless involuntary movements
most noticeable in extremities and face.
Movements disappear during
sleep. Emotional liability is characteristic.
a Most patients recover in 6 months. sex
hormones (estrogen) or pregnancy can
cause recttrrences@cr 03) .
Subcutaneous nodute
c It is a rare manifestation of acute RF Subcutaneous
nodules are a late manifestation and appear 6 weeks after the onset
ofRF.
o It is often seen in association with carditis@cr 07. 03).
They do not appear as isolated manifestation.
o These are round' firm, painless dt nontenderecl0T'*3),rr..ly
extensor surfocs5eetoz) of tendons near the bony
-orubl subcutaneous lesions. They are found along the
prominences such as elbow, knees, wrists,
occiput and spine. They
last for a week or two and disappear spontaneously.
Erytherna nnarginatum
e Rash present on the trunk and proximal
parts of the extremities. Face is spared@cro3).
Macales or papules that extend
outwards while the skin in centre returns to
normal. Never pruritic,'' ,LvEr
never ,ruuraLe(l'
indurated. Kasn .
Rash ls evanescent migrating
from place to place. No residual scarring occurs.
Treatrnent of Rheunnatic fever
o Drug of choice for treatment o-f RF is penicillin. Erythromycin is the drug
07)
of choice in penicillin allergic patienlArrMs
"
INFECTIVE ENDOCARDITIS
Crr.q.pii*,
':::a'
.:.a::,
a o Roth spots
a * Oslert nodes
Night sweats o Janeway lesions
Anorexia r Splinter hemorrhages
& Fatigue * Stroke. myocotic aneurysm
t Weakness
MISCELLAI{EOUS
Hypertension
I Hypertension is defined as the arterial blood pressur e above 95th percentile with reference to age and sex.
o Between the 90th and 95th percentile it is called borderline high blood pressure.
t Mostcommoncauseofhypertensioninchildrenisrenalparendrymaldisease@l10'es'Pcre3).Amongrenalparenchyrnal
diseases chronic glomerulonephritis is the most common (2|o7o;rouo,nt,rcl0a) followed by chronic pyelonephritis(Ar
)s).
r::,! tdlk
1-3 months 75+5 50+5
4.'12 rn0iiths '.,'84:+.5:.,..
651..5
1 -B years 95+5 65+5
9:14 years. ,.,,105 15r. 65'+ 5
Differential cyanosis
r When one extremity is cyanotic and the other is pink, it is cailed differential cyanosis. Causes are :-
1) Upper limb : Transposition of great arteries, preductal f,64rarrs1 secondary pulmonary hypertension, Interrupted
aortic archGr's).
ii) Lower limb ' PDA(PGIee), Persistent pulmonary hypertension(A/r5), right to 1eft shunt.
o ln fetal circulation'. Brain and heart (coronary) circulation receive blood with higher oxygen saturation.
.1..:.-$ffigesia.miIialieidencyin..cHDS.i'kno,wiior.:rtolroram.s}rndrome(ASDwithbanyabnormalities).
o CHDs in congenital rubella:PDA (most common), pS, VSD, ASD (least common).
. t: .:.aa. :::_
lmportont cyanotic CHDs with pulmonary oligemia: Tricuspid atresia, TOEEisenmenger's syndrome, Ebstein anomaly.
'
i:s..;*8,.T-EBr4,
True about Ebstein anomaly: Downward displacement of tricuspid valve, right atrial dilatation, systolic and diastolic murmur with
scratchy character.
CHD which may be associated with WPW syndrome: Ebstein anomely
position of aorta in transposition of great arteries (TGA) : Anterior and right to pulmonary artery.
Trueabout TGA: Cyanosis at birth, intact septum or VSD, CHF, sinq le S, , pulntonary plethora, 'Egg on side' on X-ray.
Treatment of TGA includes: PGE, Rashkind atrial septostomy, arterial switch procedures (Mustard & senning or Jatene).
I"4ost common conotruncal defect: TGA
M o st com m on type of TAPVC : Su pra-ca rd iac (Type 1 ).
tnTApVC:Oxygen saturation is higher in pulmonary artery, infracardiac type is always obstructive, pulmonary venous blood reaches
in right atrium, blood from right atrium to left atrium florvs through patent foramen ovale or ASD (but notVSD).
Figure of '8' configuration or snowman Gppearance on chest X-ray :TAPVC (su pracardiac type).
Common presentation of CoA: lntermittent claudication, headache, dizziness, hypotension, dyspnea on exertion, weak pulse in
femoralvessels.
lmportant causes of death'in CoA: CHF, aortic dissection, cerebral hemorrhage, infective endocarditis, hypertension, aortic rupture'
Ductus dependent CHDs: P5 without VSD, TOF, CoA, TGV, Hypoplastic left heart, congenital aortic stenosis, Tricuspid atresia.
Ductus independent CHDs:TAPVR, Truncus arteriosus, anomalous origin of left coronary artery from pulmonary artery.
Acyanotic heart disease with eiettion systolic murmur: ASD, VSD, PDA, CoA
True about'RF:Occurs after streptococcal pharyngitis, affect 5-15 years old in low socioeconomic status.
Major criteria in diagnosis: Carditis, arthritis, chorea, subcutaneous nodule, erythema marginatum.
RF
Minor criteria in RF diagnosis: Fever, arthralgia, previous RF, ^ ESR, leukocytosis, ^CRq prolonged PR interval on ECG.
Most common valve involved in RF: Mitral valve.
Most common valvular defectln RF: Mitral regurgitation'
Most common maior manifestation in RF: Arthritis'
Carey-Coombs mLlrmur.. Soft (low-pitched) mid-diastolic murmur in RF due to mitral regurgitation.
Sydenham's chorea of RF:Occurs in isolation; aggravated by sex hormones (estrogen) and pregnancy.
Subcutaneous nodulesin RF: Non-tender, on extensor surface, often seen in association with carditis.
I
QUESTIONS
a) ASD
NADffS CRITERIA b) VSD
c) TOF
8. NADAs criteria are used for- (All India Dec li Pattern) d) PDA
a) Assessment of child for degree of dehydration 17. Recurrent respiratory tract infections may occur in
b) Assessment of child for degree of malnutrition all of the following excePt - (AllMS Nov 05)
a) Ventricular septai defect d) Ventricular septal defect with puimonary arterial
b) TetrologyofFailot hlpertension.
c) Transposition ofgreat arteries
d) Total anomalous venous return 26, ASD is associated ryith all except - (NEE: Dec.12 pauern)
a) Infective endocarditis
18. In which of the following conditions left atrium is
b) Stroke
not enlarged - (Ar 06) c) Arrhythemia
a) Ventricular septal defect d) Puimonaryhypertension
b) Atrial septal defect
c) Aortopulmonarywindow 27 . Hinar danee on {luorosccpy is seen in -
d) Patent ductus arteriosus (ALl India Dect5 pattern)
A) ASD
19. Which one of the following congenital heart diseases
b) VSD
has cyanosis without cardiomeglay and/ or conges_
c) PS
tive heart failure - (upsc s8) d) rn
a) Transposition ofgreat arteries
b) Fallots tetralogy
c) Congenital mitral regurgitaion VENTRICULAR SEPTAL DEFECT
d) Congenital pulmonary stenosis
28. Moot eommon type of ySD- (All India Dec.14 Pattern)
ATRIAL SEPTAL DEFECT a) Membranous b) Muscular
c) Multiple d) None
2*- Lerter*bacher symdrome - in*luda A/E - 29" True atrout VSD are a.ll exeept - (All tnrlia Dec.t3 pattern)
(cET luly 15 Pattern) a) Left to right shunt
a) Mitrar stenosis b) Pansystolic mormor
b) eso c) Reverse spliting of S ,
c) VSD d) Leti arria[ hyperrrop-hy
d) Left to right shunt 30. A child with large perirnembranous vSD has
Moot eornrnon AS& is - lAll lndia Dec j5 pattern) congestive heart failure. What may be the cause of
a) Ostium primum improvement of,cardiac failure in the patient -
b) Patent foramen ovale (AIIMS Nov 01)
c) ostium secondum a) Aorticregurgitation
d) Sinus venosus b) Vascular changes in pulmonary circulation
22_ &l*lot eomrnon ASD ie down syredrorne is _ c) Infective endocarditis
(All India Dec15 pattern) d) Closure of VSD spontaneously
a) Ostium primum 31. A 29-day old child presents with features ofconges_
b) Ostium secondum tive cardiac failure and left ventricular hypertrophy.
c) Absent atrial septum Auscultation shows a short systolic murrnur. Most
d) Sinus venosum likely diagnosis is - (AIIMS Nov 2K)
23. All of the following are true about ASD except -
a) Rheumatic fever
(Ar 01)
b) TetralogyofFallot
a) Right arrial hlpertrophy c) Transposition ofgreat arteries
b) Left atrial hypertrophy d) Ventricular septal defect
c) Right ventricular hypertrophy JZ. A patient of VSD in CCF develops clubbing with no
d) Pulmonary hypertension cyanosis diagnosis is -
@Gr eB)
24. Irr atrial septal defec{ t}ee aorta is - (NEET Dec.12 pauern) a) Right to left shunt
a) Small b) Left to right shunt
b) Normal c) Subacute bacterlal Endocarditis
c) Enlarged d) Pulm. edema
d) Aneurysmal JJ. True about VSD is all except - @ttMS lune e7)
?< A young female presents with history of dyspnoea a) Small hoie closes spontaneously
on exertion. On examination, she has wide, fixed b) Defect is usually in membranous part
split S, with ejection systolic murrnur (ilr/w) inleft c) Endocarditis is a common complication
second intercostal space. Her ECG shows left axis d) Pulmonary Oligemia in chest x-ray
deviation. The most probable diagnosis is - 34. Which of the following features on X-ray chest can
(AIIMS May 2003) differentiate an Atrial septal Defect (ADH) from e
a) Total anomalous pulmonary venous drainge. Ventricular Septal Defect (vsl) (At u)
b) Tricuspid atresia. a) Enlarged Left Atrium
c) Ostium primum atrial septal defect. b) Pulmonary Plethora
ie H,Ap!jrrR::4::,:
il
b) o - blockers (CET Nov 15 Pattern)
c) Cal. channel blockers a) Aortic valve b) Tricuspid valve
d) Nitrates c) Mitralvalve d) Pulmonaryvalve
tLz. Drug of choice for Rheumatic fever prophylaxis in
penieillin allergic patient - (AIIMS May 07)
RHEUMATIC FEVER a) Erythromycin b) Clindamycin
c) Vancomycin d) Gentamycin
lrDl. All are true about rheumatic fever, except - l 13. Sternids are given in rheumatic fever when there is-
(AIIMS June 99)
(All India Dec.14 Pattern)
a) Common in poor socioeconomic group
a) Carditis b) Chorea
b) Develops after streptococcal pharyngitis
c) Subcutaneous nodules d) All
c) Communicabledisease
d) Seen in 5-15 years ofchildren I14. In a patient of rheumatic carditis full dose of steroid
is given for - (Kerala 04)
n02. Which of the following is a minor criteria for diag-
a) 3 weeks b) 6 weeks
nosis of Rheumatic fever fRF) according to modified
c) 9 weeks d) 12 weeks
Jones criteria - (Ar 07)
a) ASO titre b) Carditis
c) Fever d) Subcutaneous nodules INFECTIVE ENDOCARDITIS
103. Which is not a major criteria of fones in Rheumatic
fever? (AIIMS Nov to) 1 15' Bacterial errdocarditis is most commonly caused by-
a) Pancarditis b) Arthritis (PGl Dec 03)
c) Glomerulonephritis
d) Essential hypertension
a) Diversion of VS.D. rr-urun.orffi,ij.'ffi'
operation
e) Phaeochromocltoma
b) Diversion of the septal defect
c) Reattachment and riversal of aorta and pulmonary
MISCELLANEOUS arteries
d) No corrective procedure for this anomaly
122, Most common cause of acquired heart disease in 132, Systolic rnurmur in TOF is due to ? (APPG 08)
children- (All Inrlia Dec15 pattern) a) VSD b) pulmonary stenosis
a) Acute rheuamatic fever b) Kawasaki c) ASD d) none
c) Takayasu d) Diabetes 133. A two-year old boy presented with episodes of
123. Differential cyanosis is seen in- (All India Dec.t4 pattem) becoming dusky. On exarnination, there was central
a) TGV b) TAPVC cyanosis and clubbing. There was no pallor, oedema
c) PDA d) VSD or respiratory distress. The heart was normal sized
124. Differential cyanosis occurs in which disease - with a parasternal heave" A systolic thrill was pal_
(All India Dec15 Pattern) pable over the left middle sternal border. First heart
a) Severe coarctation b) Inturrupted aortic sound was normal and only the aortic component
arch was audible in the second heart sound. Liver was not
c) PPHN d) AII of above enlarged - (UPSC 07)
126. Pulsatile varicose veins in lower lirnbs is seen in - L34. In which of the following differential cyanosis
found? (UPSC-r a8)
(ArrMS 01)
a) Klippel trenaunay syndrome a) VSD with reversal of shunt
b) TR b) PDA with reversal of shunt
c) RV failure c) ASD with reversal of shunt
d) Carcinoid stenosis of tricuspid d) Tetralogy ofFailot
127. -
Umbilical cr:lrd has (NEET Dec.12 pauern)
135. Ductus arteriosus closes in response to - (upsC_II 0B)
a) 1 vein and 2 arteries b) 2 vein and 2 arteries a) Decrease in peripheral oxygen saturation
c) I vein and I artery d) 2 veins and 1 artery b) Indomethacin therapy
c) Prostaglandin E1
d) Increase in pulmonary vascular resistance
Q['ESTIONS OF VARIOUS OTHER EXAMINA- 136. A new born presents with deepening cyanosis at
TIONS birth, with congestive heart failure and normal first
heart sound. X-ray reveals cardiornegaly diagnosis
128. Children born to mothers with systemic lupus S rs - (uP oB)
139. A newborn baby develops cyanosis on daythree of I45. Cause of death in Acute rheumatic fever is- (up 08)
life. On auscultation, there is a systolic murmur. a) Pericarditis b) Myocarditis
Echocardiography reveals a cyanotic heart disease c) Endocarditis d) Streptococcal sepsis
in the baby. Which one of the following drugs can be 146. Which of the following manifestation of rheumatic
administered to prolong the life of the baby pending fever disappears completely? (Jipmer 11)
intervention - a) Carditis b) Arthritis
(uPSC,r oe) c) Chorea d) Subcutaneous nodules
a) Indomethacin b) Ibuprofen 147. The average B .P. of a I year old child is -(pcr 78, AMC 81)
c) Prostaglandin E, d) Propanolol a) t20180 b) 7sls0
140. The clinical features associated with coarctation of c) 95150 d) 60/30
aorta in older children are the following except - 148. The most common anomaly seen in the fetus of a
a) Upper body hypertension (UPSC-II 0s) mother taking lithum carbonate is - (Up 97)
b) Prominent pulsation in neck a) Cardiac deformities
c) Fatiguableness, tiredness in leg b) Neural tube defect
d) Absence of flow murmurs over scapular region c) Limb reduction
l4l, Commonest cause of enlarged cardiac shadow in d) Genitourinarydeformities
X-ray of a child is - (Karn.2oo0)
a) PDA b) CoarctationofAorta
IIT
ANSWERS
FETAT CIRCULATION
t. Ans. is 'b' i.e., umblical vein tRef o.p, Ghai }e/e p. 402 & fr/e p. 394; Nelson t1h/e p. 1s551
t Blood oxygenated in the placenta returns by way of the umblical vein, which enter the fetus at the umblicus and
course through to join the portal vein.
,,
Ans" is'd'i.e., Heart reeeives bloodwith htgh ffiyge& satur*tiolr lR$Netsen l#bfcp. t&SS; Gkad.pfep.3%,1
o Blood in IVC has more saturation than blood in SVC as IVC carries the oxygenated blood of umblical
vein.
r The left ventricular blood has more oxygen saturation that right ventricular blood because
it carries the blood of IVC,
while blood in right ventricle is a mixture ofblood from IVC and SVC.
r So' the brain and coronary circulatiorl receive blood with higher saturation (through ascending
aorta) than the lower
halfofbody.
r The pressure in iight and left ventricles are equal.
Ans. ie t'i.e., t0th dey fxcf ple p.395; Netrsoee r*fep. ]es6]
$n, Gk*t*fep.40J 6
3"
e In full term neonates the ductus arteriosus closes within l0 to 25 days. "
ETIOLOGY
NADA'S CRlTERIA
8. Ans. is 'C i.e., Asseesment of chitd for presemee of He*rt disease lkef 6h*6 */e p. 4M & ffile p. 39g\
The Assessment of a child for the presence or absence of heart disease can be done with
the help of some guidelines
suggested by NADA. These guidelines are called NADAs uiteria.
t
CLASSIFICATION OF CHDS
9. Ans, is 'c' i,e,, Tricuspid atresia lRel A,P, Ghai $th/e p. 404 6 Vh/e p, 410-4111
Gyanotic CHD
Left ventricular or Both Right ventricular Both ventricle Left ventricle Right ventricle
hypertrophy hypertrophy
ventricu lar hypertrophy
o
Y
I
10. Ans, is 'l i.e., Tricuspid a*esi^{Ref: O"P. Ghai $th/e p. 422 b Vh/e p. 410-4111
r A11the given options are cyanotic heart diseases.
. But, amongst the given options, only tricuspid atresia causes left ventricular hlpertrophy.
11. Ans. is '* i,e,, Atrial $eptal defect {Ref. Myung K Park sth/e p. 75 d" A,p- Ghai |th/e p. 404, 41i dr 7h/e p, 4021
Acyanotic GHD
t2" Ans. is '-p" i.e., Tricuspid atresia; 'c' i.e., Pulmonary atresia fRef: Reail helow)
o Normaily, the QRS axis ranges from -30o to + 1000.
r An axis more negative than -300 is referred to as left axis deviation.
r An axis more positive than + 1000 is referred to as right axis deviation.
Causes sJ left axis deviation (LAD)
o Left ventricular hlpertrophy
r Left anterior fascicular block or hemiblock.
r Inferior wall MI.
Causesof Bightaxisdeviation (RAD) q
r Right ventricle overload (right ventricular hypertrophy)
r Left posterior fascicular block.
o Lateral wall MI
r Dextrocardia
e Left pneumothorax
Now see the explanations of previous question and you can easily solve this question.
r Left ventricular hlpertrophy causes LAD, and CHDs causing LVH are : -
i) vsD lll) Endocardial cushion ASD v) Truncus arteriosus vii) Pulmonary atresia
li) PDA iv) COA (in older children) vl) Tricuspid atresia
"$a r d i ovi sc u I ar :Sy st e m
lJ. Ans. is'b'i.e., T'ricuspid atresia, U'i"e., Eisenrnenger complex, ?'i.e., Tetralogy of Fallot
lRef: MywngKpark
Sthle p. 75; O,F. Ghai Bthle p. 404]
Cyanotic Acyanotic
o Tetrologyoffallot e Atrial septal defect
s Transposition of great vessels e Ventricular septal defect
. Tricuspid atresia t Patent ductus arteriosus
o Ebstein's anomaly t Partial anomalous puimonary venous return
. Pulmonary atresia a Coarctation of arota
t Hypoplastic left heart syndrome t AS orAR
e Double outlet right ventricle
I Totai anomalous pulmonary Venous
return with or without obstruction
't Truncus arteriosus
Eisenmenger's syndrome
t4. Ans. is'd'i.e., VSD tfief $.F" G&ea{ &,t'k p. 4t}4 S T*ls p. 4{}s}
Appearance of chest x-ray in a patient with cHD, depends on pulmonary blood flow
:
1) Plethoric lun&fields + If the pulmonary blood flow is increased, the iung f,elds
appear plethoric throughout and
in addition cardiomegaly is present.
2)oligenic lung fields -+ If the pulmonary blood flow is diminished there is paradoxical prominence
of hilar arteries
with clear or ischemic peripheral lung fields.
I
ob'
15. Ans. is i.e., VSD [Rel O.P, Gkai Bth/e p. 414 dz Vhle p. 4A3l
o VSD is the commonest CHD.
t ySD is the commonest acyanotic CHD.
16. Ans. is ocn i.e", TOF ffi#i {}.P. Ghai 8,t,/e {}. ,j$:t, 420 * yt'le p. ,}08; Ntls*ya l{ttil/* y:.
r8. Ans. is 'b' i.e., ASD [Ry'; O.P. Ghai 8th/e p. 413 & 7h/e p. 402)
o ASD is associated with an enlarged right atrium 6 right tentricle to accommodate large volume of blood. The left
atrium is not enlarged because it decompresses itself by shunting blood to the right atrium at a minor difference
in pressure. The left atrium may enlarge once Eisenmenger's syndrome develops and a reversal of shunt is seen
across the defect.
r All congenital heart diseases given in option cause left to riSht shunt.
Size of left atrium in left to right shunts
o In left to right shunt, blood enters from left side ofheart (Lt. atrium, Ltventricle or aorta) to right side ofheart (Rt
atrium, Rt ventricle or pulmonary artery) depending on the site of abnormal communication.
o This blood then flows through pulmonary circulation and again enters the left atrium.
o The path ofblood is then depending on the defect.
r In all these defects, left atrium recieves larger volume of blood which comes through pulmonary circulalion -->
Blood from right side of heart plus some blood fr3)m left side of heart because of shunt enter into pulmonary
circulation and then into left atrium. So left atrium recieye blood volume larger than normal.
o But the effect of larger volume on left atrium will be different in ASD and other left to right shunts.
1) InASD
r Left atrium recieves extra volume of blood, but fortunate for the Ieft atrium, it also has an extra exit for blood,
i.e., septal defect.
.{rrs. is 'b' i.e., Tetralogy of Fallot lRef : O.P. Ghai 8'h/e p. a06 dz Vh/e p. a09l
o Chest infections are frequent in the following twc groups of congenital cardiac anomalies.
a) Left to right shunts + This group includes:
t Atrial septal ilefect
s Ventricular septal defect
t Patent ductus artefiosus
o This group of CHD's are characterizedby frequent chest infections.
r There is large flow of tllood in the lungs which causes lung infections'
o Each attack of cold seerns to turn into Bronchopneumonia.
r It is not uncommon for these patients to have 6-8 attacks of pneumonia in the first year of life.
b) Cyanosis with increased pulmonaryblood flow.
o A large no. of conditions result in a combination of cyanosis with increased pulmonary blood flow.
o Cornmon to these conditions is the presence of abnormal mixing of pulmonary venous blood with the systemic
venous blood and absence of obstruction to pulmonary blood flow.
o The anomalies included in this group are :
1) ItASD
r Left atrium recieves extra volume of blood, but fortunate for the left atrium, it also has an extra exit for blood'
i.e., septal defect.
ilriiltlr: !ii...: :r'::if '
19. Ans. is 'H i.e., Fallot's Tetralogy lRef O.p. Ghai Bthle p. 420 6 Vh/e p. 4081
o Cardiomegaly and CHF do not occur in Fallott tetrology.
No Cardiomegaly
o First you should know the following facts : _
i) Pressure overload to ventricles causes concentric hlpertrophy without dilatation.
ii)Volume overload to ventricles causes hlpertrophy with dilatation
-> Eccentric hypertrophy.
o Due to pulmonary stenosis, there is pressure overload to right ventricle
-> Coicentric hipertrophy of right
ventricle without dilatation -+ No Cardiomegaly.
No CHF
o The VSD of ToF is always large enough to allow free exit to the
right to left shunt.
o Since the right ventricle is effectively decompressed by the VSD,
C-HF never occurs in TOF.
20. Ans. is t' i.e., vsD IR4 clinical recognition of congenital heart diseasep. %al
o Lutembacher syndrome is defined as a combination of mitral stenosis
and a left-to-right shunt at the atrial level.
t Typically, the lefi-to-right shunt is an atrial septal defect (ASD) of the ostium
,irundul* variety.
2r. Ans. is t'i.e., Osteum secondum fRef: Nelson lgth/e ch.42.11
o Osteum secundum is the most common type of ASD.
22. Ans. is 'a' i.e., Ostium primum tRef Ghai Vh/e p. 61j, a01)
o Most common type of ASD and most common cHD in Down syndrome
) osteum primum (endocardial cushion
defect).
23. Ans. is'b' i.e., Left atrial hypertrophy lRef: o.p. Ghai 8,h/e p. 413 6 vh/eq. 402; Nelson
rrth/e p. 18g3,r8s41
o In ASD there is abnormal communication belween left and right atria
which causes left to right shunt because
pressure in left atrium is higher (3-5 mm Hg) than right atrial pr.rrrrr".
o This results in : -
1) Volume overload to right atrium -+ Dilatation and hypertrophy of right atrium.
2) Volume overlead to right yentricle -+ Dilatation and hypertrophy of right ventricle.
3) Increased blood Jlow thro.ugh lungs -+ Pulmonary plethora which can cause pulmonary hypertension.
24. Ans. is 'a' i.e., small [ne7 o.p. Ghai Bth/e p. 4r3 6 Th/e p. 402; Nelson rSth/e p: 18841
Chest x-ray in ASD
o Mild to moderate cardiomegaly . Prominent pulmonary artery segement.
o Right atrial and right ventricular enlargement. o Relatively small
aortic shadow
o Plethoric lungfields.
25. Ans. is t'i.e., ostium primum atrial septal defect fRef: o.p. Ghai B*/e p. 41j dz Vh/e p. 402-40j; Nelson lgth/e p.
1883, 1884)
o wide fixed splitting o/ s, in association with ejection systolic murmur suggests the diagnosis of Atrial septal
defect.
o Ideally with hypertrophy of the right side of the heart, right axis deviation
should be present, but sometimes left
axis deviation is also seen in A.S.D.
deviation.
o Hilar dance sign refers to vigorous pulmonary arterial pulsations due to increased blood flow, often seen fluoroscopicaily
in patients with congenital left-to-right shunts, especially atrial septal defects.
28. Ans. is 'd i.e., Membranou s lRef: Qhai Vh/e p. 40 j; Nelson 18th /e p. -1888, 18891
o VSD may be lecated at : (t) Membranous part of ventricular septum (most common -+ 90o/o), (ii) Muscular septum,
and (iii) May be multiple.
29. Ans. is t' i.e., Reverse spliting of S, [Rel Nelson 18th/e p. 1888, 18891
30. Ans. is'b- i.e., Vascular changes in pulmonary circulationlRef: Nelson 18th/e p. 1888, 18891
o A patient with large VSD develops CHF because of the large left to right shunt. Large amount of blood at high
systolic pressure is entering into the pulmonary circulation and with lhis continued exposure of the pulmonary
vascular bed to high systolic pressure and high llow pulmonary vascular obstructive disease develops.
r The pulmonary vascular resistance gradually rises and becomes equal to the systemic resistance. When this
happens the shunt becomes bi-directional and the signs of heart failure diminish but the patient becomes cyanotic
( Ei s e nm e n e n gerqthy si ol o gy ) .
31. Ans. is t' i.e., i.e., VSD lfuef: O.P. Ghai 9th/e p. 415 6 7tu/e p. 403-404; Nelson 18th/e p. 1888, 18891
35. Ans. is'b'i.e., i.e., Aorta and pulmonary artery lRel O.F. Ghai 9't'/e p. 117 (z 7h/e p. 405; Nelson 18'h/e p. 18911
c Patent ductus arteriosus is a communication between the pulmonary artery and aorta,
36. Ans. is'd' i.e., lVlore comrnon in term baby [Ref Nelson 18th/e ch. 426)
o It is a common problem in premature infants, where it can cause severe hemodynamic derangements and several major
sequelae
37. Ans. is "l i.e., Symptoms similarto aortopulmonarywindowlRef.Nelson 18th/e p. 1891, 1893; O.P. Ghai 8'h/e
p. 419 6 6th/e p. 4A4, 4A61
o Before comparing the symptoms of PDA dr Aortopulmonary window let me discuss the C/F of PDA.
o Patent ductus arteriosus is a communication between pulmonary arters' and Aorta after fetal life"
r PD.A, results in left to right shunt from the aorta to the pulmonary artery. The flow occ*rs brLth
during systole and diastole as a pressure gradient is present throughout the cardiac cycle between the 2 grcat
arteries. This flow of blood results in continuous murmur it is usually heard at 2'd left interspace.
r In patients u.'ith large left to right shunt a low pitched mitral mid diastolic murmur is audible at the
apex, owing to the increased volume of blood flow across the mitral valve.
o There are other conditions which can produce systolic and diastolic murmur in the pulmonary area such as
Aortop ulmo nar y w in dow de.fect.
o In Aortopulmonary window defect there is communication between the ascending aorta and main pulmonary
artery.Usually the defect is large therefore the pressure between the two great arteries tends to equalize and flolv is
established only during systole when left ventricular contraction increases the aortic pressure. So the murmur in
Aortopulmonary window defect is systolic with mid diastolic rurnble due to increased blood flow through mitral
valve.
t
Sometimes when the Aortopulmonary window defect is small, there is continwaus btood JTow fram Aorta to
pulmonary artery resulling in continuous murmur. trn this condition symptoms of Aorticopulmofiary windaw
drtct mrmics the sygnptoms of PDA lContinuous murmur, wide pulse pressure,mid diasiolic murmur).It is very l
Ch.ambar:. :':,, .r:: .RA+ftVr:,, ,r. ,":r: ' ,,'r IAJ IY-*Y "'--. ,,
,W.+'LA+,Rt/
Enlargement lw d / m od rate ca rd i o m eg a !y)
( t I e (Gross cartiamegaly)
Pglnronary {rtery,,,, Enlarged Enfarged' ,':
El:alrged"
Pulmonary Present Present Present
Vasculature
(Pulmonary Plethora)
Aoirta,,' ' . ::'
Normal (or small)
Enlarye4 ,'
35. Ans' is 'b' i'e', i'e" Aorta and pulmon ary artery
[Ilef: a.p. Ghai gil,/e p. 4x7 6 7th/e p. 405; blelson lg,h/e p. 1g9tr)
o Patent ductus arteriosus is a communication between the pulmonary artery and
aarta,
36. Ans. is 3'i.e., &{ore cornrnon in term baby
t.el Nelson XEh/e ch. 426)
problem in premature infants, where it can cause severe
" :H;.ilI-on hemodynamic derangements and several major
37. Ans' is'a'i'e" symptoms similar to aortopulmonarywindo w fRef; Nelson lg,h/e p. 1gg1,
1g%; a.p Ghai gth/e
p. 419 & 6'h/e p. 404, 4061
o Before comparing the syntptoms of PDA 6 Aortopuhnonary
window let rlre discwss the C/F of pDA.
o Patent ductus arteriosus is a communication bitween pui*orory
artery and Aorta afterfetal life.
r PDA" results in left to right shunt from the aorta to the pulmonary artery. The iforr occurs br:th
during systole and diastole as a pressure gradient is present
throughout the cardiac cycle betneen the 2 great
arteries' This flow of blood results in continuous murrnur
it is usuaily heard at 2,d left interspace.
r In patients with large left to right shunt a low pitched mitral mi<l
diastolic murmur is audible at the
apex, owing to the increased volume of brood flow across
the mitrar val.i,e.
o There are other conditions which can produce systolic
and diastolic murmt4r in the pulmonary area suclt as
Aor to p ulmo n ar y w indow defe ct.
r In Aortopulmonary window defect there is comtnunication between the ascending
aorta and mo.in pulmonarT
artery' usually the defect is large therefore the pressure between
the two great arteries tends to equalize and flow is
established only during systole when left ventricular contraction
increases the aortic pressure. so the murmur in
Aortopulmonary window defect is systolic with mid diastolic
rumble clue to increa.*,l blood flow through mitrai
40. Ans. is 'B i,e. Prostaglandin inhibitors {Ref: O.P. Ghai 8th/e p. 419 & Th/e p. 407)
Management of PDA
r After birth ductus arieriosus constricts within a few hours producing functional closure.
o Permanent anatomic closure follows in the next 10-21 days due to extensive intimal thickening.
o The mechanism producing the initial constriction is not completely understood, but the increase in arterial O,
tension plays an important role.
r One more factor which helps in closure of the ductus arteriosus is the decrease in concentration of prostaglandins
at the time of birth
r In the intrauterine period the concentration of prostaglandin PGF2 a is very high. This prostaglandin has a
vasodilatory effect which keeps the ductus open.
Spontaneous closure of PDA
l) In premature infants
infants pDA is due
'::ffi::ff:#:ilx*llHj:"ifflT:*#J,;:ffi,T:".* in
'lhese '{o
Z) InFullterminfants
r llnlikethatinprematureinfants,spontaneousclosureofaPDAdoesnotusuallyoccurinfullterminfants.
r This is because the PflA irr term iafants results from a structural abnormality of the ductai smooth muscle.
40. Ans. is 'd' i.e. Prostaglandin inhibitors fRef: O.P. Ghai 8*/e p. 419 & Vh/e p. 407)
Management of PDA
o After birth ductus arieriosus constricts within a few hours producing functional closure.
. Permanent anatomic closure follows in the next 10-21 days due to extensive intimal thickening.
r The mechanism producing the initial constriction is not completely understood, but the increase in arterial O,
tension plays an important role.
r One more factor which helps in closure of the ductus arteriosus is the decrease in concentration of prostaglandins
at the time of birth
r In the intrauterine period the concentration of prostaglandin PGF2 a is very high. This prostaglandin has a
vasodilatory effect lvhich keeps the ductus open.
o The synthesis of these vasodilator is inhibited at birth
by the inhibition of the enzymecycloxygenase at birth.
o cycloxygenase is an important enzymein the synthetic
pathway oif.ortugrurai.r.
o In many premature infants the ductus fail to ciose
.porrt"n"oorly. in th... cases the closure can be produced
infusion of drugs that inhibit cyclooxygenase. br
41. Ans. is 'd i.e., Prostaglandin E, [Rel O.p. Ghai Bh/e p. 419 & Vh/e p. 407]
o Ductus arteriosus rernains patent in the uterus in
the fetal life because of high level of vasodilators especialll
prostaglandin E, in the blood.
o Aftel birth the prostaglandin synthesis is inhibited
by inhibition of iycloxygenase at birth.
o So if the patency of ductus arteriosus has to be mainiained
-+ pririrgtoniins
r The drug which is specifically used for this is prostaglanain ni (Misoprost, should be given.
Rioprostil)
o If the ductus arteriousus has to be closed, prorloglonii,
tyntt nii innibitor - Indomethacinshould be given.
42. Ans. is'b'i.e., Misoprost [Ref Nelson l#hie ch. 4j0J
o This question is framed improperiy.
' iltifffLlll:l*il:t are not used in patent ductus arteriosus. In pDA, prostagtandin
antagonists (NSArDs e.g.
o Prostaglandin analogues are used to maintain the patency
of ductus arteriosus in certain cyanotic congenitai heart
diseases (ductus arteriosus dependant CHDs).
o Pro_staglandinX, is responsible for keeping the
ductus patent.
o PGE-1 used to keep open duct are Alprostadil
or misoprostol.
43. Ans' is b' i'e', It is more common in males than female s
lRef: Nekon rth/e p. 1g59, 1879, IBSI;
PDA is more common infemales thqn males - Nelson CpDT lgth/e p. 560, 561)
M. A.ns. is 1d'i.e., All of above tRel O.p Ghai Pth/e p. at9 6 fblcp. aiA6l
o Endocardial valvulitis (infective endocarditis), cHF
and Eisenmenger syndrome, all can develop in pDA.
FALLOT'S TETRALOGY
45. Ans. is t'i.e., ASD iRef A,.p; Ghai thle p. 420 & Zele p. 4},8;Nelsoa l8*1c,p. 19e7, WbSI
o Constituents of TOF
0
t Ventricular septal defect : Overriding or dextroposed aorta
t Pulmonic stenosis t Right ventricular hypertrophy.
46. Ans. is 'a' i.e., Valvular stenosis [Ref, A.p, Ghai Bele p. 42A 6 pk p. 408; Nekon \p/e p. 1524_i526; Harckon tp/e
p. 14631
o Right ventricular outflow obstruction is one
ofthe characteristic oftetrology offallot.
This right ventricular outflow obstruction is mainly caused
due to infundiu"I". ,t.roriu.
Pulmonary valve stenosis (alone) rareiy contributes to the
right ,r.ri.i.rrlu. outflow obstruction in tetralogy of fallot.
Hurst cardiology says
"The pulmonary valve is oJten malformed,
usually being either biscuspid or unicuspid. The
valve may contribute
bv the inhibition{ ur
: &:,:H'l:::Jl'*i'J:::,*'::::T:11"1"1_ll1l
eyz.'.'.ein,the synthe,i.
of the
ut€ cIenzymecycroxygenase at birth
.: :"r*:Y_r::::.",:.i:,,:15ilt J";h;;;;r;;,tagrandin.
fflH;i;ffiX[i1g3,li:j::::3rto.io,.,p";;;;ly
infusion of drugs that inhibit cyclooxygenase.
i;ffi;ffi the crosure can,beproduced by
i
'i:Ti."#*i'ilffi:ffi:Tsful and the ductus remains hemodvnamicariv
significanr, surgicar rigation shourd
o Recent studies from Europe indicate that
ibuprofen may be as effective as indomethacin for the medical
pDA.
preterm closure of
' #ir:fxi:l:xJl:il* are not used in patent ductus a.teriosus. rn pDA, prostaglandin antagonisrs (NSArDs e.g.
'ft:*:'ffii.T,::ii:f,H:fi:'j#Jt[3:l.the patencv orductus arreriosus in certai, cvanotic congenitai hearr
o Prostaglandin E, is responsible for
keeping the ductus patent.
o PGE-l used to keep open duct
are atprostadit o, *iroprostol.
TGA
:i. t:li:::j:a:: : ..i::::i.:,r'i:r '.:.:::: ... ii:: I .::...1,,i::.i:;r .::rii..,:ir_. , :
:$
M, Ans. is t'i.e., AII of above fRef: O.p. Ghai Ya/e p. 419 6 Zble p,
4a6l
o Endocardial valvulitis (infective endocarditis),
cHF and Eisenmenger syndrome, all can develop pDA.
in
FALLOT'S TETRAIOGY
i.il: rlll,lr.l,:,,rla:..*:lrll'rijl:-:.i:l7ri:;l*:$i#l{
to pulmonary stenosis, but, only uncommonly, it is the only site oi significant obstruction to the pulmonary Jlow"
Causes of right ventricular outflow tract obstruction.
i) Infundibular stenosis (4570)
ii) Obstruction at the pulmonary level (10%)'
iii) Combination of infundibular and vahrrlar obstruction (3070).
iv) Pulmonary atresia (15%).
4- Ang is'c' i.e., Predominantly left to right shunt lRe! O.P. Ghai 8th/e p. 421 6 Vh/e p. 409; Nelson 78th/e p. 1906,
1907, 19087
o There is predominately right to left shunt (not left to right shunt)'
o There is single 2"d heart sound and ejection systolic murmur in pulmonary area.
o JVP is normal.
{8. Ans. is '* i.e,,Central cyanosis with clubbingl&ef O.P. Ghai 8th/e p. 421 & Vh/e p. 409; Nelson 18'h/e p; 1907, DaSl
r Cyanosis and clubbing are seen in TOF.
o There is right ventricular hlpertrophy, no cardiomegaly, and chest x-ray shows boot shaped heart and pulmonary
oligemia.
49. Ans. is 's" i,e.,Tetralogy of fallot {Rel O.P. Ghai yth/e p. 421, 422 6 7h/e p. 4a8-4091
r The ventricular septal defect of TOF is always large enough to allow free exit to the right to Ieft shunt.
o Since the right ventricle is effectively decompressed by VSD, Congestive cariliac failure never occurs in TOF.
r Exceptions to this rule are : -
i) Anemia iii) Systemic hypertension v) Aortic or pulmonic regurgitation
ii) Infective endocarditis iv) Myocarditis complicating TOF
Remember
Following do not occur in TOF -> o Cardiomegaly o CHF o Recurrent chest infections
50. Aas. is t' i.e., Tetralogy of Fallot lRel & Vh/e p. 4091
O.P. Ghai 8'h/e p. 422
'Coeur en Sabot' refers to the radialogical appearance ofheart in a patient with Tetralogy of Fallot.
The cardiac silhouette resembles that of a'boot' or Wooden shoe in'Coeur en Sabot'fboot shaped heartl.
51. Ans. is'd'i.e., Isoprenaline lRef: O.P. Ghai 8n/e p. 422 6 Vh/e p. 409-410, Nelson 78th/e p. 1906' 19071
o In Tetralogy of Fallot there is right outflow obstruction due to pulmonary stenosis with supravalvular pulmonary
artery obstruction.
of severe obstruction, the right ventricular pressure becomes greater than the left ventricular presence and
" In case blood starts moving to the left ventricle resulting in severe cyanosis and erythrocytosis.
the deoxygenated
o In this situation the aim is to increase blood flow towards the right heart. The methods adopted are compression of
Aorta (knee chest position) and use of vasopressor drugs like methoxamine (Phenylepinephrine is also a
vasopressor).
o Any condition or drug which causes peripheral pooling of blooil should be avoided because this will red'uce
return ofblood to heurL
, Therefore isoprenaline which has marked F, agonistic action should be avoided as it will cause vasodilatation which
leads to peripheral pooling of blood. This will be harmful in a case of Tetralogy of Fallot.
52. Ans. is'o- i.e., Descending aorta with left pulrnonary afiery fRef: O.P. Ghai 7h/e p. 410]
Blalock - Taussig shunt -+ Subclavian artery - Pulmonary Artery anastomosis.
shunt
Pott's -) Descending Aorta to Pulmonary Artery
Waterston's shunt -) Ascending Aorta to right pulmonary Artery
f,J. Ans. is 'd i.e.,Aorta to Pulmonary Artery lRef : O.P. Ghai th/e p. 422 & 7/e p. 410; Nelson l8'h/e p. 19101
c Blalock Taussig shunt consists of subclavian artery (br. of aorta) and pulmonary artery anastamosis. This inturn
actually establishes a shunt between the aorta (Via the subclavian artery) and the pulmonary artery,
54. Ans. is 'b' i.e,,Modified BT shunt lRef: Nelson 18'h/e ch. 430; Iournal af cardiac anesthesiq 2014 p. 197ll \
o Modified BT (Blalock-Taussig shunt) is the most popular procedure for TOF.
55. Ans" is 'd i.e,, ASD [Rel: Dofland's Dictionary 28h/e p. 1253, 1746; Steilman's Medical Dictionary 28'h/e p' 14521
Pentalogyoffallot consists : -
o Tetralogy of Fallot -+ VSD, Pulmonic stenosis, Overriding of aorta, Right ventricuiar hlpertrophy
e Atrial septal defect
56. Ans. is 'd i.e., AS tRel O.P. Ghai 8th/e p. 420 6 Vh/e p. 40s)
5/. Ans. is'H i.e., Eisenmenger complex fRef: Ghai Vh/e p. 412)
e TOF, TA and TGA (with VSD & PS) are included in Fallot's physioiogy.
TRICUSPID ATRESIA
\
58. Ans. is 'a' i.e., i.e., Tricuspid atresia fRef: Nelson 18th/e p. 191j; O.P. Ghai Bth/e p. 422 & Vh/e p. 410-411)
. "Left axis deviation and left ventricular hypertrophy are usually present on electrocardiogram distinguishing
tricuspid atresia from most other cyanotic heart lesions.
The combination of cyanosis and left axis deviation is highly suggestive of tricuspid atresia."
- Nelion 18th/e p. 1913
59. Ans. is '-o" i.e., Tricuspid Atresia {Ref: o.P. Ghai 8th/e p. 423 & vh/e p. 410; Nelson l9th/e p. 19131
o Among the given options, left ventricie hlpertrophy is seen only in tricuspid atresia.
60. Ans. is 'a' i.e., Split S, fRef: o.P. Ghai 8,h/e p. 423 6 7h/e p. 410)
I Atresia of the tricuspid valve results in the absence of a communication between the right atrium and right veiitricle
therefore the right ventricle is underdeveloped the inflow portion being absent.
o The only exit for systemic venous blood coming to the right atrium is by way of Atrial Septal defect or patent foramen
ovale. Through this the blood goes to left atrium from rvhere it enters left ventricle. ,
o A ventricular septal defect provides communication between the Ieft ventricle and the outflow portion of the right
ventricle. The left ventricle therefore maintain both the systemic as well as the pulmonary circulatio,n thus there is hy-
pertrophy of the left ventricle which is reflected by lefi axis deviation in ECG.
r The pulmonary blood flow ls dependent on the size of the ventricular defect, the smaller the VSD, the lesser the
pulmonary blood flow. 90o/o patients of Triscuspid Atresia have diminished pulmonary blood flow.
o Auscultatory finding in case of Tricuspid Atresia -+
r S - Normal
1
r S, - Single r Murmur grade II to grade III i VI
61. Ans. is 'H i.e., Right atrial dilatation {Ref: Ghai 7h/e p. 411; Nelson 18,h/e p. 1915)
o The tricuspid valve anomaly results in obstruction of blood flow as well as regurgitation of blood from the right ven-
tricle into the right atrium -+ Dilatation and hypertrophy of right atrium due to volume overload.
62. Ans. is 'a' i.e., Tricuspid atresia fRef: O.P. Ghai 8'h/e p. 423 6 7h/e p. 411; Nelson l9thle p. 1915)
a Amongst the given options no one is correct.
a But best option is a + though tricuspid atresia is not there, abnormality of tricuspid valve is the basic pathology in
Ebsteinb anomaly.
r Ebstein anomaly consists of downward displacement of an abnormal tricuspid valve into the right ventricle.
63. Ans. is 'a' i.e., TGA IRel Nelson 19th/e ch. 124, Texas birh defect epidemiology b survillencel
o Conotruncal defects are abnormalities of outflow tract septation or ectomesenchymal tissue migration abnormalities.
r Most common conotructal defect is transposition of great arteries (TGA).
64. Ans. is 1d' i.e., Anterior and right to pulmonary artery fRef: Ghai Vh/e p. 413; Nelson.tSth/e p. tgtsl
o In TGA aorta lies anterior and to the right of pulmonary artery,
65. Ans. is 'b' i.e., Transposition of great vessels [Ref Nelson 18*/e p. 1907; O.E Ghai B,h/e p. 424 6 7h/e p. 4i4-413)
o Out of the four options, only 1st two are cyanotic heart disease i.e. TOF 6 TGV.
o TOF can be ruled ott as it does not cause cyanosis at birth.
Nelson says - "aften cyanosis is not present of birth, but with increr*ing hypertrophy of the right ventricular
infundibulum and patient growth, Cyanosis occurs later in the 1st year of hfe."
r Short systolic murmur is not of much help in reaching the diagnosis as it is present in both the conditions.
i . .: ,i.,it:.rr:.rti:il.r l-i , i..tr.tr..::ti a.ri.tr:j.ir'l!:i::i
irt:,,lrr'',i : :ri::1"'i:ir:l
i . .:r,:.:rr: :::i:'::i i a:::.: !..i,i :r'.i:l :irli:i,.:.:r:r',r:
::11.s...:iii::$l li:ilii:iii:,ffi
..
tr. Ans. is 'H i.e., Transposition of great vessels fRef: O.P. Ghai 8th/e p. 424 6 Vh/e p. 41i-414)
o Cyanosis at birth, PGE infusion and atrial septostomy to improve oxygen are typical of TGA.
TAPVC
69. Ans. is t'i.e., TAPVC lRef: O.P. Ghai 9th/e p. 427 dt Vh/e p. 415; Nelson 18th/e p. 19231
o Snowman orfigure of '8' configuration -) In supracardiac TAPVC.
:0. Ans. is 'None' lRef: o.P. Ghai 8th/e p. 426, 427 dt Vh/e p. 4151
o All options are correct.
o In supracardiac TAPVC the pulmonary veins join together to form a common pulmonary vein which may drain into
the left innominate vein.
o Not always associated with septal defect -+ Rt to left shunt may occur through Patent foramen ovale.
o There is "Figure of '8' configration" on chest x-ray in supracardiac TAPVAC.
o TAPVC is a cyanotic CHD.
EISENMENGER SYNDROME
7t. Ans. is 'a' i.e., VSD [Ry': O.P. Ghai 8'h/e p. 428 6 6'h/e p. 415; Nelson 18th/e p. 1936]
o Eisenmenger complex -+ Consists of pulmonary hlpertension with a VSD providing the right to left shunt.
72. Ans. is 'b' i.e., Left to right shunt, right ventricular hypertrophy, pulmonary hypertension, right to
left shunt lRef: O.P. Ghai 8'h/e p. 428 dt 6th/e p. 416; Nelson 18th/e p. 19361
r In VSD the flow of blood is from left to right, so the patient is acyanotic. When the direction of this shunt reverses i.e.
from right to left, the patient becomes cyanotic. This is k/a Eisenmenger's physiology or syndrome.
o There is very little or no flow of blood across the VSD in utero (as in utero right and left ventricular pressure are near
equal about 70 mm of Hg).
r At birth when circulatory pattern changes, the flow across the VSD begins from left to right.
o So it is understood thal the first eyent in sequence of development of Eissenmenger syn. would be left to right shunt
and last would be right to left shunt.
o The only confusion is whether pulmonary hypertension occurs earlier or right ventricular hypertrophy.
o For this it is known that "all children are born with right ventricular hypertrophy. As such initially all patients
of VSD have right ventricular hypertrophy" - O.P. Ghai,6h/e p. 298,
73. Ans. is 'a' i.e., Increased flow murmur across tricuspid & pulryonary valve fRef: Nelson Vh/e p. 1936-19371
o Eisenmenger syndrome refers to patients with a VSD in which blood is shunted from right to left as a result of
development of pulmonary vascular resistance. Initially shunt is from left to right as the systemic vascular pressure
is greater than pulmonary vascular pressure. With time pulmonary vascular resistance increases due to change in
pulmonary vessel wall as a result of increased flow in pulmonary vessels. When pulmonary vascular pressure
exceeds the systemic vascular resistance, reversal ofshunt into right to left shunt occurs.
o This development of right to left shunt due to reversal of left to right shunt as a result of development of pulmonary
vascular resistance and pulmonary hypertension is called Eisenrflenger syndrome.
systeft
ne.crotizing *i,r,
I ::::l::"::::::n:.lnd
with"resuttant I time irreiersibre changes
I ant
I
::r::::,:rru.r
oot,teratron oJ pulmonary II
of smalt putmonary arteritLs
IqARCTAT|ON OF AORTA
75. Aas. is'H i.e., Turner,s syndrome {Ref, Nelson lge/e
p- 19001
r coA may be a feature of furner syndrome, and is associated
with a bicuspid aortic valve.
76' Ans. is t'i.e., Bicuspid aortic valve
IfieJ o.p Ghai p.
8e/e 432 & F,/e p. 420)
r Bicuspid aortic valve is associated in more thanT}o/oof
patients.
It is also associated with : -+ pDA, vsD, ASD, TGA,
' ruyiritrrtx le{t heart
Ans. is'c'i.e,, Pulmonary stenosis lRef: C,P.D.T. p.
564, 5i65; Nelson Ig
ISth/e Sh/ep. D0Al
o Bicuspid aortic valve, Turner syndrome and tubular hlpoplasia of aortic arch (atresia of aortic arch) may be associated
with CoA.
:8. Ans. is 'a'i.e., Most common site is distal to the origin of left subclavian artery fRef: a.p. Ghai ttu/e p. 431 &
7le p. 419-420 ; Nelson 18th/e p. DA\, D01l
e Most common site of COA is distal to the origin of left subclavian artery.
o There is left ventricular hypertrophy and rib notching of inferior border (not upper).
o Neonates become symptomatic immediately, especially in preductal coarctation (not at 15-20 years).
:9. Ans. is'c'i.e., Incorcostal arteries and superior epigastric artery fRef: www.emedicine.com/radio/topic42.htm;
http://perfline.com/student/coq.html; Grays anatomy 38th/e Section 10 cardiovascular system|
r The coarctaion may be :
- Preductal - where is narrowing is proximal to the ductus arteriosus or ligamentum arteriosum. or
: Postductal - where the narrowing is distal to the ductus arteriosus or ligamentum arterosum.
o Collateral circulation connects the proximal and the distal aspects of the vessels over time. This collateral circulation
will develop mainly from the : -
r Subclavian, r Internal thoracic r Intercostal arteries
r Axillary, r Superior and inferior epigastric and
o Following collateral connections may be seen :
r In the anterior thoracic wall, the internal mammary arteries (arising from subclavian arteries) and the epigastric
arteries join to form collaterals which supply the abdominal wall and the lower extremities.
o Internal mammary artery gives rise to anterior intercostal arteries which forms anastomoses with the posterior
intercostal (post intercostals arise from descending aorta).
e Superior epigastric artery is terminal branch of internal mammary artery and forms anastomoses with inferior
epigastric artery which arises from external iliac artery.
o Musculophrenic artery is terminal branch bf internal mammary artery and forms anastomoses with inferior
phrenic and post intercostals.
r The Para scapular arteries (arising from subclavian artery and axillary arteries) connect with the posterior intercostal
arteries to form collaterals which supply the distal aortic compartment.
o The suprascapular artery from the subclavian; and the thoracoacromial, lateral thoracic and subscapular
arteries from the axillary; and the first and second posterior intercostal arteries from the costocervical trunk
anastomose with other po sterior intercostal arteries.
r One route of collateral formation can be subclavian artery - vertebral artery-spinal arteries - post intercostals and
lumbar artery - aorta.
80. Ans is '& i.e., Coarctation tf *a** LRd: A.n 6hai thle p. 432 & ?kle p. 420; Nelso?r I*/e p. 1900, $7tj
I Symptoms of coarctation of aorta occurs due to decrease in blood supply distal to aortic obstruction.
e If obstruction is distal to left subclavian artery, manifestations are due to arterial insufficiency to lower limbs.
t Intermittent claudication r Pain
r Weakness of Leg t Dysnea on running
r Weak pulses and lower BP in the lower extremities --> Delayed or weak impatpable femorals compared to
str ong br achi al arte rie s.
8l- Ans. is '& i.e., Anterior Nll lRef: Nelson 18b/e p. DA0, DAl; O.P Ghai */e p. 4j2 & fi/e p. a2l
o The causes of mortality in co-arctation of aorta are :
. Hypertension t
Aortic dissection s Premature athero s clero sis
s Rupture ofaorta - Left ventricular failure t Infe ctiv e en do car diti s
s Cerebralhaemorrhage (due to aneurysm rupture)
82. Ans. is'H i.e., Coarctation of aorta lRef: A.P. Ghai */e p. 32 & 7/e p. 2Al
Feeble femoral pulsations com.pareil to strong brachial pulsations suggests the diagnosis of coarctation of aorta.
Hypertension and strong pulsations in the upper extremities anll absence, maiked dimunition or delay in pulsations
in the femoral artery are characteristic in coarctation. Also failure to thrive and congestiye heart failure are
consistent with the diagnosis of congestive heart failure.
Remember:
o Differential cyanosis is a maniftstation of PDA
o Differential pulses/Blood pressure is a manifestation of Coarctation
83. Ans. is t' i.e., coarctation of aorta fRef:Nelsorc 18*/e p. 1900, 1901; o.p. Ghai 8th/e p. 432 6 Vh/e p. 420)
c Isolated upper extremity hypertension (200/140 mm Hg), together with absent/diminished
characteristic feature of coarction of aorta.
femoral pulses i-, r.
OTHER CHDS
84- Ans. is 'a'i.e., Down syndrome lRef: Nelsan Igth/e chap" 426.5]
o Ostium primum ASD (an incomplete atriventricular septal defect) or endocardial
cushion defect is common in Drr :
syndrome.
86. Ans is 'b' i.e., Hypoplastic left heart syndrorne lRef Nelson Pediatrics 18th/e p. t9_26-1925)
l'lypolastic left heart syndrome
o Hlpoplastic left heart syndrome occurs when parts of the left side of the heart (mitral
valve, left ventricle, aor:::
valve, and aorta) do not develop completely. The condition is present at birth (congenital).
o Hlpopiastic left heart is a rare t)?e of congenital heart disease. It is more common in males
than in females. As rr i::,
most congenital heart defects, there is no known cause. About l0 % of patients with hlpoplastic left
heart syndron:=
also have other birth defects.
o The problem develops before birth when the left ventricle and other structures do not
grow properly, including the:
i) Aorta-the blood vessel that carries oxygen-rich blood from the lett ventricle to the"entire bodv
ii) Entrace and exit ofthe ventricle
iii) Mitrai and aortic valves
I This causes the left ventricle and aorta to be poorly developed, or hypoplastic. In most cases, the left ventricle anc
aorta are much smaller than normal.
o In patients with this condition, the Ieft side of the heart is unable to send enough blood
to the body. As a result, the
right side of the heart must maintain the circulation for both the lungs and the 6ody. The right ventricle
can suppor:
the circulation to both the lungs and the body for a while, but this extra workoad eventually causes
the right side oi
the heart to fail.
o The only possibility of survival is a connection between the right and left side of the heart,
or between the systemic
arteries and pumonary arteries (the blood vessels that carry blodd to the lungs). Babies are normally
born with two
ofthese connections:
i) Foramen ovale (a hole between the right and left atrium)
ii)Ductus arteriosus (a small vessel that connects the aorta to the pulmon ary artery)
o Both of these connections normally close on their own a few days after birth.
o In babies with hlpoplastic leIt heart syndrome, blood from the right side of the heart traveis
through the ductus
arteriosus. This is the only way for blood to get to the body. if the ductus arteriosus is ailowed to close
in a baby with
hlpoplastic left heart syndrome, the patient may quickly die because no blood will be pumped to
the body.
o Babies with known hlpoplatic left heart syndrome are usually started on a medicine
to keep the ductus arteriosu-
sopen.
o Because there is little or no flow out ofthe leftheart, blood rearning to the heart from the lungs
needs to pass through
the foramen ovale or an atrial septal defect (a hole connecting the collecting chambers on"the
left and rlght sid""s
of the heart) back to the right side of the heart. If there is no foramen ovale, or if it is too small,
the baby cluld die.
Patients with this problem have the hole between their atria opened, either with surgery
or using a thin, flexible tube
(heart catheterization).
Symptoms
o At first, a newborn with- hypoplastic left hegt may apper normal; Symptoms usually occur
in the first few hours of
life, although it may take up to afew days to develop symptoms. These symptoms may inciude:
r Bluish (cyanosis) or poor skin color
r Cold hands and feed (extremities)
I Lethargy
r Poor pulse
r Poor suckling and feeding
r Pounding heart
: Rapid breathing
r Shortness ofbreath.
t Since the systemic circulation is dependent on the patent duclrs arteriosu s the closure of ductus arterious leads to shock.
s failure usually appears within the first few days or weeks of life and include dyspnoea, hepatomegaly
Signs of heart
and low cardiac output. When PDA closes suddenly shock occurs all the peripheral pulses may be weak or absent.
Ve nt r i cul ar s eo t al d efe c t
o Thesepatients with VSD's become symptomatic around 6-10 weeks of age.
o They usually present with congestive cardiac failure.
Ebstein's anomal)t
o Ebstein\ anomaly consists of downward displacement of an abnormal tricuspid value into the right ventricle.
o Thesepatients usually present in teenage/adoEstent years.
o They may also present in infancy but they usually do not present with shock or severe hypoperfusion.
87. Ans. is t' i.e., Truncus arteriosus lRef: V, Mohan Reddy Cardiac surgery for premature qnd low birth weight neonates.
Pediatric cardiac surgery annual of seminarsl
o Congenital heart disease in the newbo.rn can be broadly categorized by the relationship between the patients cardiac
defect and the patent ductus arteriosus; this categorization yields four distinct groups:
88. Ans is t' i.e., Obstructive TAPV&tRel Pediatric cariliology Sthlep. 164, 1651
.
+ -------_]
Severe cyanosis at birth a Mild cyanosis at birth
r SingleSz a Widely split S,
o Cardiomegaly a Cardiomegaly
t No murmur or ejection systolic a Tricuspid flow murmur-diastolic &
murmur pulmonary ejection systolic murmur
. ECG-RVH ICGR/H
Egg shaped heart on x-ray
+ +
TGA TAPVR
HEART FAILURE
\
.d, o. P. Ghai 8th/e p, j96 dt 7e/e p. 373)
96. Ans. is i.e., Congenital heart diseas e |Ref :
-+ Congenital heart disease' '
o The most common cause of CHF in infants rheumatic heart disease'
childien -+ Rheumatic fever &
c The most common .""r" .f Cftp in the older
o'P' Ghai }th/e p' 396 & ?hle p' 3731
97. Ans. is [, i.e., Hlpoplastic left heart syndrome [Rel
left heart syndrome causes CHF in First week'
r Amongst the given options, hlpoplastic
98. Ans. is 'd'i.e., Hepatomegaly teel O.P, Ghai 8,h/e p. 39V & Th/e p. 375; Nelson tr,hle p. 1977]
o In infants, heart failure may be difficult to identify.
r Prominent menifestations include:
i) Symptoms
r Tachypnea, tachycardia r Feeding difficulties r poor weight gain
r Excessive perspiration r Irritability r weak, cry often hoarse
r Noisy, labored respption r Flaring of alae nasi r Intercostal and subcostal retractions
ii) Signs
rWheezing , rHepatomegaly
r Cardlomegaly i . cailop rfrytnm 1s:;
o Clinical assessment bf luglar venous pressure in infanJs may be difficult because of the
shortness of the neck and
the difficulty of observing a relaxed state.
o Edema of face occurs early, Edema on thefeet occurs late.
99. Ans. is 'a' i.e., Pulmonary edema [Ref: O. p. Ghai Bth/e p. 398 6 Vh/e p. iZS]
o Pulmonary edema is due to Lt sided heart failure that results in increased back pressure
in pulmonary circulation.
100. Ans. is 'a' i.e., ACE inhibitors [Rel aP Ghai Sth/e p. 398-399 6 Hanison tVh/e p. 15601
r Drugs for patients with hlpertension and cHF -+ 1. Diuretics 2. AcEinhibitors 3. B-blockers
RHEUMATIC FEVER
l0l. Ans. is t' i.e., communicable disease {Re! a.p Ghai Bth/e p. 434 6 vh/e p. 379; Nelson tSth/e p. 11401
r The disease is immune mediated, not a communicable disease.
l02. dns. is t' i.e., Fever [Rel Nelson tsth/e p. il4t; o. p. Ghai 8th/e p. 435 6 vh/e p. 3s0]
o Fever is a minor criteria
o Major criteria are: Carditis, arthritis, subcutaneous natule, chorea, and erythema
marginatum.
r Minor criteria : (A) Clinical: fever, arthralgia, previous RF or RHD; (B) taboratory: Increased ApR, CRp, ESR,
leukocltosis.
r Essential criteria: Increased ASLO titre, postivie throat culture, recent scarlet fever.
103. Ans" is'd'i.e., Elevated ESR [Rel: O.p. Ghai B,h/e p. 4j5 6 Th/e p. 3s0]
o Elevated ESR is a minor criterian.
o Carditis (Pancarditis), Arthritis, and chorea are major criteria.
104. Ans" is 'b' i.e., Arthralgia [Ref Nekon ttthte p" 152 (table js2-2)]
o In Rneumatic fever = major criteria is arthritis, arthalgia comes in minor criteria.
105' Ans, is 'd'i.e., Pancarditis [Rel o,p. Ghai Sth/e p, 434 6 v'le p. 380; Nelsan trth/e p. 1141]
r It is a pancarditis involving all the three layers -+ Myocardium, endocardium & pericardium.
r06. Ans. is t' i.e., Can be associated with AR fRef: o.p. Ghai 8th/e p. 436 6 vh/e p. j81l
Carey-Coombs Murmur
o Heard in patients with acute rheumdtic fever.
o Occurs due to inflammation of mitral valve cusps or excessive Ieft atrial blood flow
as a consequence of MR.
o Soft middiastolic murmur usually follows Sr.
rc7 " Ans. is 'H i.e., Acute rheumatic fever [Ref: o. p. Ghai 8*/e p. 4j6 6 Th/e p. 381)
108" Ans. is 'a' i.e., Arthritis l&ef a,p. Ghai Bth/e p. 434, 436 6 Th/e p, 3ga; Nelson IBil,le p" t 14tl
r Arthritis is the most frequent maj or manifestation (75% of cases).
109. Ans.is'a',i.e.,choreaisaggravatedduringpregnancy[Rel o.p.GhaiSth/ep.4i66Vh/ep.380-381;Harrisonl6th/e
p. 1978; Nelson 18th/e p. 11421 g
o The characteristic picture of chorea is th at it ofien occur in isolation,either unaccompanied
by other major manifestations
of RF or after a latent period of several months, at a time when all other manifestutlorr. of RF
have subsided.
oSexhormones(estrogen)orpregnancycancauSerecurrenceS.
About option'd'
Erlthema marginatum (not erlthema multiforme) is seen in RF.
110. Ans. is'a'i.e., Mitral regurgitation [Rel 0.P. Ghai 8'hle p. 436 & lh/e p. j84; Harrison 16h/e p. 1978, 1979;
Nelson 18th/e p.1142)
r In rheumatic fever vall'ular abnormalities usually are associated with chronic disease but mitral regurgitation is seen
in acute rheumatic fever.
t Mitral regurgitation is the commonest manifestation of acute as well as previous rheumatic carditis. - O.P. Ghai
ll2. Ans. is 'a' i.e., Erythromycin [Re/ A.P. Ghai 8*/e p. 438 6 6h/e p. 377, 378)
r Drug of choice -+ Penicillin
o Drug of choice in penicillin allergic patients -+ Erlthromycin
I 13. Ans. is 'd i,e,, Carditis lRel A,p. Ghai 9e/e p' 437 lt Vh/e p' 3831
Suppressive therapy of RF
r If patient has carditis with CHF --) Steroids
r If patients has carditis without CHF -) Steroids or aspirin (steroids are preferred)
r If patient does not have carditis -) Aspirin
The total duration of suppressive therapy is 12 weeks.
114. Ans. is ? i.e., 12 weeks fRef: O.P. Ghai 8*/e p. 437 6 7h/e p. 383)
INFECTIVE ENDOCARDITIS
115. Ans. is 'c' i.e., Staphylococcus aureus fRef: A.P. Ghai 7h/e p. i91; Harrison 17/e p. 790; Nelson 18tb/e p. 1953)
116. Ans. is 'd' i.e., Small ASD [fief O.P, Ghai Vh/e p. 3901
o Infective endocarditis is rare in secundum ASD, unless associated with mitral valve prolapse.
t Endocarditis is unusual in sites with a small pressure gradient as ASD -Harrison
: Infective endocarditis is very rare in patients of ASD -Ghai
ll7. Ans. is t' i.e., Staphylococcal endocarditis [Rel: O.P Ghai thle p. 444 6 7h/e p. 390-i9il
r Any fever in a patient with known heart disease raises the question of endocarditis. It can occur over the mitral valve
or Aortic valve in patient with Rheumatic fever.
t The minimum uiteria fo. the diagnosis of endocarditis consists of unexplained fever of Z-lO days duration in a
patient with known heart disease. If this is associated with other clinical manifestations of endocarditis, the
diagnosis becomes more firm. (In this case besides fever, hematuria and palpitations are other 2 symptoms oJ
endocarditis).
HYPERTENSION
118. Ans. is'c' i.e., Renal Parenchymatous diseas e LRef: O.P. Ghai 8e/e p. 451 6 7e/e p. 432i
r Essential hypertension is relatively uncommon (107o) in children in contrast to aged persons.
o The four most common causes of hlpertension in children are : -
i)
Chronic glomerulonephritis (most common) 25 o/o -)
ii) Chronicpyelonephritis -+ l0 o/o
Essentialhypertension 0
iv) -+ rc6h
I19. Ans. is ? > d i.e., Renal Parenchymal disease > Chronic glomerulonephritis l&ef CPDT l$th/e p. 598\
MISCELLANEOUS
122" ,4ns. is 'a' i,e", ,{cute &}lear*xlatie fever
I Rlieurnatie carditis is the most common acquired heart disease in chiidren and most common cause of CHF in
. ,-rl14fe 11.
#t
1" lnfection x Viral, Bacterial, Fungal, Rickettsial, parasitic.
2- Metabolic dnd sndairihe dlsorders x
..
126. Ans. is ? i.e., Klippel - Trenaunay syndrome {Ref: Nelson 18"/e p. 26691
127. Ans. is 'd i.e., I vein and 2 arteries [Re/; o.P Ghai */e p. 402 & 6elc p. 674]
128. Ans. is '& i.e.,Cornplete heart block lRef Myutrgk park S'hle p' 4|
c Maternal lupus erythmatosus has been associated with a high incidence of congenitai heart block in offspring'
130. Ans. is 'c' i.e.,squatting lfuef: A-P" Ghoi 8*le p' 421 & Vhlc p' 409],
r The patients of ToF assume a sitting posture (squatting) as soon as they get dyspneic.
o TOF is the commonest congenital lesion in which squatting is noted.
131. Ans. is'b'i.e., Diversion of the septal defecllRef Nekan l*le p" 1922, 1915, 192CI1
r Double-outlet right ventricle with transposition of great arteries is known as Taussig-Bing anomaly.
It also has
associated VSD.
o Surgical correction is bY: -
A) Rastelli procedure which includes
: patch closure of the VSD, with left ventricular flow is directed to aorta.
an extra cardiac
r Connection of right ventricle to pulmonary artery by ligating the proximai artery and placing
homograft conduit between the right ventricle and distal pulmonary artery.
OR
B) Arterial switch (Jantene) procedure
r The operation involves dividing the aorta and pulmonary artery just above the sinuses and re-anastomosing
them in their correct anatomic positions'
L3Z. Ans. is "H i.e., Puknonary stenosis lRef : O. P. Ghai 8&/e p. 42A, 421 e /n/e p. A9|
135. Ans. is'H i.e., Indomethacin therapy lRef: aP Gk*i 8*/e p" 419 {, */e p. aa7}
136. Ans. is 'c' i.e., Transposition of great vessels [-&ef O. P. Ghai 8* le p. 425 & */e p' 414]
137. Ans. is 'H i.e., Transposition of great vessels [Ref O. P. Ghai Sele p. 425 d7 */e p- ala]
l3g. Ans. is
.b,
i.e", Transposition of great arteries [Raf: Nelson 78e/e p. $a7-ag, ]919-2]; A-P" Ghai *le p- 425 &
7ele p. 412-131
139. Ans. is t'i.e., prostaglandin ErlRef : GuptqS" 8*le p. 2$; A"P Gboi 8*/e p. 419 er Ple p- V34;Davidsatls
20h/e P. 7441 !
140. Ans. is .d' i.e., Absence of flow rrurmurs over scapular region lRef Herrisan l*le p. 1462; l6e/e p' 1387;
O.P" Gh*i }tu/e P. 432 & Ple P" a20|
:.!:A:t ::, :i. ii:..:;.. :: : :i :.
:1+:q::'i::1:1!rr . lr'
l4r. Ans. is ? i.e., Rheumatic carditis [Rel 0.p. Ghai 8*/e p. 436 6 fl/e p. 380, 372)
o Cardiac failure causes cardiomegaly
o MC cause of cardiac failure in children (elder than infants) is rheumatic
fever and rheumatic heart disease.
142. Ans. is'c'i.e., 0.04 - 0.06 [Re, O.p. Ghai B*/e p. 3gg 6,fl/e p. 372]
o Premature and neonates -)
0.04 mg/kg
o 1 months to 1 year -)
0.08 mg/kg
r Between 1 to 3 years -)
0.06 mg/kg
r Above 3 years -+
0.04 mg/kg
143. Ans. is'b'i.e., Aortic stenosis;'c'i.e., Petent ductus artriosus {Re! iulyungKpark Sn/e p. 463, 6641
r ASD usually does not cause HF.
o AS & PDA increase the strain on left ventricle _) LVF
r PS increases the strain on right ventricular failure _+ RVF
l44. An* is'b'i.e., coxsackie B IR,J o.p. Ghai Bn/e p. 442 & fl/e p. a2sl
o The commonest cause of myocarditis is coxsackie B infegtion, which
occurs any where from the age of a few hours
to 7 weeks, with a peak around two weeks. ' '
145. Ans. is'c',i.e., Endocarditis tRef o. p, Ghai g*le p. 436 & */e p. 3s0-3s21
146. Ans. is 'b'i.e., Arthritis [Ref park 2r$/e p. t7s; o.p. Ghai g&/e p. 436, 43zl
I There is no residual damage in the joint affected by rheumatic arthritis and there is complete resolution.
t47. Ans. is'c'i.e., 95/50 [Rel O.p. Ghai Be/e p. 452, 453 & */e p. a31)
148. Ans. is h'i.e., Cardiac deformities fRef: Has been etplained)
o It causes Ebstein anomaly.
lIr
,
T3 Tf }-} Y T} ,q r}"-r ft m q r
ff..n*rtgqfi." t LjgE x
{-r
qYqTFh,,g
!--, -:. LJ A t_r"
AIRWAY OBSTRUCTION
c Children (especially infants) are more prone of upper airway obstruction because :-
i) Airway is small and narrow(Pclee) .
ii) Proportionately larger head and tongue(DNB rs), the tongue is often pushed against the palate.
iii) Lar,vnx is anterior and cephalad(DNBrs) with anterior inclination. Larynx extendsfrorn Crto Coveyteb'rsl
oo).
leyelecl
iv) Vocal cord is at Crlevel and Subglottic regian is the narrawest portion of laryfix@NB ls'PGt0)"
r Hypersensitivity pneumonitis
r Cystic fibrosis.
r External compression from enlarged mediastinal lymph nodes, cysts or tumor.
r Tropical eosinophilia
ea*rrnn'5 Respiratory System
B) Stridor
r Stridor refers to the physicai finding of excessively n'isy breatnirrg a,cl is ge*eral due to airway obstruction.
lnfecticns
Congehital
Croup (laryngotracheobronchitis)
Laf yn goma lac ia(Att
tt4s 8a, PG] /s)
Subglottic hemangiorna
Epiglottitis Vocal cord palsy
Laryngeal papillornas
Bacterial tracheitis
Subglottic stenosis
2-3 months
Retropharyn geai abscess
vascula r ring{ArMs 8a, PGt 7s)
6=7 mOnthsrP6/ee
Treatment
1) Foreign body in upper respiratory tract
I Foreigr1 bodv can be removed by Abdorninal thurst (Heirnlich e{))
maneuver('l, or Magill forceps.
2i Foreign body in lower respiratory tract
I The treatment of choice is prompt removai
of foreign body by rigid bronchoseope (endoscope)(r\..trx Are7,
* $ttring inspirstion ne|'*i ive presslire is created through lary* , l'hich rcs*lts i' a collapse of these structures into the
aii:lvay and a narrolvel. breatlr ii-lg passage.
c Partial obstruction is the source of ihe noise
r'vith breathing (stridor), and sometimes
clranosis.
o Tie halimark sigu lricludes interwiilee*
siridorn.icstly in inspiratiane.;r02,Apa2).It is
usually rnare praruinent when
the. infant is lying on kis/her back (supiwe
pasitiafl c.02' tt16rkhaillt0a)), crying,
feetling, excitetl or has a cold. stridor gets
relieved an pl^citug tke patient in prane positianeGl att' 02' ltiarkhattt 01),
This is usually first noticed in the
*-f lifs{te azl . first few weeks
I ii :nay
worsen over the first ferv months and becorne
loucler. Tnis is irecause as the baby
grolvs, inspiratorl, force is
grealrr' wlrich canses greaier coilapse of the larvngeai
st*lr:t*res into the airway'. vhis is nsually
worst at 3-6months
and then gradually improves as the rigidity
of the cartirage iniproves.
o Mast children are sy?nptsflt
free by I ta Z yeflrse,Gr aB ) .
o Sonreiinres, cyanosistApa2) ntav occur.
e i-)irect larvngoscopy sholl s :_
o Mild cases (i.e. no stridor at rest but seen on crying or activity) require only supportive therapy (hydratiorciP$I
00),humidified oxygen@Groo)) and minimal handling. Moderate to severe cases (stridor at rest) are treateci i:.1r
axygen@etoo), hydration withJluidsecloo), corticosteroids, i.e. high dase dexamethasone (drug of chaice@ilMsa8)), a*:.1
Epigloftitis
o It is the inflammation of epiglottis with inflammatory edema of hyopharynx. It is a true medical emergency.
e H.influenzae is the most common causative organismallMs 0s, 04, e4, PGr 08, NEET).
Other organisms are -) Pneumococci,
Streptococcuspyogenes, N.meningitidis, Staphylococcus
Clinical manifestations
o Onset is sudden. Symptoms are -) fever, dysphagia(Pcrost, drooling(pcros), muffled voice, inspiratory retractions, cyanosis
and soft stridor. Patients often sit in snffing dog position. Respiratory arrest may occur.
'The risk of sudden death for persons is high due to sudden airway obstructiono(DPce6).
Treatrnent of epiglottitis
e Once the diagnosis of epiglottitis is made, endotracheal intubation must be performed immediately.
e After an airway is established, cultures of the blood and epiglotiis should be obtained and patient started on appropriate
intravenous antibiotics to cover H. influenzae (Ceftriaxone or equivalent cephalosporins). "Third generation
cephalosporins are prefeneil as first line agents because of incieasing resistance to ampicillin. Cefiriaxone is the
08) D.
treatment of.choice for epiglottitisecl
c Other antibotic options are :-
t Ampicillin plus sulbactam t Cefuroxime : Clindamycin
La ryn giotracheobronchitis (Croupl
o Laryngotracheobronchitis is the most common infectious cause of obstruction of lower respiratary tract@Ils) i?i child.ren
Epiglottitis
r It is the inflammation of epiglottis with inflammatory edema of hyopharynx. It is a true medical emergency.
c H.influenzae is the most common causative organismqrrus 0s' 04' e4' PGI08' NEE'),
Other organisms are -) Pneumococci,
Streptococcuspyogenes, N.meningitidis, Staphylococcus
Clinical manifestations
e Onset is suilden. Symptoms are -.> fever, dysphagia@Gr08l droolingrPcr0s), muffled voice, inspiratory retractions, cyanosis
and soft stridor. Patients often sit in snffing dog position. Respiratory arrest may occur.
'The risk of sudden deatlyfor persons is high due to sudden airway abstruction"tDre%) .
Treatment of epiglottitis
r Once the diagnosis of epiglottitis is made, endotracheal intubation must be performed immediately.
o After an airway is established, cultures ofthe blood and epiglottis should be obtained and patient started on appropriate
intravenous antibiotics to cover H. influenzae (Ceftriaxone or equivalent cephalosporins). "Third generation
cephalosporins are preferred as first line agents because of increasing resistance to ampicillin. Cefiriaxone is the
u.
treatment of choice for epiglottitistPGl 0e)
o Mild cases (i.e. no stridor at rest but seen on crying or activity) require only supportive therapy (hydrati{}?i(P<;'
00),
humidified oxygen(Petoo)) and minimal handling. Moderate to severe cases (stridor at rest) are treated tr;:;
oo),
OxygenQcr hydration with fluids{Pct 00), corticosteroids, i.e. high dose dexamethasone (drug of chcfce(rl"Ms 031
J, ani,
nebulized epinephrine. Antibiotics have no role(PGI00).
a) Epiglottitis
b) Foreign body aspiration
c) Pneumonia
4.,
$.re1ii11p],.:1,,,4;;' .,; ;,,;,.
Epiglottitis
e It is the inflammation of epiglottis with inflammatory edema of hyopharynx. It is a true medical emergency.
0s' 04' e4' PGt 08' NEET).
o H.influenzae is the most common causatiye organism4llt'rs Other organisms are -) Pneumococci,
Streptococcuspyogenes, N.meningitidis, Staphylococcus
Clinical manifestations
c Onsetissudden.Symptomsare-+fever,dysphagia(Pcr08),drooling,Petott,muffledvoice,inspiratoryretractions,cyanosis
and soft stridor. Patients often sit in snffing dog ltosition. Respiratory arrest may occur.
"The risk ofsudden deoth for personsis high dueto sudden airwoy obstruction'4DPcs5).
Treatment of epiglottitis
o Once the diagnosis of epiglottitis is made, endotracheal intubation must be performed immediately.
e hfter an airway is established, cultures of the blood and epigiottis should be obtained and patient started on appropriate
intravenous antibiotics to cover H. influenzae (Ceftriaxone or equivalent cephalosporins). "Third generation
cephalosporins are preferred as first line agents because of increasing resistance to ampicillin. Ceftriaxone is the
0s)".
treatment of choice for epiglottitis{Pcl
o Other antibotic options are :-
t Ampicillin plus sulbactam s Cefuroxime t Clindamycin
,:;:5:,' Ri s iimt o ry Syste m
a Chloramphenicoluipnete3) a Cefotaxime
e Intravenous antibiotics should be continued for 2-3 days, followed by oral antibiotics to complete a 10 days course
a) Epiglottitis
b) Foreign bodyaspiration
c) Pneumonia
d) Croup
Bronchiolitis
o Bronchiolitis is the most common serious acute lower respiratory tract infection in infants and young children.
o Most mlnerable group is between the ages of I and 6 months@Gr02'01'e8). Bvt the disease can affect children up to 2
years. More common in males. Bronchiolitis is predominarrtly a viral ilisease.
i) Rsy (most common)@NB 1s' AI o<'s+' AIIM9 00' PGI0s)
. lnfant & children . 1-5 years '. 1-3 years . . 1-6 months
. 6 months to 4 years
' lntermittent H/O upper respiratory Sudden onset . Violent paroxysm off ' H/O rhinorrhea (URTI)
inspiratory stridor tract infection . Severe respiratory . Wheezing
. lnspiratory stridor Coughing .
. No other complaint distress Respiratory distress
. Barking (Croupy) cough . Sore throat, Chocking . Chest crepitation
Gagging
dysphagia . Chest x-ray-)
I I
Wheeze
I
I I Aphonia Hyperinflation
I I I
I Stridor (incomplete V
I
+ + + obstruction)
Laryngomaiacia Croup Acute epiglottitis Bronchiolitis
I
Y
Foreign body aspiration
Bronchiolitis obliterance
o Bronchiolitis obliterans is a rare chronic lung disease of the bronchioles and smaller airways.
o Bronchiolitis obliterans most commonly occurs il ped.iatric population after respiratory infections (i.e. adenovirus,
mycoplasma, measles, influenza, pertussis).
r There is respiratory obstruction due to inflammation and fibrosis.
o Cough, fever, cyanosis and respiratory distress followed by initial improvemen{At 11' AItMs 08' oz) maY be the initial signs
of bronchiolitis obliterans. Progression of the disease may ensue with increasingdyspnoea, cough, sputum production
and wheezing.
o Chest radiographs may be relatively normal compared with the extent of physical findings but may demonstrate
hylterluscency@l11,AlIMs08,07) and,patchy infiltrates (occasionally, a swyer Iames syndrome, i.e. a unilateral hlperluscent
lung has developed).
11' AIIMS 08'
o Pulmonary function tests demonstrate varaible findings but qpically shows signs of airway obstructionqr
07).
o Ventilation perfusion scan shows a tlpical motheaten appearance of multiple matched defects in ventilation and
perfusion.
PNEUMONIA
o Pneumonia is an inflammation of the parenchyma of lungs, and mostly caused by bacterial or viral infection.
o Most common cause of paediatric pneumonia is respiratory syncytial virus (RSV)(DNB 12' Ar 04) . Other viruses causing
pneumonia are influenza yirtts\t1a) (2d most common virus), adenovirus, rhinovirus, and parainfluenza virus.
AIes).
o Most common bacterial cause of lteiliatric pneumonia is streptococus pneumoniae (pneumococcus)al Bacteria
1s'
history of antecedent skin infection (pyoderma)u'nusos), (Note : Pneumatocele may also be caused by E,coli and
kleb s i ella pneumoni a).
o Measles causes primary giant cell (Hecht's pneumonia)(Arr3).
o Organism complicating pneumonia with lung abscess are staphylococcus aureusLrtr), H. influenzae,
er.),
S, pneum o ni arrar p seudomonas, and kl eb si ella@I e1 )
.
Tratment
o For mildly ill patient (not require hospitalization)
r Emperical treatment + Amoxicillin is the DOC.
t Atypical (mycoplasma) pneumonia -+ macrolides (Azithromycin, Erythromycin)Gress.
o For Hospitalized patients
r IV cefuroxime or cefotaxime or celtriaxone.
r If clinical features suggest staphylococcal pneumonia, vancomycin or clindamycin are also added.
a) Str. pneumoniae
b) Slaph.4ureus'
c) Str. pyogenesl
d) tisteria,,:
r The given chest X-rarr is showing laige pn€umatoeele in right lung,:,+ characteristic rof giap! aureus pneu
monia.
BRONCHIAL ASTHMA
o Bronchial asthma is a disease characterized by arn increased resltonsiveness of airway.s to a yariety of stimulus
and causes recurrent attacks of wheezing, breathlessness, chest tightness and cough.
r Thesymptomsareduetobronchoconstrictionwhichisreversibleinalargemajorityofthecases,eitherspontaneously
or in response to treatment. Asthma is the corumonest chronic illness during childhood.
o Childhood asthma usually improves with agsailMsst).
o Asthma is type-l hyersensitivity and is mediated by IgEazus ea). Usually there is positive family history of asthma or
other atoltic iliseases (atopic dermatitis, allergic rhintis)Auus s<1.
Clinical presentation
e Most characteristic clinical feature of asthma is wheezinglAl 13' e7).
Other clnical features are cough, dysnealt sz),
tachycardia, apprehension, restlessness, cyanosis@te7), fatigue, hJper-resonant chest and pulsus paradoxus. In chronic
cases, chest becomes barrel shaped(tl e3). Clubbing of finger is not seen\r e7).
Treatment
o Treatment of asthma can be divided into :-
A) Treatment of Acute Asthma
1) Mild attack
s Inhaledshortacting$r-agonistlikesalbutamol(abuterol)isthedrugofchoice@||7).Ifthereisnosatisfactory
response, inhaled antichlolinergic (ipratropiura) is added.
rChiidren refractory to inhalation therapy are treated by intravenous aminophylline (theophylline@IlMs s7)).
ffi
r Other drug which intravenous aminophylline
(theophylline) and in
o Obstruction of airways leails to bronchiectasis and atelectasis; pancreatic duct obstruction leads to pancreatitis and
ts).
malabsorption; and plugging of bile ducts leads to obstructive jaundics@Nn
Clinical features
o Most patients with CF present in childhood. Approx l87o of patients present within the first 24 hr of life with
gastrointestinal obstruction, termed Meconium ile:us,MAHE 07).
o Other systems dysfunctions are not present at birth(Pcr0o, they may manifest within the first year or two of life
including respiratory tract system.
1) Lungs and sinus disease
r Sinusitis r Pulmonary hypertension -+ can cause heart failure
r Bronchiactasis r Allergic bronchopulmonary aspergillosis
r Nasal pol)?s r Lower respiratory tract infection
i Chronic lung disease
2) GIT, Liver and pancreas
t Meconium ileus@A$E 07) r Rectal prolapse
r Malabsorption r Pancreatitis
t C n stiP ati n(MAHE )
o o
07 r Intussusception
r Meconium peritonitis r Bile duct obstruction and biliary cirrhosis
4) Infertility
r Tn men due to absence of vas deference r In women due to thick cervical mucus.
Respiratory System
Diagnosis
r The diagnosis is confirmed by demonstration of a high sweat chloride (>60 mEq/L) on repeated rneasurernents(Pcr
06 ),
qONGENITAI. LE IQNS
Bronchoganic cysts
e Bronchogenic cyst is a congenital lung defect, which develops from abnormal lung budding of primitive foregut.
* Most of the bronchogenic cyst arise in the mediastinum, where they are usually located in the mid mediastinum near
carin.t6llMse6). About 15% of Bronchogenic cyst also occurs in pulmonary pdrenchyma(AttMseo). When located in the
lung they are more common in right lung and lower iobe.
I They are lined by cuboidal or ciliated columnar epithelial cells and are usually f,lled with mucoid material"
o Infection of the cystleadin{utttsoel b lung abscess (Mediastinal bronchogenic cysts do not communicate with the bronchi
but those situated within the lung may communicate with the airways leading to abscess formation).
r Compression can produce either hyperinJlation of the lung or atelactasis due to obstru ction. Tension pneumothorax
(due to rupture of cyst that communicates with bronchus) may occur.
Pulmonary sequestration
o In this congenital anomaly, there is a discrete mass of lung tis sue without any mormal connectian to the airway system.
As there is no connection to airway, the lesion does not fill on bronchography4t ou.
r It may be :-
i) Intrapulmonary (intralobar) -+ More common
ii) Extrapulmonary (extralobar)
o Sequestrated tissue receives its arterial supply from the systemic arteries (rnost cawmonly aorta)6t se).
. it returns blood to the right side of heart throuch IVC (extrapulmanary seqwestratian) ar tr'sulmonary veins
(intrapulmonar y s e questration)Qct ss t
.
c The sequestration functions as a space-occupyinglesian within chest, it dcles not function in gas exchange, and clces
nQt contribute to a ieft to right shunt or dead space.
e GaQc or pancreatic tissue may also be found in sequestrated segment.
e Associated anomalies -+ cystic adenomatoid malformation, congenital diaphragmatic rl.er.ia, esophageal cvsts.
Macleod syndrome
o It is also krrown as Swyer - lanes slndromseuqs).
o It is a cause of unilaterfll?Gl0s) hyperlucent lung. It may present as acute pneumonia, but most patients are discovered
when a chest X-ray is obtained for an unrelated reason.
o This is not a true etnphysema@Glqst.
o On examination there is hyperresonance and a small lung with rnediastinum shifted towards the more abnormal lung.
o There is no vascular a.brxormality(Pcl0s).
r ldo specific treaiment is required, it may become iess symptorlatic with
: '-
: r;1. 1:..:.,:.,:r... , : .,.'ggtrligARyof CF;APTERl1l ONELIf,iERStQLIlfK'REVtSOfitf'anmfE'FATTEf$Il. ' : ': '
iarge epigiotiis' larynx extends from C' tc C ''
lfilpartantfeatures of" neonatal
:'"" airtuay., t*''i &* narrort//
^'"'^''" ' Smail
'
^""'' larqe iongue, ornega Snraped &
narrowest, more compliant chest wall'
";;;r;-ir', region
suLglottic
hypersensitrvity pneumonitis, external compression
by
,oru*, o,r *nun in chir6ren: F.sthnra. foreign body,, lnfection,
mediastinal lYmPhadenoPathY'
cord pa!sy, subglottic hemangioma
epigicttitis, laryngomalacia, vascular ring, vocal
lmportant causes of stridor in children: Croup,
or stenosis.
and yaung ch i/dren : LarYnomalacia'
Most common cause of stridor in infant
Laryngonralacia'
Mast common congenital abnormality of lerynx:
prominent in supine position and rerieved i, prone
position'
;;;;;;r rr;;;;;r**oto,r,n ,lnspiratory inrermittenr srridor more
Sealbarkingtikecroupycoughischaracteristicof:Laryngotracheobronchitis(croup).
/pe 1.
Mostcommoncauseofcroup(laryngotracheobronchitis):Parainfluenzavirust,
adenovirus' rhinovirus
Other causes of croup:RSV influenza virus'
is aggravated by crying'
-3
presentation cfcroup: Hio URTI for 1 days
foliowed by barking cough, inspiratory stridor which
Typical
Teatment of choice for croup: Dexamethasone
(helium plus O')'
hyd ration' nebulized epinephrine' heliox
ather measures in treatrnent of croup :Oxygen'
Drugswhichhavenoroleincroup:Antibiotics,sedatives,opioids(morphine).
;e X-ray sign of crouP: SteePle sign
@ Most common cause of epiglottitis: !l' influenzae
w Rladiologica! signs af epiglattitis:Thumb sign' vallecula sign'
e Most common cause of bronchiolrtis : RSV
. on ches t X-raY is seer; i;': : Bronchiolitis'
* Dyspnea, wheezing, bilateral crepitation with bilateral hyperinflatian -o)
(drui* of aheieei'
anr;i-:l ret!rs, aerosoiixed ribavarin
,!, .rreatment af bronchioriiis incrudes: Hurnid atmosphere, or, bronchodirators,
I':used bv ' ''
a Aerosollzed ribavarin is drug of choice fcr: Acute irronchioiit:; ''
lviorphine'
Dr-g wiffi no role in treatment of bronchiotitis:
(mc cause) foilowed by influenza virus (as 2nd mc cause)'
; ;;:r rr;*ion cause of pneumonia in chirdren: RSV
pneumoniae (Pneumococcus)'
* commonest cause of bacterial pneumonia in children: Streptococcus
,,isr rc ,^onnrrirr rq parainfluenza virus, rhinovirus'
^-- virus, adeno.lirus, narainfluenza rhinovirus
g Virus causing pneumonia in children: RSV influenza
e Notrd caue of viral pneuittaitia: Mumps virus'
(mcst co r.nrnon), less commonry by E. coii and klebsieila.
* or"u*loirorrle is seen in pneur' oniawit'r :Staphylococcus aureus
* Prirnary giant cell pneumonia (llecht's pneumonia) is causeC by Measles'
"'
#;;;.l-tmphadenoPathY'
ring, vocal cord palsy, subglottic hemangioma
lmportant cLuses of stridor in children: Croup, epiglottitis, iaryngornalacia, vascu|ar.
or stenosls.
Most common cause of stridor in infent and young children: Larynomalacia"
Laryngomalacia'
Most common congenital abnormality of laryn'x: posltlon'
in supine positicn ancr r'erieved in prone
;;;;;;,r r,r;;;;;r***)r,-,l , roiratory int"rmitt*nt ,t,i,*n, more prominent
adenovirus' rhinovirus
Other causes of croup: RSV, influenza virus'
. by crying'
by barking cot)gh, inspiratory stridcr which is aggravated
, Typicol presentation of croup: H/o URTI for i -3 days foilowed
Lcbeaflungmost.arnfi.lanlyinvo|vedinaspiration:PosterisrSegmentofrightacicalloLle'
. rrl,i gleriise,
o Cystic fibrosis is :An autosomal recessive disorder due to mutation in cFTR gene on long arm of chromosome 7.
r* in,cyiticnuros*:Non-mucoid pseudomonas.
"Mottigmmbnlnfecting'organlsn
& Diagnostictest of choice in cysticfibrosis: Transepithelial nasal membrane potential
difference.
* Mucoviscidosisis most commonly associated wlth : Fibrocystic disease
of pancreas.
& True about bronchogenic cyst: Mostly in mediastinum near
carina, muliiloculated, often infected, only 15olo occur in lung.
.;Blqadsupply.of:{ungseg.qes|rytlon:Aorta..oritsbranches'..
?
& venous drainage of pulmonary sequestration: IVC (extrapulmonary
sequestration), pulmonary veins (intrapulmonary sequestration).
&'
* Components of Kartagener's syndrome : (i) Bronchiectasis, (ii) sinusitis, (iii) situs invertus, (iv) lnferttiility.
* KartagenerS''syndrAme:isasubgroipof,tprimaryiiliarydyskinesia., ..i' , ...... .,:..,r:
& Most common posterior mediastinar mass in chirdren : Neurogenic tumor.
*'. Mast cq m ma n eause of A:s ai M in c rt it d ren : srrep{o c o cc u s p n e u {n an i ae. :
& Most common cause of acute bronchitis (not bronchiolitis) in children : lnfluenza virus.
* Cyanisi5 and respiratory'syrnptoms improve on aying ; Choana! airesic.
* Most common pulmonary tumor in children: Carcinoid.
xan
QUE5TIONS
l. Pediatirc afuway difrer from adult _ @ET luly 15 pauern) c) Should be done
a) Large tongue d) None ofabove
b) Short epiglotitis
c) Narrowest part is glottis
d) Larynx in lower posittion LARYNGOMALACIA & CROUP
2. Leveloltrachea trifurcation in pediatic patient is-
11. A 3 month old child presents with intermittent
(CET luly 15 pattern)
stridor. Most likely cause is - (AI 01, AIIMS Dec 95)
a) T, b) r, a) Laryngotracheobronchitis
c) T, d) r, b) Laryngomalacia
3. True about upper airways of neonate_ @GI Dec 00) c) Respiratoryobstruction
a) Cricoid is narrowest part d) Foreign body aspiration
b) Larynx extend from Cn to Cu 12, Most common cause of stridor shortly after
c) Epiglottis is big & omega shiped
d) Atl
birth - (NEET Dec.t2 pattern)
a) Laryngeal papilloma
4. Child'srespiratoryphysiologydifiersfromadult b) Laryngeal web
because of - @GI June 99) c) Laryngomalacia
a) Smaller airways d) Vocal cord palsy
b) Increased O, demand 13. 2 week old neonate with history of stridor in supine
c) Decreased tidal volume
d) Decreased residual volume
position - what is treatment -
GET Jub) ts pattern)
a) Oral calcium
5. Most comnon cause of stridor in infant andyoung b) Nebulisation
children - @il India Dec.lj pattern) c) Wait &watch
a) Abductor palsy b) Croup d) Antibiotic
c) Laryngomalacia d) Epiglottitis t4. Steeple sign is seen in - (CET Nov 15 Pattern)
a) Acute epiglottis
FORf IGN BODY ASPIRATION b) Laryngotracheobronchitis (croup)
c) In both cases
6. Acute onset ofcouglr, stridor and dysponea in a d) None ofabove
child is mostly due to - ecr sj) 15. A child-with three days history of upper respiratory
a) Foreign body tract infection presents with stridor, which
b) Acute Asthma decreases on lying down postion. What is the most
c) Aspirationpneumonitis probable diagnosis - (Ar 07)
d) Primary complex a) Acute Epiglottitis
7. Immediate management of a child with foreign body b) Laryngotracheobronchitis
inhalation is - (All India Dec.14 pattern) c) Foreign body aspiration
a) IPPV d) Retropharyngeal abscess
b) Bronchoscopy
c) Tiacheostomy
16. False regarding croup is - (Al1 India Dec15 pauern)
a) Disease include epiglottis, laryngitis,
d) Exploratory Thoracotomy laryngotracheitis
8. In child, foreign trody in lung - (NEET Dec.12 pattern) b) Brassy cough is main presenting feature
a) Rigid bronchoscopy c) Causes upper airway obstruction
b) Chest x-ray d) AII of above
c) Flexible endoscopy 17. A2year old child is brought to emergency at 3 AM
d) Direct laryngoscopy with fever, barking cough and stridor only while
9. Commonest sign of intrabronchial foreign b6dy crying. The child was able to drink normally. On
in children is - examination respirator rate is 36lmin and
a) cough
/ (cuPGEE ee)
b) wheeze temprature is 39.6"C. What will be your next step -
c) Dyspnoea d) Srrfuor @IIMS Nov 08)
10. Swiping of oral cavity not to done in foreign body a) Racemic epinephrine neburization
ingestion in children because - b) High dose dexamethasone injection
(All India Dec15 pattern) c) Nasal wash for influenza or RSV
a) Oral cavity small, inability to clear d) Antibiotics and blood culture
b) Leads to in advertentlypushing offoreign body t8. A 4 yr old child has 'seal barking, like croupy cough.
deep in respiratory system Management includes A/E - @ci tune zooo)
a) O, inhalation c) Pneumococcus
b) Antibiotic d) Streptococcus
c) Hydration 27. In a child I years the commonest cause of resp.
d) Morphine Infection witl wheeze is - (PGt es)
a) RSV b) Influenza viurs
EPIGLOTTITIS & BRONCH IOtITIS c) Adenovirus d) para influenza
L9. Which of the following is the aetiological agent
PNEUMONIA
most often associated with Epiglottitis in
children -
28. The commonest cause of Bacterial pneumonia in
All India Dec.13 Pattern,AIlMS May
a) Streptococcuspneumoniae
05, Nov 04, May 94)
children is- All India Dec,14 pattern)
a) Streptococcuspyogenes
b) Haemophilus influenzae type b
b) Hemophilusinfluenzae
c) Neisseria sp c) Streptococcus pneumoniae
d) Moraxellacatarrhalis d) Staphylococcusaureus
20. The most common etiological agent for acute 29. Most common cause of lower respiratory tract infec-
bronchiolitis in infancy is -
tion in 3 year old child is (All India Dec15 Pattern)
(CET Aug.13 Pattern, At 06,94) a) Klebsella
a) Influenza virus b) H-influenza
b) Para influenza virus
c) Streptococcalpneumonia
c) Rhinovirus d) Staphe aureus
d) Respiratory syncytial virus
30. An infant develops cough and fever. The X-ray
21. A 6 months old baby coming with H/o increasing
examination is suggestive of broncho-pneumonia.
difficutty in breathing of
2 days duration and on All of the following viruses can be the causative
examination baby is afebrile & B/L wheeze & CXR
agent ex€ept - (Al 0,1)
shows B/L hyperinflation of the lungs with normal
a) Parainfluenzarriruses
I{BC count, the diagnosis is - (PGI Nov 14)
b) Influenza virus A
a) Bronchiolitis b) Asthma c) Respiratory syncltial virus
c) Ch. Bronchitis d) Pneumonia d) Mumps virus
e) F.B.
31. Most common cause of pneumonia in children is?
22- A l1 month old child pre$ents with complaints of
(CET Aug. 12 Pattern)
respiratory distress" On examination there is
a) RSV
bilateral crepitation and wheezing. Which of the
b) Streptococcus pneumonae
following is the nrost likely cause - (ArrMS Nov 2K) c) Staphylococcusaureus
a) Pneumonia d) Klebsiella
b) Adenovirus
32. A child with pyoderma becornes toxic and presents
c) Respiratory synchl'tial virus
d) Rhinovirus with respiratory distress. His chest radiograph
shows patc\ areas of consolidation and multiple
23. Treatrnent ofbronchiolitis includes all except -
bilateral thin walled air containing cysts. The most
(All India Dect5 Patternl
likely etiological agent in this case is-
a) Macrolides b) Humid oxygen
(AIIMS Nov 03)
c) Bronchodilator d) AII of above a) Mycobacterium tuberculosis
24. Treatment of choice in bronchiolitis in - b) Staphylococcus aureus
(NEEl'Dec.12, CET Nov. 12 Pattern) c) Mycobacterium avium intracellulare
a) Ribavirin b) Amantadine d) Pneumocystiscarinii
c) Vidarabine d) Zidorudine _ 33. Pneumatocele is caused by- (All tndia Dec.13 pattern)
25. A month old HlYpositive child following URTI a) Staphylococcus
developed sudden onset ofbreattlessne$$. The chest b) Streptococcus
x-ray shows hgrerinflation. The O2 saturation wa.s c) Streptococcus pneumoniae
greater than 90%. The treatment of choice A d) P. carnii
is- (AIIMS May 01) 34. Pneumothorax could be a complication of -
a) Cotrimoxazole b) Ribavarin (All India Dec.14 pattern)
c) IV Ganciclovir d) Nebulized Acyclovir a) Staphylococcalpneumonia
26, Aerosolized ribavirin is used in the treatment of b) Pneumococcal pneumonia
bronchiolitis with - (CE?'Nov.14 Pattern) c) Klebsiellapneumonia
a) RSV d) Viral pneumonia
b) H.influenza 35. The commonest organism causing Ernpyema in
::,::r::.ir;:ai:
40. NOT a feature of childhood asthma is - (AIMS Dec 94) 49. A 3 month old child has moderate fever and non
a) History of atopic dermatitis productive cough'and mild dyspnea. After course of
b) Raised lgG level mild antibiotlc the condition of the child improved
c) Improves with age transiently but he again develops high fever,
d) Absence ofwheezing after exercise productive cough and increased respiratory distress.
Chest X ray shows hlperluscency and PFT shows
41. Characteristic symptom of asthma -
obstructive pattern. Most probable diagnosis is -
(All India Dec.13 Pattern)
(AI 11, AIIMS May 07)
a) Clubbing b) Wheezing
a) Alveolarmicrolithiasis
c) Slridor d) Bradycardia
b) Post viral syndrome
42. All are seen in asthma except - (AI 97)
c) Follicularbronchitis
a) Cyanosis b) Wheezing d) Bronchiolitis obliterans
c) Clubbing d) Dysnea
50. A7 year old child presents with non productive
43. All are used in acute attack of asthma in a4 year old cough, mild stridor since 6 months. On oral
child except - @IIMS lune 97) antibiotics, patient is improving but suddenly
a) Theophylline develops wheezing, productive cough, mild fever. X-
b) Corticosteroids ray shows hyperlucency and PFT shows obstructive
c) Sedatives curve. Most probable diagnosis is -
d) Salbutamol (Al 11, ?9,AllMS Nov 08,07)
44. A 3- year old boy is brought to the casualty by his a) Post viral syndrome
niother with progressive shortness of breath for 1 b) Bronchiolitisobliterans
day. The child has history of bronchial asthma. On c) Follicularbronchitis
examination, the child is blue, gasping and d) Pulmonaryalveolar microlithlasis
unresponsive What will you like to do first -
(AIIMS Nov 02)
cYsTtc FtBRosrs
a) Intubate
b) Administer 100 % oxygen by mask 51. Which of the following exocrine glandular ducts are
c) Ventilate with bag and mask' not obstructed in cystic fibrosis - (CET luly 15 Pattern)
d) Administer nebulised salbutamol a) Pancreas
45. Most common mode of treatment of a I year old b) Lung
c) Sweat gland b) Pulmonarysequestration
d) All of above c) Cystic fibrosis
52. Infant with cystic fibrosis (cF) are likely to develop- d) Bronchopulmonarydysplasia
(All lndia Dec.14 Pattern) e) Bronchogenic cyst
- ''-a|-XQconium ileus
b) Loo\e motions MISCELLANEOUS
c) Vomiting
d) Constipation 50. A child present with recurrent sinusitis and
recurrent chest infections. Chest X-ray reveals
53. Which of the following statements about cystic
dextrocardia and situs invertus. The diagnosis is -
fibrosis (cF) is not true - @nMSMay 11)
(AIIMS Nov 11)
a) Autosomal recessive disorder a) Kartagener'ssyndrome
b) Abnormality in CFTR which leads to defective b) Good-pasture's syndrome
calcium transport c) Ehlers-Danlos syndrome
c) Mutation in cystic fibrosis transport regulator d) William Campbell syndrome
54. Most comrnon organism associated with cystic 01. Bronchitis in children is caused by - (PGI Nov 14)
fibrosis - (AIIMS May 11)
a) H. influenzae b) R.s.v.
a) Pseudomonas aeruginosa (non mucoid) c) Mycoplasma d) EBV
b) Burkholderia cepacia e) Influenza virus
c) Pleisomonas
62. In which disease, syrnptoms improve with
d) Aeromonas
crymg - (NEET Dec.12 Pattern)
55. 4 year old boy presented with recurrent chest a) Tetralogyoffallot b) Choanal atresia
infections. Sweat chloride test was done, showed c) Bronchial asthma d) All of above
values of 36 and 42. What is the next best
63. Most cornrnon cause of mass in posterior mediasti-
investigation to confirm the diagnosis?
(AIIMS May 11, Nov 07)
num in children - (PGl June 01)
3. Ans. is 'c' i.e., Epiglottis is big & omega shaped [Rel Morgan 3'd/e p. 849; Logan Turner tTth/e p. 382)
o Epiglottis is soft, large and patulous, Omega shaped and inclined at 450.
o The Subglottic region rather than the rima glottidis is the narrowest portion of the airway.
o Larynxlies opposite 2d, 3'd and 4th ceryical vertebra at birth.
6. Ans. is 'a' i.e., Foreign body tRel O.P. Ghai 9th/e p. j91 6 Vh/e p.
p. 1769;CPDT l}th/e p. 505)
367-358; Nelson 18th/e
foreign body"
"Choking and coughing episodes accompnied by wheezing are highly suggestive of airway - Nelson
"Foreign body aspiration should always be considered as a potential cause of stridor and airway obstruction in
children". --- O.P. Ghai
7. Ans. is'b'i.e., Bronchoscopy {Ref: Nelson 18th/e p. 1770; CPDT 18th/e p. 5051
8. Ans. is'd i.e., Rigid bronchoscopy [Ref: O.P. Ghai 8th/e p. 391 (z 7h/e p. 367)
o Treatment of choice is removai of foreign body by rigid bronchoscope with appropriate antibiotics.
9. Ans. is 'd i.e., Cough fRef: Nelsan 18th/e p. 1770; CPDT 18th/e p. 5051
10. Ans. is 'b' i.e., Leads to in advertently pushing of foreign body deep in respiratory system [Ref: Clinical
peiliatrics 2d/e p. 7121
11. Ans. is'b' i.e., Laryngomalacia[Rel O.P. Ghai 8'h/e p. 369 & Vh/e p. 340; Nelson 18tu/e p. 1762)
o Laryngomalacia is the most common congenital laryngeal anomaly.
o It is the most common cause of stridor in infants and children.
12. Ans. is t' i.e., Laryngomalacia [Rel O.P. Ghai 8th/e p. 369 6 7/e p. jA0l
13. Ans. is t' i.e., Wait & watchlftef: Nelson 18'h/e ch. j8j.1l
o Most common cause of stridor (prominent in supine position) in neonates is laryngomalacia.
o Treatment is only reassurance.
14. Ans. is'b' i.e., Laryngotracheobronchitis (croup) lRef: Nelson l8,hle ch. 3821
15. Ans. is 'H i.e., Laryngotracheobronchitis [Re/: O.F. Ghai yth/e p. j76 6 7h/e p. 351; Nelson lyth/e p. 17631
o This child has : -
i) 3 days history ofupper respiratory tract infection.
ii) Followed by stridor
o These features suggest the diagnosis ofcroup.
t6. Ans. is'c'i.e., Causes upper atrrwayobstruction
[Ref Ghai 7,t,/e p. 35]
: Croup
e 3lHi is[TJ,]3,"J:ffi],:ffTfffilIjj:l:::':li:r::I,r.,
variety o&condition *ti.t lrr.t.ra; ;;,'""""''u1v
traci oDsl
obstructroa (not upper respiratory
tract)
ute epiglottis, laryngitiis, trachiobronchitis.
c. Brassy corroh i"
Brassv cough the *^;-
is rh^ main presenting fealure.
77. *:T.:J;;.fl":ljxff:::ll::::,*::'l:"'^'r,*:':ontB'h'|ep
1765;aFGhaiB'h,ep3766vh,ep351)
and stridor on crying in a
;ffi*Tr";::*
Mariagement of eroup
2 yearotd child ,"r*.* ,;:;;;; ::3:::;
c The main treatment for children
with croup is airway management.
o Tieatment of respiratory distress
shouid ,"i.. p.r".rq1;;;; .",
o Following treatment is indicated testing.
-
t) Humidifed oq)gen
2) HydrationwithJluids
3) Corticosteroids
t Are benificial in, even in mild croup.
! They decrease the edema in the
laryngeal mucosa through their
e They.reduce anti-inflammatory action.
the need of subsequent epinephrine
use,
d"xi*"io,o,n"
4) '.:t:;:::;:;:;:;;;,ed
are --> o'ot
6p),"y,,red), im dexamethasone or nebutized
budesonide.
a Mechanism of action is believed
to be constriction of precapillary
fluid resorption from the interstitial arterioles through
space and a de.rease in laryngeal B-receptors, causing
r Indication for nebuiized stridor are _ edema.
i) Moderate to severe stridor at rest
iii) Respiratory distress
ii) The possible need for intubation
s) Hetiox (Bio/o hetium,",t;;;;;;;;" May vv #..T,HT,.hildren
--l be !'eLLrYE witl severe croult who may need
intubation. 'r Lrrl-tclren wfi}]
6) Antibiotics are not indicated
. 7) Sedatives should not be given
1()
lus influenzae rype b
"ii;f,f,,,1;i;,::-,Y,nn :s' it is almost always causecl
{Ref : o.p. Ghai 8,1'/e p. 375 6 7h/e p. i51;
cFDr 1,th/e p. 5a1l
by Haemophilus influenzae
2{r. A na i. (,{r : ^. n ^_. .
Ans'is'd'i'e.,Respiratorysyncytiarvirus[frel: type 8,,. - cpDT
o"F.Ghaia"np.sstiZ!l,'ro"uri,"iirrlan*u/ep.tzza)
'#;{r:i,;',::::f";:::if;i!,i,!f"t f,, Bronchiotitis
is Respiiatory synctiat virus.
RSV is responsibte
for more
21. Ans. is 'a'i.e., Bronchiolitis
tRel o.p Ghai yth/e p. 381 6
7h/e p. 357; Nelsan 18th/e p.
1775; CFDT 18th/e p. 5141
e Biiateral wheeze, hlperinflation
of lungs and normal WBC c ount
are characteristic oiacute U.orr.t with respiratorl, distress in a 6 months
ioti,i.. old infant
22' Ans. is t'i.e., Respiratory
synchytiar virus [Relr o.p. Ghai
8th/e p. 381 6 7h/e p. 356_357; Nerson lVh/e p. u16]
o The child presenting with respiratory
distress and bilatpral crepitations
23, Ans. is 'a'i.e., &{acrolides
and wheezing, we have to suspect
brochioritis.
[Ref; A.p, Ghai gth/e p. 3g2 d. Tt,/e p,. 3Sg;Nelson lgth/e p" 1776)
Treatmeni of Bronchiolitis
c Treatment is essentially symptomatic.
o The child should be ,urrld in
humid atmosphere.
a Oz_ remains the mainstay of treatment.
o Antibiotics - Though antibiotics
have no role* but Ribavarin can
o Iffever is present antipyretics sometime be used.
can be usecl.
o Continuous positive airway pressure.
' 0' adrenergic drugs and Ipratropium bromide are
also not recommended for
infants < 6 months.
^{ns. is 'a' i.e., Ribavirin lRef: O.P. Ghai th/e p.
Arrs. is 'b- i.e., Ribavarin fRef: Nelson 18th/e p. 1776; o.P. Ghai 8th/e p. 382 lt 6th/e p. j53)
c The child with HIV is suferingfrom Bronchiolitis.
o Antibiotics are not usually used in the treatment of Bronchiolitls who are previously healthy but Ribavarin shortens the
duration of treatment in patient who have -+ Immunodeficiency, Congenital heart disease, Chronic lung disease
c The child in the question is having immunodeficiency due to, HIV infection. Therefore Ribavarin should be used in
the treatment of this Patient.
16. Ans. is'a' i.e., RSV IRel O.P. Ghai 9th/e p. j82 6 Vh/e p. 35/
3:. Ans. is'd i.e., RSV tRe/ O.P. Ghai 8n/e p. 381 dt Vh/e p. 3561
r Wheezing due to respiratory tract infection in a I year old child is due to bronchiotilis'
PHEUMONIA
lB. Ans. is t' i.e., Streptococcus pneumonia lnef: O.P. Ghai 9th/e p. j77 6 7h/e p. 352; Nelson 18th/e p. 17951
o Stre7ttococcuspneumoniae(pneumococci)isthemostcommonbacterialpathogensfollowedbychlamydiapneumoniae
ani mycoplasma pneumoniae. - Nelson 18th/e 1795
30. Ans. is t' i.e., Mumps virus [Rel o.P. Ghai 8th/e p. 377 6 vh/e p. 352; Nelson 18'h/e p. 1795)
o The peak attack for viral pneumonia is between the age of 2nd and 3'd years and decrease thereafter.
o Viruses causing pneumonia are -
3l . Ans. is 'a' i.e., RSV tRel Oski's paediatrics : Principles & practice p. 13951
"Respiratory syncytial virus (RSV) is the most common cause of pediatric pneumonia" - Oski\ Paediatrics
"Reipiratory viruses are the single most important cause of community-aquired pneumonia in pediatric'age group"
- Iawetz
.-o-
i.e., Staphylococcus aureus fRef: O.P. Ghai 8th/e p. 378 dt Vh/e p.
j53l
32. Ans. is
c pneumonia with pneumatoceles (multiple thin walled air containing cyst) is s/o staphylococcal pneumonia.
. o The diagnosis of slaphylococcal pneumonia is suspected in a newborn or an infant with respiratory infection who has
evidence of staphylococcal infection elsewhere in the body (here it is pyoderma).
JJ. Ans. is'a'i.e., Staphylococcus I Ref: O.P. Ghai 8tu/e D. 378 d, Vh/e p. i531
c Staphylococcus aureus is the most common organism causing pneumatoceles and pneumatoceles are considered
p atho gnomonic of st aphylo co ccal p neumo nia.
o E.coli and.klebsiellap.terr-o.,ia may have pneumatoceles. -- O.P. Ghai 6'h/e 350
j78 6 p. 354)
34. Ans. is 'd i.e., Staphylococcal pneumonia [Rel O.P. Ghai 8th/e p. Vhle
35. Ans. is 'b' i.e., Staphylococcus [Ref O.P. Ghai Sth/e p. 379 6 7/e p. 35a)
36. Ans. is 'b'i.e., Measles [Ref; Harcison lVhle p. l2]S]
t cell (hecht's pneumonia) is most often documented in
immunocompromized and malanourished patients
#t#JJ:J:nt
o It is a rare complication of measles. .t
r Pseudomonas r
iY,iir"Kr:^l',...r, itifJ{r"#}""' Bacteroides, fusobacterium, peptostreprococci
o Others are -) Nocardia, Legionella, Fungi (candida
and aspergillus)
39. Ans. is'b'i.e., Right apical lRef:.Grant,s atlas af anatowy jgl
ltrh/e page
r
Lobes of lung most susceptible to aspiration
in supine position -+ po;t-segment
o superior segment of right rower robi, superior of Rt. (Jpper lobe(Most common),
segment of reft lower lobe,
ASTI"IMA
40. Ans. is 'b' i.e., Raised IgG level A.p Ghai ytk/e p.
[Ref: 353, 384 & p"
Zh/e 3SB_359;Nelsate l8nle p. 953, 954;
C?DT t&*le p. 1049, 10501
o It is tvpe I hlpersensitivity, which is mediated by IgE
a
-+ IgE is raised(not IgG)
n be family hklory of atopic disease
T"::.*o,
c Childhood
@iopc deriatitis, oi"rgi, rhinitis).
asthma usually improves with age.
Mild exercise can cause bronchodiratation and
may reduce wheezing.
,o
41. Ans. is'b'i.e., Wheezing lRef: Ghai Z',/e p. 3S9l
r Most characteristic symptom of Asthma is wheezing.
42. Ans. is t' i.e., Clubtring fRef: O.F. Ghai 8th/e p. 353 & Vh/e p. 3591
"Clubbing of
fingers is unusual in uncomplicated cases,,.
43. Ans. is t'i.e., Sedatives lRef: O.p. Ghai Bth/e p. - O.P. Ghai
386_jgt & Vh/e p. 360_j62; CpDT tythle p. N58l
o Pharmacological treatment of Asthma
i) Mild
r Inhalation of sh3rj acting p, receptor agonist, e.g.
r If there is nosatisfactory response, addlnhared salbutamot (albuteror).
(ipratropium).
r In patients who are refractory to inhaled therapies,
"ffirn"ti"rrgtc
,.". (theophylline) may be effective.
ii) Moderate and severe "*inZplrylline
t oxygen plus z systemic steroids plus t continuous administration of aerosolized salbutamol
44. Ans' is 'b'i'e" Administer loao/o arby masft
[Ref: o.p. Ghai 8*le p. 391 6 7/e p. j6a462; IAp Tdle p. 4A4]
Management of life threatening asthma
{status asthmaticus}
1) Immediate O.inhalation
2! Inj,ection of tirbutaline or adrenaline (s.c.)
3] Inhalation of salbutamol or terbutalinte and ipratropium
4) Injection of hydrocortisone llmg/kg.
45. Ans. is 'a'i.e.' Inhaled short acting beta-2 agonist
fRef: preuious expranations]
o Treatment of choice for acute asthma -+ i
Inhaled short acting Bz agonist.
e Treatment of choice for chronic asthma -+ -'
Inhared gr".o.o;ti.oiJ'r.
o Even in chronic asthma, stage I (miid intermittent),lnhaled
short acting Bz agonist is used, as needed for symptoms.
46. Ans" is'b'i.e., Short acting budesonide {Ref: CpDT tY*/e p. ta57}
o Tolerance is potential problem with Bz_agonists.
a
ll'
ru
o It is advised that patients requiring regular medication should be treated with inhaled steroids and use of p,
ed patients agonist inhaler should be restricted to symptomatic relief of an acute attack.
{ Ans. i"e., ?rophylaxis ryith beta agonist [Ref: O.P. Ghai 8*/e p. j90; Vh/e p. 365-366; CPDT 18th/e p. 1058]
is'lf
o The meilications most widely used by people with exercise induced asthma are short and long acting beta 2-agonist
t
bronchodilators.
48. Ans. is "C ie., MDI viith spacer with rnask fnef Ghai 7h/e p. 36j)
r MDI (Metered-dose inhaler) alone require better press and breath co-ordination so used above 12 years of age.
o MDI with spacer overcome breath co-ordination so used above 4 years of age.
rcocci r MDI with spacer with mask can be used successfully in children below 4 years of age.
BRONCHIOLITIS OBLITERANS
o Bronchiolitis obliterans is a rare chronic lung disease of the bronchioles and smaller airways.
r Bronchiolitis obliterans most commonly occurs inpediatric population after respiratory infections (i.e. adenovirus,
mycoplasma, measles, influenza, pertussis).
o Other causes include connective tissue disease (i.e. juvenile rheumatoid arthritis, systemic lupus erythematosis, scle-
roderma)
o Bronchiolitis occurs in all age groups.
tasa] o Cough, fever, cyanosis and respiratory distress followed by initial improvement may be the initial signs of bronchiolitis
f
obliterans.
o Progression of the disease may ensue with increasitg dyspnoea, cough, sputum production and wheezing.
. . Cheit radiographs may be relatively normal compared with the extent of physical flndings but may demonstrate
hyperluscencyind patcfu infiltrates (occasionally, a swyer fames syndrome, i.e. a unilateral hlperluscent lung has
developed).
o pulmonary function tests demonstrate varaible findings but typically shows signs of airway obstruction.
o Ventilation perfusion scan shows a tlpical motheaten appearance of multiple matched defects in ventilation and
perfusion.
o CT scan demonstrates patchy areas of hlperluscency.
r Open lung biopsy or iransbronchial biopsy remains the best means of establishing the diagnosis of bronchiolitis
oblite.rans.
50. Ans. is 'b- i.e., Bronchiolitis obliterance {Ref : See above explanationl
cYsTrc FrBRoSls
51. Ans. is t'i.e., Sweat gland
o The sweat glands are not obstructed in CF patients because in serous glands such as sweat glands there are abnormal
concentrations of inorganic ions, rather than glandular obstruction with thick mucus.
o Obstruction of Lirwiys leads to bronchiectasis anil atelectasis; pancreatic duct obstruction leads to pancreatitis and
malabsorlttion; and plugging of bile ducts leails to obstructive jaund.ice,
52. Ans. is'd i.e., Meconium ileus [Ref Nelson 18*/e p. 1807; O.P. Ghai 8e/e p.
j9j & 7/e p. 369]
r Most patients with CF present in chfdhood. Approx 187o of patients present within the first 24 hr of life with
Gastrointestinal obstruction, termed Meconium ileus'
o Other systems dysfunctions are not present at birth, they may manifest within the first year or two of life including
respiratory tract sYstem.
53. Ans is'o- i.e., Abnormality in CFTR which leads to defective calcium transport [Rel Robbin's 8*/e p. 465-681
o Cystic fibrosis is an autosomal recessiye disorder of ion transltort in epithelial cells that affect fluid secretion in
exocrine glands and the epithelial lining of the respiratory, gastroiytestinal and reproductive tracts.
o Cystic fibrosis occurs due to mutation in the CFTR gene'
o CFTR was initially recognized as chloride conductance channel but it is now recognized that CFTR can regulate
multiple ion channek and cellular ptrocesses. These include :- Chloride channels, Potassium channels, Gap junction
channels, and Bicarbonate ions.
Ex,, ri :.,llesrJirAtai! Sy gt e m
:
ua'
'dns is i"e., Fseudomonas aerugenosa (non rnucoid)
lRef: Nelsarc pediatrics lgth/e p. l2ag, ulal
a The most commin and important pathogen in cystic
fibrosis is Pseudomonas aeruginosa,which causes infections
that, once established, are impossible to eradicate.
e Acquisition of Pseudomonas infection begins early in childhood.
The initial acquisition of p. aeruginosa in the CF
lung is with nonmucoid strains and occurs early in life. Over time there is transition
to mucoid strain, and with age
mucoid strain becomes predominant with age.
o Non-mucoid P. aeruginosa can be eradicated with aggressive anti-pseudomonal
antibiotic theraphy. Mucoid strain
cannot be eradicated by current antibiotics and therefore predicts shortened
survival.
Etr
.A.ns. is t' i.e., Transepithelial nasal potential difference [ll.ef. a.F" Ghai 8,h/e p. 393 & 7h/e p. 369; Nelsan n Sth/e p.
18A4,18A3)
o The sweat test is the standard approach to diagnosis.
o The diagnosis is made by elevated sodium and chloride level in the
sweat > 60 meq/1.
o Two test on different days are required for accurate diagnosis.
e A normal sweat chloride dose not exclude the diagnosis. Genotyping
and other tests such as measurement of nasal
membrane potential dlfference, pancreatic function should be done ifihere
is high clinical suspicion of cystic fibrosis.
s6. '{ns. is 'a' i"e., Cystic Fitrrosis fRef. Idarrison t7h/e p.1632, id3,l; R.obbins Th/e p. 494; I{elsow lgth/e p.1g0g;
R.udolph's Fediatrics 2 1
*/e p 1 9 7 2l
"
e Recurrent chest infection in a child with evidence of exocrine pancreatic insfficiency (bulky, foul smelling
stool) suggest a diagnosis of cystic fibrosis.
57" Ans. is oa' i.e., Fibrocystic disease of pancreas e fRef. Nelson rgth/e p. g07l
58" ,A^ns. is 'b' i.e., 58-7$a/ar occurs in lungs {R.ef. Scbwartz gth/e p. 59Zl
c Only 15% of bronchogenic cysts occur in lungs (puimonary parenchyma).
&
59. Ans. is 'b' i.e', Fulmonary sequestration tfi€l Nersan nSth/e p" tr784)
o Sequestrated lung has no connection to airu'ay, so this part does not
fill on bronchography
MISCELLANEOUS
&. Ans" is ? i.e., Bronchosccpy lR$ Indian leiarnal af prartieel pediatries 2w2 p 4l:32\
o A history of recurrent pneumonia in the same lobe or segment or slow resolution (> 3 months) of pneumonia on
successive radiographs3uggests the possibility ofbronchial obstruction and the needfor bronchoscopy.
65. Ans. is'b" i.e., Reassure &give saline nasal drop lRef park2*lep" 156|
r This 3 weeks male child with noisy breathing does not have chest indrawing or fast breathing (as clinical examination
is normal).
r So, this child is having simple cough or cold, no pneumonia.
o Management includes :-
(i) Reassurance to mother (iii) Keep the baby warm
(ii) Frequent breast feeding (iv) Clear the nose
6. Ans. is "a' i"e", Careinoid ER.6 Pedi&triq swrger.y jaucnatr zSIe|
III
G.&SYK,*XefYffiSY'KKAt
Y'EACT
Gep#g
Clinicalfuatures
. Neaonates present withfrothing, excessive drooling coughing and cyanosis
withfeedinglArrMsl3,ol).This is followed
by respiratorY distress(en'us 0i 0r). Newbor n regurgitates of its first and subsequent
feeds.
Diagnosis
o Inability to pass a nasogastric tube('4rrMs 03)
confirms the diagnosis of TEF.
r Lateral chest X-rayarMso3) shows a lucent proximal pouch that may displace trachea anteriorly.
r X-ray abdomerr(A,Ms shows gas in stomach in commonest variety type-c rEF.
03)
INTESTIIIIAL T}ISORDERS
MEGACOLON
e Megacolon is an abnormal dilatation of colon that is not caused by mechanical obstruction. It may be :-
1) Congenital megacolon: Hirschsprung disease.
2) Acquired megacolon : It may be due to poor bowel habi{scPcr 0} drugs (antipsychotics), and infection (chaga's
disease).
Clinical features
o ThereischaracteristicallydelayedpassageofmesenisTn6nnsu'02).Thisisfollowedbybiliousvomitingandabdominal
distension. Enterocolitis is seen between 2-4 weeks with bloody stools and fever.
o Complications may occur, e.g. perforation, constipation and rectal bleeding.
Diagnosis
c Rectal manometryar13) is a useful screening procedurear'3). There is failure of the internal anal sphincter to relax
(pressure fails to drop in internal sphincter) after dilatation of rectum. An abnormal test is not absolutely diagnostic
but a normal test excludes the diagnosis(AllMsee), i.e. it is a sereening test.
o Rectal biopsy is the definitive diagnostic procedurs@I t3). It shows :
AUMS}4)
1) Absence of ganglion cells and ganglia in affected segmenf
o Technique demonstrating ACHE (acetylcholinesterase) staining in aganglionic instestine are also of interest in
diagnosis(Ar rs).
Treatment
o Surgical resection of the affected segment and anastomosis of normai segments is the treatment of choice. Surgical
options are Swenson, Duhamel, Soave and Boley procedures. Diversion colostomy is done initially to gain time if
patient is not fit for surgery.
The diagnosis in t}te given barium
enema study is _
A) CHPS
b) Hirschsprung disease
Oiagnosis
t The mainstay of diagnosis of intestinal
obstruction is plain abdominal
a X-ray whichshows :_
Complete intestinal obstruction: Fluid
: gas (air) levels.
x Meconeum ileus: Growd,glass appearance.
* Doudenal atresia: Double bubble sign(Nrar) (two
air_fluid levels).
Nlejunal atresia: Triple bubble sign. (three airfluid
levels).
a Ileal atresia: multipie bubble sign (multiple
air fluid levels), and christmas tree
r volvulus neonatorum is diagnosed by birium appearance.
contrast studies with
However' perforation is suspected plain fluoroscopy lborium mear follow through).
.if X-ray abdomen is the initial investigation
of choiss{u to).
Also know
httussusceptian is the most common cause
' of intestinal obstruction between
3 months
to 6 years of age (not in neonates).
INTlJSSUSCEPTION
c Intusssception may be : _
Clinical features
o There is sudden onsel of severe paroxysmal colicky abdominal pain that recur at frequent intervals. Child cries loudly
(screaming@Gr03)) and there is straining efforts with legs and knee flexed.
r Blood and mucus produce a current jelly stool and there may be reflex vomiting.
o There may be abdominal distension@Gro3) and tenderness.
r Occasionally intestine prolapses through rectulrlr producing mass per ,"r1urn(ed oo)
.
Diagnosis
r On palpation there is sausage - shaped tender palpa$ls tnq5seetot) and emptiness in right iliac fossa (dance sign).
r Barium enema is both diagnostic and therapeutic. It shows claw sign and coiled spring sign.
r'X-ray abdomen shows :-
i) Crescent sign : Intussusception lead to point into gas filled lumen.
ii) Target sign: Mass in right upper quadrant forms a shape of target.
Treatment
r Correction of intussusception by barium enema is the initial management of choice.If it fails, surgical correction is
done.
, a)l Elirschsprungdisease
, .
b) Tropical sprue
c) Coeliac sprue
d) Intussusception
', t''':
d) Crohni disease
.'..
'Ans:,,istif!;e*CrOhtrsdiieage, r.,' : ': .,:1 : 1. '.1'.1: '.:' , 1,. ' 1i'' ' .
Ulcerative colitis
o Uicerative colitis involves the rectum and extends proximally.
o In severe cases entire colon may be involved + pancolitis.
r It is a disease ofcontinuity, and skip lesions are not found.
o In some patients"distal ileum may also develop muscosal inflammation
+ backwash ileitis.
r only mucosa and submucosal layers of colon are involvement, deep layer
are not involved usually.
o Isolated islands of regenerating mucosa bulge upward to
create ps"uJopolyp (Ar s8, e4) .
e There are superficial mucosal ulcer but they are not serpentine
as seen in cD.
o There is inflammation of crypts -) Crlptilis(er,usoar.
o Neutrophilic infiltration into crypts leads to formation
of crypt abscess.
c In sever cases of UC, toxic damage to the muscularis propria
and neural plexus lead to complete shutdown of neuro-
muscular function -+ colon progressively swells to create toxic
megacolon(.4re8, e4).
c There may be epitheliat dysplasia with progression to frank carcinoma.
c Barium enema shows : (i) Garden hose appearance; and (ii) pipe stem 8e).
appearance(Ar
o UC is associatecl w.ith HLA-DR2, potymorphism in lL-l0 gene andan abnormal r-cell response
particularly of
CD4 T-cells (T ce lls).
*2
. cI Ulcerative colitis
d) Crohn's disease
NECROTIZING ENTEROCOLITIS
MALABSORPTION
r Steotorrhea is defined as increased fecal fat excretion (> 7gmlday).
r Azotorrhea is defined as increased fecal nitrogen (> 3 gm/day), which is derived from protein.
o Both these conditions occur in malabsorption syndrome due to any cause as fat and proteins are not absorbed.
r Important causes in children are chronic pancreatitis (pancreatic insuficiency){ttss), coeliac disease (coeliac sprue)
(Aree),
ileal disease (Crohn's disease), intestinal lymphangiectasia, and bacterial overgrowth Slfldroms@tss).
r Work-up of a child suqpected to have chronic diarrhoea and malabsorptions includes the following investigations :
Clinical features
r The child presents afier 6 months of age when weaning is started and gladin containing grains are introduced in the
diet. Child presents with diarrhea, anorexia, weight loss andfailure to thrive1re3).
r There is malabsorption with deficiency of iron, folic acid, andfat soluble vitamins (A, D, E, K).
o CNS manifestationsarse.) like ataxia and seizure can be seen.
o There is secondary lactase (disaccharidasq) deficiency@Gree). Individuals with celiac disease have a higher chances of
malignancy : enteropathy associated T-cell lymphomaecl ee) (most common) and small intestinal aderuocarcinoma.
Diagnosis
r The definitive diagnosis is based onhistopathologicalfindings which show :
Lactase.deficien$J
r Lactase deficiency is the most common enzyme deficiency in human.
I Congenital lactase deficiency is due to mutation in lactase gene on chromosome-2.
c Acquired lactase deficiency is seen in infective enteritis (viral
or bacterial)arost, cystic fibrosis, pEM, cow,s milk
protein intolerance and use of neomycine.
Patient present with diarrhea, vomiting, bloating and abdominal
' ee)'Reducingsubstancesandorganicacidsarepresentinthestool.
painfollowing intake of milk or milk producls@rrus
Hydrogenbreathtestispositive@NB13).
DIARRHEA IN CHILDREN
r Diarrhea is defined as passage of liquid or watery stooles more than three times
a
I Persistent diarrhea is defined as acute diarrhea of infectious origin which lasts for day@cros1.
> 14 days (2-4 weeks).
c chronic diarrhea is difined as diarrhea rasting for more than
4 weeks.
o Intractablediarrheaisaformofchronicdiarrheainwhichno
infectiousetiologicalagentcanbeidentified.rtmaybe
seenin cysticfibrosis@Gro,),blleductatresia,cowtmilkproteinintolerance(milkallergyecr00)),abetalipoproteinemia,
secretory diarrhea dueto tumors@croo), carbohydrate intolerance,
lactase intolerance, congenital enterokinase and
trypsinogen defi ciencies, and pancreatic insuffi ciency.
c Dysentery is defined as presence of blqod mixed with pus and mucus in s1,,61seeros). shigella is the most common
cause of dYsentryoio-e' ea).
CONSTIPATION
e Chronic abdominal pain is defined as recurrent or persistent bouts of abdominal pain that occur over a minimum of
3 months.
o The commonest cause of chronic abdominal pain in older children is functional (non organic) that may be due to
emotional or behavioral problems(AllMs 83)
.
:
: r'::i:'r.:,'::::l:: &lniillign$!pat1hii*|,::;::,,,;.,,''.'..:i=,1:.,rLij!iil'pci:isonlng{rern
Constipation Pancreatitis
'..i:i:'i r .i.: f::'
Causes
o Exact cause is unknown. o Overactive child and overanxious parents
r Aerophagia c Cow's milk intolerance
e Hunger e Overfeeding with high carbohydrate containing food
e Immaturity of intestine
NEONATAL CI{OLESTASIS
c Neonatal cholestasis is defined as prolonged elevation ofserum levels ofconjugated bilirubin beyond the first 14 days oflife.
o Neonatal cholestasis can be divided into extrahepatic and intrahepatic disease and clinical features of any form of
cholestasis are more or less similar.
a Neonatal hepatitis is the prototlpe of intrahepatic cholestasis
e Biliary atresia is the prototlpe of extrahepatic biliary atresia
A) Extrahepaticcholestasis
r Extrahepatic cholestasis (obstructivejaundice) is due to obstruction of bile flow outside the liver.
r It is characterized by elevation of alkaline phosphatase\lrMs\6), 5-nucleotidase@IlMs06) and. gamma glutamyl
transp eptidaseqllMs 06' 02' At o1),
ii) lnfections: Hepatitis B and CaIIMse% rubella, CMV, slphilis, toxoplasmosis, Coxsachievirus
AI.MS 02)
rii) Idiopathic : Neonatal heltatitis{Al0a' '
r There is elevation of serum transamiruases (ALT, AST) and mixed (conjugated & unconjugated)
hlperbilirubinemia.
r Biliary atresla is the most common indication for liver trarsplantation ln childrenffr''1.
PORTAL HYPERTENSION
pressure.
8s' Iipmet 87)
r It the most common cause of gastrointestinal bleed and esophageal variceal bleeding in children(wsc
is '
Dribbling and regurgitation after feed, respiratory distress, frothing & bubbling at mouth in a neonate: Tracheo-esophageal fistula.
Congenita! hypertrophic pyloric stenosis (CHPS) usualty presents: After 3 weeks (but may be as early as 1 week).
Metabolic derrangement in CHPS: Hypochloremic alkalosis with paradoxical aciduria and hyponatremia.
Non-billous vomiting with palpable mass in epigastrium : CHP5.
Ramstedt operation is done in: CHPS.
A[Ms t'3).
* It is the most common cause of portal hypertension in children in India$EE\ Obstruction of
portal vein is caused by thrombosis (intraluminal obstruction) or by external compression by tumors/
pancreatic mass (extraluminal obstruction).
* The presentation is usually seen in childhood (7" and 2d decade){Arr3). Clinical features are variceal
bleeding (hematemesis, melena), and mild splenomagaly. As the pathology is proximal to liver, LFTs are
normal, there is no hepatomegaly/cirrhosisiascites/jaundice and massive splenomegaly does not occur.
,r,roi*ion rhould be avoided in coeliacdiseose : wheat. oa! barley, rice (but not maize).
leliac disease is associated with : HLA-DQ2 (mc), HLA-DQB (2'd mc), HLA-88, HLA-DR3, HLA-DR7'
;";r r;;;;, aunrirncy after infectious enteritis: Lactose'
"nry*o
a for lactose deficiency and lactose intolerance : Hydrogen (H, ) breath test.
-est
(2"d mc).
* l.4ost common cause of cholestaticjaundice in newborn: ldiopathic neonatal hepatitis (rnc), extrahepatic biliary atresia
lmportant features of extrahepatic cholestasis (e.g. bitiary atresla) : Raised alkaline phosphatase, 5-nucleotidase and
GGT.
disease.
Giant cells are seen in : Neonatal hepatitis,, EHBA, q1 antitrypsin deficiency, viral infections, Niemann-Pick
Diagnostic procedure for extrahepatic biliary atresia (EHBA): Percutaneous liver biopsy.
(EHPVO).
Most common cause of portol hypertension in children in lndia: Extrahepatic portal venous obstruction
Most common cause of massive hematemesis in a child: Portal hypertension.
t Most common cause af diarrhea in clrildren: Rotovirus.
(but not reovirus)'
& lmportant viral causes diarrhea in children: Rotovirus, calcivirus adenovirus, astrovirus, norwalk virus
I Most common bacterial cause of diarrhea in children in lndia:ETEC'
Parasites causing diarrhea in immunocompromized child: Giardia, cryptosporidum.
n commonest couse of ab:dominal pain in children: Behavioral (functional) pain.
Most common cause of abdominal pain in an infant: colic (evening colic).
For anorectal malformation x-ray (invertogram) is done: At 12-24 hours after birth.
* o6r",r* oirr*,m,arcln UuOAte on anterotat-usG; Fetal esophageal atresia'
w Home made emiting agentfor children in suspected poisoning :syrup of ipecac.
Most common cause of vomiting in neonate; Aerophagy.
& Most common cause af bleeding per rectum in infants:Anal fissures'
Most common indication of liver transplantation in children: Biliary atresia.
xxx
d
QUESTIONS
A premature neonate on top feeding develop ab- 39. Antiendomysial antibody is used in screening of -
dominal destension and bleeding per rectum. He (All India Decl, Pattern)
recently recovered from acute upper respiratory a) Myasthenia gravis
tract infection. What is the probable diagnosis - b) Auto immune hepatitis
(PGI Dec 08) c) Coeliac disease
a) Necrotizingenterocolitis d) Graves disease
b) Vahulus 40. The histological features ofcoeliac disease include
c) Meckeltdiverticulum all of the following Except - (CET Nov.14 Pattern)
d) Intussusception a) Crlpt hlperplasia
A newborn sufiering from perforated necrotizing b) Increase in thickness of the mucosa
enterocolitis is having very poor general condition. c) Increase in intraepithelial ll.,rnphocytes
He is currently stabilized on ventilator. Which of the d) Increase in inflammatory cells in lamina propyria
following should be done in tlre management of this 41. Gluten sensitive enteropathy is most strongly associ-
patient - (Ar 08) ated with - (All India Dec.14 Pattern)
a) Conservativetreatment a) HLA-DQ2 b) HLA-DR4
b) Resection and anastomosis c) HLA-DQ3 d) Blood group'B'
c) Stabilization with membrane oxygenator and defer In celiac disease A/E - (PGI lune 2000)
surgery a) Gliadin is cause
d) Peritoneal drainage by putting drains in the flanks b) Associated with HLA-BS
35. A neonate is suspected to be suffering from necro- c) Decreased villi to crypt ratio
tizing enterocolitis Nrc). On further examination d) Increased brush border
and investigation, he is diagnosed to be Bell's stage I
NEC. The management of choice would be -
LACTASE DEFICIENCY
(AttMS May 12)
a) Laparotomy and proceed
43. A boy comes with complains of vomiting, bloated
b) Insertion of bilateral pelvic drains
abdomen and abdominal pain. He has history of
c) Conservative management with IV fluids and
attending ice-cream eating competition last night.
antibiotics
He also has past history of similar episodes follow-
d) Initial conservative management and laparotomy
ing ingestion of milk and milk products. The likely
after 24 hours
cause - (AllMS Nov 99)
a) Pancreatic amylase deficiency
MALABSORPTION b) Lactase deficiency
c) Salivary amylase deficiency
36. A 12yeadold girlhashistoryofrecurrentbullcy d) Foodpoisoning
stools and abdominal pain since 3 year of age" She One of the intestinal enzymes that is generally
has moderate pallor and her weight and height are deficient in children following an attack ofsevere
below the 3rd percentile. Which of the following is infectious enteritis is - (Ar 0s)
the most appropriate investigations to make a spe- a) Lactase b) Trypsin
cific diagnosis ? (AllMS Nov 04)
c) Lipase d) Amylase
a) Small intestinal biopsy
Lactose intolerance in a suspected patient is diagnosed
b) Barium studies
by giving an oral load and measurirrg concentrations
c) 24hrs fecal fat estimation
of? (CET Aug.1j Pattern)
d) Urinary d-xylose test
a) CO2
37. In children presence ofincreased fecal fat excretion b) H2
and increased fccal nitrogen levels is a feature ofAll c) One/two carbon compounds
Except - (At ee)
d) N2
a) Pancreatic-insufficency
b) Bacterior overgrowth syndrome
c) Coeliac sprue CHOLESTASIS
d) Ulcerative-colitis
In a child presenting with obstructive ]aundice all
afe seen except - (AIIMS Nov 06)
a) Gamma glutamYl transPePtidase turmeric colored urinc and pale stools since birth.
b) Alkalinephosphatase Examination reveals liver span of l0 cms. The most
c) Glutamatedehydrogenase specific investigation for establishing the diagnosis
(At 03)
d) 5'Nucleotidase wouldbe -
a) Liver function tests
{-. In neonatal cholestasis, if the serum gamaglutamyl-
b) Ultrasound abdomen
transpeptldas€(gamma GTP) is mote than 600 IU/L the
(AI 04, AllMSNov 02)
c) Peroperative cholangiogram
most likely diagnosis is -
d) Liver
a) Neonatal hepatitis b) Infection lirpty
c) Sclerosing cholangitis d) Biliary atresia
{& Neonatal cholestasis is seen in - (AIIMS Iune 98) PORTAL HYPERTENSION
a) Chronic hepatitis
b) HepatitisB&C 55. Portal hyfiertension in children in India is common*
ly due to - (AllMS Nov 0j)
c) Glycogen storage disorders
a) Indian childhood cirrhosis
d) Mucopolysacchroidosis
b) Extrahepatic portal venous obstruction
49. Most cornmnn caus€ of cholestatic janudice in new c) Idiopathic portal hlpertension
born is - (NEBT Dec.12 Patter-n)
d) Hepatic out flow tract obstruction
a) Hypoplasia ofbiliarYtract
b) Neonatal heptitis 56. A 12 year old boy presents with hemetemesis,
malena and mild splenomegaly. There is no obvious
c) Choledochal cYst jaundice or ascitis. The most likely diagnosis is -
d) Physiological (AI 11)
50. The most common genetic cause of liver disease in a) EHPVO b) NCPF
(AI 02)
children is - c) Cirrhosis d) Malaria with DIC
a) Haemochromatosis b) o1 antitrlPsin
57. Most common €ause of portal hlpertension in chil-
deficiency (NEET Dec.12 Pattern)
d) dren is -
c) Cystic fibrosis Glyocgen storage
a) ExtrahepaticcomPression
disease
b) Budd chiari syndrome
c) Veno-occlusive disease
NEONATAL HEPATITIS d) Post necrotic
58' A 7 year old girl from Bihar presented with three
51. A neonate presents with jaundice and clay coloured
episodes of massive hematemesis and melena' There
stools. Liver Biopsy shows giant cells diagnosis is -
(AIIMS Nov 01, AI 01)
is no history of jaundice. On examination, she had
a large spleen, non-palpable liver and mild ascites'
a) Neonatal hepatitis with physiological iaundice
Portal vein was not visualized on ultrasonography'
b) Neonatal hepatitis with extrahepatic biliary atresia
tiver function tests were normal and endoscopy re-
c) Physiological jaundice
vealed esophageal varices. The most likely diagnosis
d) Physiological jaundice with extrahepatic biliary
is - @t 03)
atresia
a) Kala azar with portal hypertension
52. A neonate isbeinginvestigatedforiaundice' Aliver b) Portal hlpertension of unknown etiology
biopsy shows features of a "Giant CelUNeonatal c) Chronic liver disease with portal hypertension
hepatitis". Which one of the following conditions d) Portal hypertension due to extrahepatic
(AIIMSNov 04)
usually results in this case - obstruction
a) Congenital hePatic flbrosis
Ramu, a 8 yr old boy presents with upper Gl bleed-
b) Hemochromatosis
ing. On examination, he is fouad to have splenomeg-
c) Alpha-1-antitrypsin deficiency
aly; there are no signs of ascites, or hepatomegaly;
d) Glycogen storage disease TYPe 1
esophageal varices are found on UGIE Most likd
(AI o1)
diagnosis is -
EXTRAH EPATIC BI LIARY ATRESIA a) Budd chiari syndrome
b) Non cirrhotic portal hlpertension
53. A 2 months old exclusively breast fed child develops c) Cirrhosis
jaundice since birth, acholic stool high coniugated d) Veno-occlusive disease
Lilirubin in blood and absent urobilinogen in urine' 60. A child is brought by mother with H0 massive
(AllMS Nov 99)
The likely cause is - hematemesis with HO drug intake previouslywith
a) Hlpothyroidism NSAIDS and on Rx. Associated $'ith moderate sple-
b) Congenital biliarY atresia nomegaly diagnosis is - (PGI Dec 06)
c) Neonatal hePatitis a) Oesophageal varices b) Duodenal ulcer
d) Breast milk jaundice c) Drug induced gastritis d) Peptic ulcer
54. A 2 month baby presents with history of jaundice'
61. Most common caltse of seyere hemateraesis in a ABPOMINAL PAIhI
child is- (All India Dec.14 Pattern)
a) Portal hypetension b) Peptic ulcer 70. Recurrent atrdornianl pain in children in most often
c) Mallory weiss syndrome d) None of the above due to - ArrMS s3)
a) Roundworms
LIVER CIRRI.IOSIS b) Emotional/hebaviourai problems
c) Amoebiasis
62. Cause of liyer cirrhosis in childhood include- d) Giardiasis
(PGr 81, 84) 71. Comrnonest cau$e of abdominal pain in children is -
a) Alpha-1 antitrypsin deficiency (PGt 87)
b) Coeliac disease a) Porphyria b) Worm colic
c) Phenylketonuria c) Lead poisoning d) Appendicitis
d) Cow's milk intolerance 72. Colicgenerallydisappearbyage- (L/psc83, AMCBi)
a) 1 year b) 2 years
DIARRHE,q c) 4 months d) 8 months
ffi
i:.iu i:::r;r,rii. :ir'.i.1r.::ir:l
:r'if ..,. :.i, ri)t:ita|1.11::,:,titiiri:,
IIT
ANSWERS
TRACFI EOESOPHAGEAL FISTU LA
t. Ans. is 'a' i.e., Tracheoesophageal fistula iRef o,R Ghai }e/e p. rz6
& vhlc p.Jsr; Nelson rrn,le p. rs43, rs44l
e/F of tracheo esophageal fistula -
a) The newborn regurgitates all ofits first and subsequent feeds.
b) Saliva pours almost continuously from the mouth of the infant (This is'the sign of tracheoesophageal atresia.
It does not occur in any other condition)
c) Attacks ofcoughing and cyanosis occurs on feeding.
? Ans. is t' i.e., Around 2 weeks after birth tRd o"p. Gh6.i Sele p. 279 & Vele p.253; Nslso,l tSthlc p. 1555]
t The symptoms vomiting usually starts after 3 weeks of age but
symptams may develop as eaily as 1,, week of life
and as late as 5 months of life.
- Nelson
4. Ans. is 'a' i.e., Hypochloremic alkalosis [Rel a,p, Ghai 8lhle p. & I'lc p.253; Nelson
229 rSth/e p. tsss, .r5s6]
r Due to vomiting, there is progressive loss of -+ Fluid, Hydrogen ion,
chlorides
r This results in hypochloremic metabolic alkalosis.
5. Ans' is t' i.e., Paradoxieal aciduria with hyponatremia and hypochloremia
tRef o.p" Ghei Sthlep. zz9 & ple
p.253; Alelson tSth/e p, tSSZ)
r Persistent vomiting leads to loss of large amount of gastric fluid.
r Gastric fluid consists of large amount of HCt.
r Thus in pyloric stenosis, repeated vorniting causes hypochloremic metabolic alkalosis.
o In earlystages the kidneys are able to compensate by reabsorbing hydrogen
and chloride ions in exchange for
sodium, potassium and bicarbonate, however as the body stores of sodiirm
and potassium becomes depleted,
these ions are selectively retained while hydrogen is excreted in urine,
causing the paiadoxical aciduria.
r This aggravates the alkalotic stage.
6. Ans. is t' i.e., Pylorie stenosis B*iley (r Lave p. 899; O"p, Ghe.i g,hle p. 229
fRef: Z3,,Ue & Vhle p. 253; Nelson trpthle p.
r55sI
Diagnosis of congenital hypertrophic pyloric stenosis
r History of vomiting without bile (nonbilious vomiting).
r Physical examination -
1) Palpable mass in the epigastrium
ii)After feeding, visible gastric peristatic wave that progresses across the
abdomen.
7. Ans. is'b'i.e., Hypertrnphic pytr,ric stenosis [Rs Netrscn tvhre chapter 326]
n. Ans. is 'b'i.e., Bad bowel habit [Ref Bailey 6 Lave 24tu1e p^ ttl6)
o Acquired megacolon is caused by
r Poor bowel habit r Infections -+ chaga's disease
r Idiopathic r Medication Antipsychotic drugs
9' Ans. is'd i.e., Distat to dilated segment [Ref: Nelson l8thle p" 1565, 1566;
O,p. Ghai Sthlep. 2851
c An intestinal segment lacks both Meissner submucosal and Auerbach
myenteric plexuses. This loss of enteric neural
coordination leads to functional obstruction and intestinal dilation pro*imal
to the affected segment.
10. Ans. is 'b' i.e., Lack of ganglion cells lRe! Nelson r8n/e p. 1566, 1567; op Ghai gthlep. 2BSl
"Whenever neonate presents with delayed passage of stool,
Hirscfisprung's disease should be suspected,,.
o Rectal suction biopsies demonstrate _
i) Hypertrophied nerve bundles
ii) Absence of ganglion cells
ll. Ans. is t'i.e., Manometry excludes the diagnosis [Rel Robbin, s vh/e p. g0s; chandrasoma Taylor 3d/e p.59]
o Anorectal manometry is a useful screening procedure for
the diagnosis of Hirschsprung,s disease . A normal
response in course of manometric eualuation precludes diagnosis
of Hirsihsprung! disease.
o However the confirmation of diagnosis in case of Hirschspru.rg'.
dir.ur. is d'one by rectal biopsy.
12. Ans. is t' i.e., Congenital aganglinosi s [Re! Nelson IB,h/e p. tS66]
o Read whrtNelson says about Hirschsprung's disease (Congenital
aganglinosis).
o "Ninety nine percent of full term infants pass meconiui withii sairs
of Lirth. Hirschsprung disease should be
suspected in any full term infant with delayed passage of stool,,.
13. Ans. is 'a'i.e., Rectal biopsy fRef: Netson tBth/e Chapter 329,j1
o Rectal suction biopsyis procedure ofchoice.
15. Ans. is'a'i.e., Acetyl cholinesterase [Re, Nelson lgth/e ch. 329.3; Histochem, 1990]
INTESTINAL OBSTRUCTION
19. Ans. is '* i.e,, Plain X-ray fRef: lones clinical pediatric surgery Sth/e p. 40]
o Barium contrast studies withtluoroscopy (Barium mealfollow
through) is the investigation of choiceas X-ray is not
reliable in early stages ofvoh,ulus.
o Horvever, if the perforation is suspected, barium contrast should
not be used because of risk of perotinitis . water
soluble contrast studies (iodine based) should be used. Plain x-ray of abdomen/chest
is the initial investigation to
demonstrate free air under the diaphragm in suspected. cases of pirforation.
C H.+prrn 6 Gastrointestinal Tract
INTUSSUSCEPTION
: i:iilJ#t"mpanied
by straining efforts with legs'and t r...
n.*.a and toud cries (screaming).
o Blood and mucus produce a current jelly
stool.
o Reflex vomiting is an early sign.
c In later stages vomiting becomes bile stained.
c Abdominal distension and tenderness
develops as intestinar obstruction becomes
e Tender sausage - shaped palpable mass.inthe more acute.
right upp.. ubdolnen with its long axis
* Occasionally intestine prolapses through rectum] cephalocaudal.
H ECROTIZING ENTEROCOLITIS
31. Ans, is *ff i"e", AJlotth* abav* {Ref; Netson 1*/e p. 755; Ghai ft/e p. ti9)
rl'l'
j,!.
'{'
32. Ans. is 'H i.e., Increased bowel sound [Ref: O.p. Ghai 8th/e p. 165 6 Vh/e p. 139; Nelson l8n/e p. Z55l
c Bowel sounds are diminished or absent.
33. Ans. is 'd i.e., Necrotizing enterocolitis [Rel o.p. Ghai 8th/e p. 165 dr vh/e p. t3B, 1391
r This child is -
i) Premature
ii)
On artificial feeding (top feeding)
iii) Having abdominal distention and bleeding per rectum.
o All these are suggestive ofnecrotizing enterocolitis :-
i) The greatest riskfactorfor necrotizing enterocolitis is prematurity
-- Nelson lythle755
ii) Almost all patients of neonatal enterocolitis are artificially fed prior to the onset of illness.
iii) In stage I, there is abdominal distention and blood in stool.
r So, the child in question is suffering from necrotizing enterocolitis.
About other options
o The hallmark of vohrrlus in neonatal period is bilious vomiting.
7;. Aas" is'# i-e.,Tlksativecolitio {Ref : Nelson 1*/e p. 1576, tszT; Robbin's Th/e p. s49)
r Pseudopollp is seen in UC.
18. Ans is'd i,e."Chroaic noaspecificulceratwecolitis {Re! Nelson tye/e p, t|zs;
Robbink Th/e p. B49l
r In sever of UC, toxic damage to the muscularis propria and neural plexus lead to complete
cases
shutdown of
neuromuscular function -+ colon progressively swells to create toxic megacolon.
1O
Ans. is 1d'i.e., crohrt's involvement of the colon [Ref, www.springerlink.coml
On barium enema CD shows hose pipe (lead pipe) appearance.
30. Ans. is'b'i.e., Crohn's disease {Ref: Nelson lgth/e p. ligl, 15g2)
See each option one by one.
Option a
o In this child sigmoidoscopy is normal.
r Ulcerative colitis almost always start from rectum.
r So, sigmoidoscopy is not normal in UC.
Option b
r All the given clinical features of this child can occur in CD.
r Renal colic is due to renal stone.
Option c
r Montoux is negative.
r In a child less than 2 yeats of age montoux is strongly positive if the child has tubercular infection.
Option d
r Stool culture is negative for enteropathogens.
r So, strongyloidosis is excluded.
NECROTIZING ENTEROCOTITIS
31. Ans, is '* i"e., iJlatthe fuoy*{Re! Netaon 1*/e p.755; Ghai p/e p. 1391
t\Ll:qa1:.i!ti:::6.==+:tts:!1sffi;:
Stage tll : r Above signs + infant has low BP, bradycardia, apnea, acidosis, DlC, anuria
Advanced r Frank signs of peritonitis with abdominal tenderness, distension and erythema of abdominal
wall.
r X-Ray: shows Pneumoperitonium.
32. Ans. is'b" i.e., Increased bowel sound fRef: O.P. Ghai }th/e p. 165 dt Vh/e p. 139; Nelson lgth/e p. 7551
o Bowel sounds are diminished or absent,
,J. Ans. is 'a' i.e., Necrotizing enterocolitis fRef: o.p. Ghai gth/e p. 165 6 vh/e p. 138, 13g]
r This child is -
i) Premature
ii)
On artificial feeding (top feeding)
iii)
Having abdominal distention and bleeding per rectum.
o All these are suggestive of necrotizing enterocolitis :-
i) The greatest risk factor for necrotizing enterocolitis is prematurity. Nelson lgthI e 7 55
ii) Almost all patients of neonatal enterocolitis are artificially fed prior to the onset of illness.
iii) In stage I, there is abdominal distention and blood in stool.
o So, the child in question is suffering from necrotizing enterocolitis.
About other options
e The hallmark of voh'ulus in neonatal period is bilious vomiting.
. IntussuscePtion presents between the age of 3-9 months (not in neonatal period).
r Symptoms of meckel diverticulum usually arise in the lst 2years of life (average2.5year)
and most common
presentation i4s painless rectal bleeding.
34. Ans. is ? i.e., Peli-tgngal drainage by putting drains in the flanks {Ref: Gellis & Kagan's Current pediatric therapy
15e/e p. 220; Grosfeld's Pediatric surgery t&/e p. 14401
Treatment of NEC
A) Stage 1 6 2 (without petforation) : Conservative treatment in the form of iv fluid, systemic antibiotics, nil ora-
and gastric decompression.
B) Stage 3 (with perforation): Treatment depends :-
i) Difinitive ascites but no perforation: Peritoneal drainage (paracentesis) is indicated.
ii) Perforation: Laprotomy and surgical resection of necrotic bowel with ileostomy.
From this discussion, we choose the answer to be peritoneal drainage because :
1. Patients is on ventilator (too unstable).
!
2. Surgery for NEC is resection and creation of ileostomy, which is not given in the options.
3. Primary anastomosis is done only in stable patients with walled-offperforation.
35. Ans. is t' i.e., C^olgervalive management with IV fluids and antibiotics [Re//rrry://www.netsuic.org.anlnets/
handbook /index.efm?Doc*id=6j4,http://www.abhb.govt.nz/newborn/ teaching resources,radiilogy/nec"htm)
MALABSORPTION
36. Ans. is ? i.e., Small intestinalbiopsy [Ref ]Iarrisan t*/ep. fi7AiZVl; O.p. Ghai&/ep.2S0-251 & Vh/ep.271_ZV2)
r Clinical profile of the child given in question make the diagnosis of malabsorption syndrome associated with
chronic
diarrhoea.
r Intestinal biopsy is necessary to differentiate chronic diarrhoea due to different pathophysiologic reasons.
37. Ans. is id'i.e., Ulcerative colitis {Ref Reud belowl
o This child has steotorrha (increased fecal fat) and azotorrhea (increased fecal nitrogen). Important
causes in children
i) Chronicpancreatitis i|) Bacterial overgrowth syndrome iii) Ileal disease (crohn\ disease)
iv) Celiac sprue v) Intestinal lymphangiectasia
CELIAC DISIASE
38. Ans. is 'c' i.e., Maize [ReJ Nclson 18e/e p, 1624; Robbin"s */e p. 843; Chqndrusoma Taylor 3d/e p. Sgll
r The fundamental disorder in celiac sprue is sensitivity to gluten which is alcohol soluble, water insoluble
protein
component. It is found in wheat and closely related grains such as oat, barely and rye.
39. Ans. is t' i.e., Coeliac diseases fRef: Nelson ISth/e ch,590 (Table. 590-12)l
r Antibodies in coeliac disease are anti-endomysian, antigliadin and anti-transglutaminase.
40. Ans. is 'b' i.e., Increase in thickness of mucosa {Ref: Robbin's Vh/e p. g43; Nelsan lgthle p. 1624)
r In celiac disease proximal intestine is commonly involved while ln tropical sprue whole of the intestine is involved.
c Biopsy of intestine in celiac sprue demonstrates.
t_Villous atrophy, loss of microvilli brush border
t The crypts are hyperplastic and become elongated.
s Presence of following cells on lamina propria -+ Plasma celk, Lymphocytes, Macrophages,
Eosinophils, Mast cells.
r Remember that overall mucosal thickness remains same in celiac sprue
s The basic abnormality is thought to be an inteased rate of loss oj epithelial cells. Crypt cells show in*eased
activity. This causes hypertrophy of crypt, But even this increased activity cannot keep-pace with loss of cells,
resulting in progressive decrease in height of villi causing villous atrophy
t The epithelial cells show decreased cytoplasm and mucus
t The intestinal biopsy shows a decreases in the villus: crypt ratio.
41, Ans. is 'a' i.e., HtA - DQ2fRef: Robbin's Yh/e p, 843; Nelson l}th/e p. 1624; Harrison lVhle p. 1gg0)
. Almost all individuals with celiac disease share the major histocompatibility complex II HLA-DQ2 or HLA-DQ8.
o Gliadin is deamidated by the enzyme transglutaminase and deamidated gliadin peptides bind to DQ2 and DQ8.
o Recognition of these peptides by CD4+T cells leads to secretion of IFN-y, which damages the intestinal wall.
r Other HLA types associated with Coeliac disease are HLA-88, DR3 and DR7.
4i. Ans. is'd'i.e., Increased brush border {Ref: Robbin's ?h/ep. 84j;Netson l8e/ep. 1624)
o There is loss of microvilli brush border (not increased brush border).
II-ACTASE DEFICIENCY
{1. Ans. is 'b' i.e., Lactase deficiency [Rel O.P. Ghai &h/e p. 110, 281 & //e p. 27i-2v4; Nelsor t8e/e p. J598]
e History of ice cream ingestion and subsequent symptoms of vomiting, bloated abdomen, are characteristic findings
oflactase deficiency.
4{. Ans. is 'a' i.e., Lactase p. 281 6 fl/e p. 223)
[ReJ Nelson 18e/e p. "1598; Ghai 6h/e
'Because Lactase activity in the mucosa is at best marginal, this enzyme is particularly likely to be depleted
secondary to diffuse mucosal disease'- Nelson
{i. Ans. is 'b' i.e., HZ lRef: Nelson lSth/e p. 15981
r Hydrogen breath test is used for lactase deficiency and secondary lactose intolerance.
CHOLESTAS!5
"GGT levels are commonly elevated to values more than 10 times normal in biliary atresia while in hepatic
causes it is raised to about three times normal!'
Normal values for GGT is about 5-40 IU/L and thus a value of 600 IU/L in the patient in question reflects an
elevation of more than ten times the normal value. The patient is thus likely suferingfrom 'biliary atresia'.
48" Ans. is '-o" i.e., Hepatitis B & C [Ref 0.P. Gkai 8'h/e p. 327 & */e p. 29j; Nelson tr8:/e p" 1669-1674)
o Hepatitis B & C cause intrahepatic neonatal cholestasis.
49. Ans. is'b' i.e., Neonatal hepatitis lRel CPDT 18th/e p. 6441
NEONATAL HTPATITIS
51. Ans. is'b'i.e., Neonatal hepatitis with extra hepatic biliary atresia t,Re/ CPDT 15e/e p. 524; Nelson 1*/e
r ]aundice wilh clay coloured stools suggests cholestasis. p. 13171
e::6
55.
l&ef a.F.GtcaiB,*/ep.3Ls&7etep.2B9;Netsonrse/e
;\r;;:;i'e"Extrahepaticportalycnousobstrucrion
c Most common cause of paediatric portal hypertension in India is EHpVO.
56. Ans is 'd i.e.,EHpVO fRef, C*rrent Diagnosis & Treatment
Surgery by Daherty p. 532|
r Information in question are:
i) Patient is 12 years male
ii) Hematemesis, melena and mild splenomegaly
-+ signs of portal hlpertension
iii) No |aundice or Ascitis
o So, the boyin question has portal
hypertension.
o Three most common causes of portai
hypertension are:
Extrahepatic portal vein obstruction (EHPVO)
ll.
ii) Non-cirrhotic portal fibrosis (NCPF)
iii) Cirrhosis.
o In cirrhosis, jaundice & ascitis
are prominent. so, this option
is ruled out.
' );ilJ: xcpr" Both these ca uu'.., non-,,,,iiic portat hypertension,i.e.
l;'i::il[t.tf,:rf.1na portar hypertension
c Both these have simirar crinical picture
except for the age of presentation.
male children (tst anJznd d..na.j *t it. NCpF
: ffiy.:"1lrT::iH':."#lifr: is a disease oraduits (2s-3s,years).
Signs of portal hypertension
o Esophageal varices
o Hematemesis and melena
o Splenomegaly
+
Signs of Liver dysfunction
o Jaundice & ascitis
o ftrt
Absent Present
+ +
Non-cirrhotic portal hypertension Cirrhosis
60. Ans. is 'a' i.e., oesophageal varices lRe! o.p. Ghai 8h/e p. 3rg-i20 6 vh/e p. 28g_2g0)
r Clues in this question are -
1) H/O massive hematemasis 2) Splenomegaly
r Amongst the given options, splenomegaly will be seen only in
.rophugeul varices due to portal hlpertension.
61. Ans. is 'a' i.e., Portal hnrertensio n [Ref: See above explanation]
"Massive hematemesis in a chird is almost
always due to variceal bleeding,,.
Schwartz
Variceal bleeding is due to portal hlpertension. -
LIVER CIRRHOSIS
62. Ans. is 'd i.e., Alpha-r antitrypsin deficiency fRef: cpDT rSth/e p. 664)
r Causes ofcirrhosis in children are _
1) Post necrotic
r Viral hepatitis -+ HBV HCV I Idiopathic neonatal hepatitis r o,-antitrypsin deficiency
r Autoimmune or drug induced hepatitis r Wilson disease r Hemochromatosis
r Tyrosinemia r Galactosemia
2) Biliary
r Biliaryatresia r Choledochal cyst r Tumor of bile duct
r Caroli disease r Cystic fibrosis r Primary sclerosing cholangitis
r PFIC r Paucity ofintrahepatic bile ilucts
3) Hypersensitivity to drug -+ phenytoin
DIARRHEA
63. Ans. is t'i.e., Rotayirus {Ref: Ananthnarayan #/e p. 529; O.p. Ghai B&/e p. 291)
"Rotaviruses are recognized as the most common cause of diarrheal
disease in infants and children,
- Ananthnarayan
64. Ans. is t'i.e., Reo virus [Ref: Nelson lgth/e p. 1605, 1606; Op Ghai 8th/e p. 291]
65. Ans. is 'H i.e., Rotavirus [Ref: o,p. Ghai gth/e p, 29r 6 6h/e p. 261; Nelson rgth/e p. 160s, 1606)
o Rotauirus is the single most common cause of diarrhea
amongst children in both developed
o ETEC is the single most common cause of bacterial d-iarrhea"amongst developing world. and
children in the develop,iing world.
o ETEC is the most common bacterial cause Traveler\ dia,heaa.'-
for
66. Ans. is'a' i.e., Enterotoxigenic E.coli (ETEC) {Rd o.p. Ghai Ei/e p.
291 6 7tule p. 2611
o Enterotoxigenic E.coli (ETEC) is the most comrnon bacterial cause
of diarrhea in India.
67. Ans. is 'b' i.e., Carry Blair medium [Rd Nelsor lThle p' 1274; 16h/e p. 751
c In acute gastroenteritis stool culture should be obtained as eaily as possible.
o "Fecal specimens that cannot immediately be plated for culture can be transported to the laboratory in a non-
nutrient holding medium such as Carry-Blair to prevent drying or overgrowth of specific organisms.". - Nelson
ABDOMINAL PAIN
MISCELLANEOUS
73. Ans" is 'b' i.e., Biliary atresia lRet Ghai Vh/e p. 2951
o Biliary atresia is commonest indication for liuer transplantation in pediatric age group.
74. Ans. is'-o- i.e., Lymphoma fRef: Nelson l8hte Ch' 491,492, 342)
o Lymphoma is the most common malignancy of the gastrointestinal tract in children. About 30o/o of children with non-
Hodgkin lymphoma present with abdominal tumors'
75. Ans. is 'b' i.e., fejunal polyp lRef: o.P. Ghai 8il/e p.
js4 & 7tu/e p' 2s5l
o ]ejunal pol1p is not an organic cause ofconstipation. Other three options are organic causes ofconstipation.
76, Ans. is 'd i.e., Anal fissure lRef: Nelson 18th/e Chap. 341)
o Anal fissures are the most common cause of rectal bleeding in infants and children.
77. Ans. is t' i.e., Neimann Picks diseas e lRe! O.P. Ghai dh/e p. 616 6 Vh/e p. 29i; Nelson lVh/e p. 4641
7g. Ans. is t, i.e., Traumatic pancreatitis lRef. O,P, Ghai Sth/e p. 289 d, 7tu/e p. 260)
o Blunt abdominal trauma is the most common cause of acute pancreatitis in childhood.
o pseudcyst occurs in up to 15% ofpatients as a complication ofacute pancreatitis.
79, Ans. is'a' i.e., Tracheo oesophageal fistula {Ref : o,P. Ghai 8'h/e p. 176 6 vh/e p. 151}
gl. Ans. is t, i.e., crohn's disease lRef : crohn\ disease has been explainedl
82. Ans. is'H i.e., 24-48 hours lRef : O.P. Ghai }th/e p. 177 d2 Vh/e p' 152!
o An X-ray film of the abdomen is obtained l}-24hours after birth, with baby being kept in an inverted position.
83. Ans. is 'd i,e.,Galactosemia &'d' i.e., Cystic fibrosis lRef : O,P, Ghai 8th/e p. 327 dt Vh/e p. 29jl
84, Ans. is 'H i.e., Oesophageal atresis in the foetus lRef: O.P. Ghai 6th/e p. 178 & 7h/e p. 151; Baity & Love 24th/e
p. 9941
85. Ans. is'H i.e., Lactose intolerance lRef: O. P. Ghai 6h/e p. 281 6 7h/e p. 273; Harrison 16h/e p. 2i0, tZ6Z)
86. Ans. is ? i.e., Syrup of ipecac lRef : KDT 5'h/e p. 6aAl
87. Ans. is t'i.e., Aerophagy fRef.: O.P. Ghai 6th/e p. 263 d, 7tu/e p. 2511
88. Ans. is'a'i.e., Non specific bowel dilatation fRef: O.P, Ghai 9th/e p. 165 & 7h/e p. 139)
o Earliest X-ray finding in neonatal necrotizing enterocolitis -+ Nonspecific dilatation of intestine.
o Characteristic X-ray finding of neonatal necrotizing enterocolitis -) Pneumatosis intestinalis (Gas in intestinal wall).
89. Ans. is'b'i.e., Gas in intestinal wall [Rel Nelsan 18th/e p. 755; a,P. Ghai *th/e p. 165 d, Vh/e p. 1j9l
90. Ans. is'a'i.e., Neonatal necrotizing enterocolitis lRef: Nelson 18th/e p. 755; O,P. Ghai 8th/e p. 165; Thle p. l jgl
91. Ans. is'd i.e., Enterotoxigenic E. coli [Ry' A.P. Ghai 8th/e p- 291 dr Th/e p. 261)
92. Ans. is t' i.e., Tracheo-oesophageal fistula lRef: Antenatal diagnosis of vtacterl anomaly, RD Dani, V Gandhi,
GN Thakkar PN
IIT
WKKM.&'KY Y'Kr&CY
o At birth kidney has lower concentrating ability. A neonatal kidney achieves concentrating ability equivalent to adult
by the age of 7 yearat oa)
. A neonate can concentrate urine upto a maximum of 700-800 mOsm/kglK"-. o,), but c&n
dilute the urine to 50 mOsm/kg (as like adults).
Renal agenesis
o Renal agenesis is the absence of kidney due to failure of development.
o Unilateral renal agenesis is associated single umbilical artery@nnr), absent ureter, contralateral vesicoureteral reflex,
and absent ipsilateral vas deferens.
'o Bilateral
renal agenesis or Potter syn drome(MAHE\s) is associated with maternal oligohydraminosMAHEos),pulmonary
hlpoplasia andpotterfacies (widely separated eyes with epicanthic folds, low set ears,broad compressedflatnose@AHE
05),
receding chin). The condition is incompatible with life, death occurs shortly after birth due to pulmonary hypoplasia.
r Childhoodpolycystickidneydiseasehasautosomqlrecessive1tls)inheritance,thereforeitisalsoknown asautosomal
recessive p oly cystic kidney diseas e.
o Defective gene is the PKHDL (Polycystic Kidney and Hepatic Diseasel) which codes for a proteinf brocystin.
r It is associated with maternal oligohydramnion, Potter's syndrome, pulmonary hypoplasiaLloe), hepatic cysts and
orrMs 07)
fibrosisro'ot, , and bilateral ductal atresia.
Clinical presentation
o Majority of patients present in infancy. Presentation is variable :-
1) Renal : Enlarged cystic kidney at birthql 0e), hypertension, renal failure, proteinuria.
2) Respiratory: Respiratory distress dte to pulmonary hypoplasia\rle).
3) Hepatic: Hepatomegaly, portal hypertension (esophageal varices, hypersplenism).
o Both kidneys are markedly enlarged and show innumerable cysts radiatingfrom medulla fs flxs ssygsyutrbrsoz).
r MRI of kidney shows radially arrangedfusifurm dilated collecting ductsallMs0T).
r Prenatal USG shows a salt and pepper appearance ofkidney.
Nephronophthisis (Juvenile Nephronophthisis)
r It is the most common genetic cause of end stage renal disease (renal failure) in childhood and adolescence.
r It is an autosomal recessive disease.
o The patients present before the age of 20 years. The patient presents with polyureaLuMs03'01), polydipsia, anemiaallMs
03),
growth retardation (short statureallMs03'ot)). BP is norrnal\IlMs0r) and theie is no proteinuria or hematuria (no
red cells ifi urineatrMs oi))
.
Ectopic ureter
o A ureter that drains outside the bladder is referred to as an ectopicureter.
r Ectopic ureter usally drains the upper pole of a duplex collecting system (two ureter -+ duplication of ureter).
r It is more common in girls.
o The most common site of opening of ectopic ureter is posterior (prostatic) urethra in malesLl ee) and urethra near
bladder neck in females. Other sites of opening in males are seminal vesicle, prostatic utricle, ejaculatory duct and vas
deferens (in decreasing order ofpercentage).
a ln females other sites for opening are urethrovaginal septum, vagina and cervix.
a Females usually present wlth urinary incontinance and UTI (dysuria)uMu se,Iipmera1). Treatment includes :-
1) If renal function is satisfactory -+ (Jreteral reimplantation into bladder neck or ureteroureterostomy.
2) Ifrenal function is poor -+ Partial or total nephrectotny.
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
07).
Most common cause is streptococcus pneumoniae followed by E.coli (?d most common).
':,:*rE
:::::l:t
1,,;,.::4,,
;.a,a:a:|.'..
a:l::a.:aa,a
..;,:aa:,::
:
NPHS=1
LlPhrlfilAf.MsoI'lrde061. S;ipt diaphragm
!rylyolicsyndromeoffy[ 1pe
NEPHRITIC SYNDROME
3) EdemarN,Er)
r usually mild and results from sodium and water
retention.
4) HlPertensl6l(nrrrl
r Is variable depending upon the severity of glomerular disease.
s) Oliguria
r Reflects the severity of glomerular involvement.
Treatment
o Management is directed at treating the acute effects of renal insufficiency and hypertension.
e Although a 10 day course of systemic antibiotic therapy with penicillin is recommended to limit the spread of
nephritogenic organisms, antibiotic therapy does'not affect the natural history of glomerulonephrifis{tet ott
.
Clinical presentation
o Grosshematurit(Al\8'e8'AIIMsor'e6)within 7-2daysatos'et'ArrMsol'e6)afteronupperrespiratorytractinfection.Thisfeature
distinguish it from PSGN. In PSGN hematuria occurs 7-21 days after respiratory infection.
0s' e8' AilMs 01' e6).
c Can also present with nephritic or nephrotic syndromeat
e Mild to moderate hlpertension.
Pathotrogry
0s' e8' AIIMS 01' e6)
o Focal and segmental mesangialqt proliferation.
os'sa, drrMs 01' e6)
e IgAGt deposition in mesangium.
e Serum complement level is normalqr 0s'e8' ArrMs 01' e6)
. This feature also differentiates it from PSGN. In PSGN complement
(Cr) level is decreased.
r Whereas lgA nephropathy is an isolated renal disease, s imilar lgA deposits are alsofound in systemic disorders of children
like Henoch shoileiin,puipura,'which ilso,iave reial.vasculltis'qs o'co:mpan€it,'brvtew af tie high frequency of lgA
nephtopathy la chltdren, lgA can be used.as matkerfor renal vasculllls{At08;e8'Afi8sat.:e6t. ,':.
r There is no proven treatment. The drugs which are used : corticosteroidsallMs,B),
ACE inhibitors and AT-II antagonists
antibiotics, and fish oil.
*lenoch-Schonlein purpura
r Henoch - Schonlein purpura is vasculitis of small vessels (capillaries, venule
or arterioles) and characterized br
deposition of IgA in the wall of involved vessels(nzn4s 0s).
r H'S. purpura is characterizedby tetrad of purpura, arthritisd/EE'r, PGtos),
glomerulonephritis(NErr), and abdominal
paino'tnnr'ruo8). Gross hematuria is seen in2}-3}o/oof cases(Arrs).
o All changes result from the deposition of circulating immune complexes,
containing IgA and complement on the
endothelium of the blood vessels throughout the body and within the glomerular mesangial
regions.
c Diagnosis confirmed by presence of palpabte purpura with normal platelet count@EEr, pcr 0B) along
is
with one or more
of the following: abdominal painNmr eq08), arthralgia/arthritis@EEl: PGI0s) and
mesangial deposition ozt.
of lgA(enus
t Renal manifustations usually start at the onset or within 3 months of onset
of other symptoms@NB 13).
Pauci*immqne glornerulonephritis
I Pauci-immune glomerulonephritis is dehned as the iack of anti-GBM antibodies or immune
complex.
r It is a type of rapidiy progressive glomerulonephritis.
e Causes are :-
i) Idiopathic renal-limited crescentic glomenrlonephritis (AI{CA associatecl).
ii) Microscopic PAN
lli) Microscopic polyangitis
iv) Wegner\ granulomatosis
o It is treated aggressively with glucocorticoids with or without cyclophosphamide
or azathiopr inearrMs02)
Lab findings
a Thro mb o cy top eni s4uu s ss' st )
r It behaves as flap valves so, although urine does not flow norrr,ally a urethral catheter can be passed without dfficulty.
Sometimes, the valves are incomplete and the patient remains without symptoms until adolescence or adulthood.
o Approximately 30o/o of patients experience end stage renal disease(Pcrr0). Vesicoureteral reflux occurs in 50% of
patients.
o Complications include lrydronephrosis@EBr' pct 10) , distended bladder@r ls) with dilatation of prostatic urethra@cr 1o),
recurrent (JTINEET'PGr10) ar'd renal failure (posterior urethral valves is the most common cause of end-stage renal
disease in a male child).
Ureterocele
o It is characterized by narrowing of ureteral orifice, (pinpoint ureteral orifice) with cystic dilatation of terminal ureter.
o It is more common in females and is associated with duplication of ureter.
o Child may present with vesicoureter reflux, unilateral hydronephrosis(Aroo) and UTI.
o Vesico-cystourethrogram (VCU) which showsfillingdefectinbladder^Ioo), Cobra-head
is the investigation of choice
appearance ofureterocele and droopinglilly appearance ofkidney. USG show hy droureter andhydronephrosis(Al 0o).
o Treatment of choice is endoscopic removal of ureterocele
A Childwith urinarytrect obstruction is showing
fiollowing excretory urograph. Diagnosis is -
a) Posterior urethral valve
b) Meatal stenosis
c) Ureteric stone
d) Ureterocele
VESICS[.IRTTERIC REFI.UX
* Retrograde flow of urine from the bladder to the ureter and renal pelvis is referred to as yesicoureteric reflux.
* It is the most common cause of recurrent UTI in children\IlMs Ar 0s). It is more common in
03' 0a)
femalssailMs .
e The reflux is present since birth, but it is usually detected at 2-3 years of age, however infemales the age of detection
is eaflierqilMs 04) .
* VUR presents as recutrent U71, causing pyelonephritis or cystitis. It is the most common cause
of pyelonephritis in
children. Infection is followed by renal scarring(aro:r and hypertension.
* Micturating cystouretrogram is the investigation of choigs{dr sst.
* Based on micturating cystourethrogram, VUR is divided into :-
Grade I : VUR does not reach the renal pelvis.
Grade II : VUR extending upto renal pelvis without dilatation of pelvis or calyceal fornices.
Grade III: VUR extending up to kidney with mild dilatation or tortuosity of ureter and renal pelvis;
and no or
minor blunting of calyceal fornices.
Grade IV : Moderate dilation or tortuosity of ureter, renal pelvis and calyceal fornices with normal appearance
of
papillary impression on calyces.
Grade V : Gross dilatation and tortuosityofureter, renal peivis and calyceal fornices with loss ofpapillaryimpression
on calyces.
II
I
Treatment Reeommendation Sor WUR
1) Grade I d 1I: Antibiotic prophylaxis only.
CnaprBn 7,
.Uiinctrtt,Trtrct
n
2) Grade III & IV t
ii) Age 1-5 years : antibiotics for unilateral and surgery for bilateral VUR
i11) >5years;surgery.
Note - Surgical management involves, modifying the abnormal uretrovesical attachement to create a 4:l
or 5:1 ratio of ntramural length to ureteral diameter, and it is done by reimplantation of ureter.
Ans. is t'i.e., V
* There is gross dilatation and tortuosity of ureter and renal pelvis > Grade V VllR
e UTI is more prevalent in males during infancy and in females afier infancy. Most common causative agent is E. coli
(DNB r2), AIIMi0i).
followed by klebsiella and proteus. Most common cause of recurrent UTI is VURaI05,
CNinieal featalres
o Clinical features depend on the type of UTI :-
1) Pyelonephritis : Abdominal or flank pain, feverallMs 00),
nausea & vomitinglAllMs 00),
abdominal distension\IlMs
oo),
and malaise.
2) Cystitis: Dysuria, urgency, frequency, incontinence, suprapubic paln and malodorous urine.
3) Asymptomatic bacteriuria : Positive urine culture without symptomsal ee).
Diagmosis
* A UTI may be suspected based on the symptoms or finding on urinalysis or both, but a urine culture is necessary
for confirmation and appropriate therapy. Thus the diagnosis of UTI depends on having the proper sample of urine.
There are several ways to obtain a urine sample, some are more accurate than others.
a In older children midstream urine sample is sufficient but in infants (< 1 year) suprapubic aspiration is best method
to collect urine specimen for cultureqilMs 0a) .
o Microscopic analysis show pyuria (> 5 WBC/hpf) (/r 0r)
but it is not confirmatory1l 03),
because infection can occur
without pyuria and pyuria can present without infection{etost.
* Deep stick test for nitrite and leucoclte esterase can add to diagnosis but are not specific. WBC casts are specific
for pyelonephritis.
. Urine culture is the mainstay of diagnosis. > 100,000 colonies/ml (with or without symptoms) or> 10,000 coloruies/
04).
ml in symptomatic patient confirm (JTIGtrMs
r Microscopic examination of urine showing 1 bacterium per oil-immersion field on gram stain also confirms UTI
(equivalent to > 100,000 colonies/ml).
o Vesicocystourethrogram is indicated in a male child with > 1 UTI episode and in female child with > 2 UTI epidoses
within 6 months.
Treatment
r On suspection of rJTl, urine sltecimen is sentfor culture and emperical antibiotic treatment is started6'rMso0).
Cotrimoxazole is used in uncomplicated UTI and 3'd generation cephalosporin is used in complicated UTI. After
culture report, specific antibiotic therapy is started.
" ,ana.atiytawit ab;n:oimattty, Recommended investigitions are UsGrar'"'*'r:;,radionucllde scan (DJi4$AaIaso;, and
: filisturatinggystourethrogrqm'(MCU), ,', ' " I :'': ,
Xanthogranulomatous pyelonephritis
r Xanthogranulomatous pyelonephritis is a form of chronic pyelonephritis characterised by destruction of renal
parenchyma and the presence of granulomas, abscesses and collection of lipid laden foamy macrophages (foam cells).
t os)
Age of presentation ranges from infancy to 76 yearsal .
c Focal form being more common in childrenal o:) --1 Appear healthy.
r Those who affected diffusely, present with non-specific symptoms of chronic infection.
i) Weight loss
ii) Fever
iii) Lethargy
iv) Failure to thrive
RENAL FAILURE
MISCELLANEOUS
Bartter syndrome
o Bartter syndrome is an autosomal recessive disorderarrs) caused by mutation
in gene coding fo r basolateral chloride
channel (Clc-kb). There is loss of sodium, chloride, potassium and calcium in urine.
o The major clinical findings are hyponatremiaLltMs 04' 03,02), hypokalemia(AtrMs 04, or,or),
polyureaLrrMs o,t,03, o2),
polydipsiaqllMs o't' os' 02),'metabolic alkalosis@I 1s),
normal to low BP, hypomagnesemia (only in some patients),
lrypochloremia, hypercalciuria (causing nephrocalcinosis)Ltttus o<,03),
and growth retardation (failure to thrive)
(AIIMS 04' 03)
. Neonate may have sensory-neural hearing loss(,{r Is)
Gitleman syndrome
o It is an autosomal recessive disorder catsed by mutation of genes encoding
sod ium-chloride cotransporter (NCCT).
There is hypocalciuria, hypokalemia, hypomagnesemia and metabolic alkalosis.
Clinically there are recurrent muscle
cramps and growth retardation.
Dent's disease
o Dentt disease, a familial proximal tubular syndrome, is an x-linked recessive(AllMs rr) disorder of proximal tubules
characterized by: -
l) HypercalciuriaqllMs 11)
and nephroc^lginesis\,us 11)
and nephrolithiasis
ii) Low-molecular-weight proteinuria
iii) Metabolic bone disease/RickeSIGIIM; 11)
Characteristic peripheral smear findings in HUS: Fragmented RBCs (shistocytes), helmet cells, burr cells.
Most common cause of urinary tract obstruction in a male infant: Posterior urethral valve.
lmportant features of posterior urethralvalve: Hydronephrosis, distended bladder, recurrent UTl, vesicoureteral reflux in 500/0.
a
eased
a
lcium
a
I
a
a
r's
a
a
a
ta
III
Cn,tp'r:rr'7
rtx
QUESTIONS
l. Theneonatalkidneyachievesconcentratingability c) PulmonaryHlperplasia
equivalent to adult's kidney by - (Ar 04) d) Flat chain
a) One year ofage 9. Pulmonary hypoplasia with uropathy diagnosis is-
b) Eighteen months of age
(CET Nov 15 Pattern)
c) Three to six months of age a) Potter syndrome
d) Just before puberty
b) Patau syndrome
2. Whic one of the following is the most common cause c) Perthe disease
of.abfisminal ma;s in neonatec - d) All of the above
(All India Dec. 14 Pattern)
a) Neuroblastoma
b) Wilm's tumour ECOTOPIC URETER
c) Distended bladder
d) Multicystic dysplastic kidneys 10. A3year old male child diagnosed to have acute
UTI developed left flank pain on ulatrasonogram,
the left ureter w{rs found to be duplicated the
most probable site of opening of ectopic ureter
will be - (CET luly 15 Pattern)
3, Which of the following is the most common renal a) Prostatic urethra b) Vas deferens
cyetie disease in infants is ? @ET Nov. 15 pattern) c) Seminal vesicle d) Trigone ofbladder
a) Polycystic kidney
b) Simple renal cyst
c) Unilateral renal dysplasia
d) Calyceal cyst
4. All of the following are true about childhood
polycystickidneydisease, except - PATHOPHYSIOLOGY
(Arls)
a) Autosomal dominant
b) Pulmonaryhypoplasia
It. All are features of nephrotic syndrome in children
except -
c) Renal cyst present at birth (All India Dec.13 Pattern)
d) Hepatic fibrosis
a) Lipiduria
b) Hyperlipidemia
5. Baby born at 30 weeks for 18 year old primi gravida c) Hyperalbuminemia
of weight 2 kg which died after 48 hours. Apgar d) Proteinuria
scores were 5 and 8 at 1 and 5 minutes. On autopsy
,1 All of the following are decreased in nephrotic
bilateral enlarged kidney with multiple radially
syndrome, except - (AIIMS lune 98. Dec 95, AI 97)
arranged cysts. Which of the following finfing is
expected to be associated with ?
a) Serum transferrin
(AIIMS Nov 07)
a) Imperforate anus b) Serum fibrinogen
b) Hepatic cyst and fibrosis c) Serum ceruloplasmin
c) Absence ofureter d) Serum albumin
d) Holoprosencephaly 13. Which is seen in nephrotic sundrome -
(NEET Dec.12 Pattern)
6. Unilateral renal ageneois is associated with -
(NEET Dec.12 Pattern)
a) Low serum calcium
a) Polycystic disease ofpancreas
b) Raised AT-III
b) Hiatus Hernia
c) Low lipid
c) Single umbilical artery
d) Platelet activation
d) Hlpogonadism 14. Edema in nephrotic syndrome is due to -
(AllMS May 12, Nov t0)
7, "Potter'c oyndromd' ie assoclated with -
(CET Nov.14 Pattern)
a) Sodium & water retention
a) Renal anomalies
b) Increased venous pressure
b) Severe oligohydramniot
c) Hypoalbuminemia
c) Flattened nose
d) Hyperlipidemia
d) All the above
8. Not a finding in potter syndrome- CAUSES
(All India Dec15 Pattern)
a) Bilateral renal agenesis
15. Most common cause of Nephrotic Syndrome in
b) Polyhydromnios children- (All India Dec.1j, NEET Dec.12 Pattern)
a) Minimal change disease
CHApts&:i7
a) Associated with Ureteric reflux (NEET Dec.12 Pattern) 69. In a child, non - functioning kidney is best diag-
b) Associated with Intrarenal reflux nosed by - (At os)
c) Associated with renal scarring a) Ultrasonography
d) Males are more affected than female b) ryu
c) DTPA renogram
d) Creatinineclearance
RENAL FAILURE
70. Method of choice for a New born child not passing
63. In children renal failure in terms of urine output is urine for 36 hrs -
defined as ? (CET Nov. 13 Paxern) a) Ultrasound of kidney & bladder (AIIMS May es)
65. In SCHWARTZ formula for calculation of creatinine 72, A male child with Fanconi syndrome with nephro-
clearance in a child, the constant depends on the calcinosis has a variant of dent disease. All are true
following except - (AllMS Nov 06) except - (AIIMS May 11)
a) Age a) Hypercalciuria
b) Method of estimation of creatinine b) Proteinuria
c) Mass c) Similar presentation in father
d) Severity of renal failure d) Rickets
d) Radio nucleotide studies MISCELLANEOUS
59. Which of the following is the most appropriate
method for obtaining a urine specimen for culture
in an 8 month old girl - (AIIMS May 04) BARTTER SYNDROME
a) Suprapubicaspiration
b) indwelling catheter sample 66. True about bartter's syndrome are all except -
c) Clean catchvoid a) Hlperkalemicalkaiosis (All lndia Decl5 Pattern)
d) Urinary bag sample b) Presents in neonate with ototoxicity have bartin
60. An 8 year old boy during a routine check up is found gene mutation
to have E. coli 1,00,000 cclml on a urine cultsre. c) Decreased K* assorption from thick descending loop
The urine specimen was obtained by mid-stream d) Autosomal recessive
clean-catch void. The child is asymptomatic. Which 67. L2 month old girl has failureto thrive, polyuria and
is the most appropriate next step in the manage- medullary nephrocalcinosis affecting both kidneys.
ment- (AIIMS May 0a) Investigations show blood p}{7.48, bicarbonate 25
a) Treat as an acute episode ofurinarytract mEq/ 1, potassium 2mEqll, sodium 126 mEqll and
infection chloride 88 mEq/I. The mnst likely diagnosis is -
b) No therapy a) Distal renal tubular acidosis (AllMS Nov 04)
65. In SCHWARTZ formula for calculation of creatinine 72. A male child with Fanconi syndrome with nephro-
clearance in a child, the constant depends on the calcinosis has a variant ofdent disease. All are true
(AIIMS Nov 06) except * (AIIMS May 1t)
following except -
a) Age a) Hypercalciuria
b) Method of estimation of creatinine b) Proteinuria
c) Mass c) Similar presentation in father
d) Severity ofrenal failure d) Rickets
with single umbilical artery - (SGPGI 0s)
/ -r. 8 yr old child with BP 180/100 mm Hg' urea 90'
cells' 1-2 a) Central nervous sYstem
creatinine 5.3, urinalysis shows 15-20 pus
past h/o of b) Cardiovascular
RBC, protein 1+ & has no significant
diagnosis is- c) GenitourinarY
similar complaint. Most likely d) Skeletal
b) Hypoalbuminemia
c) IdioPathic RPGN c) Hlperlipemia
d) Chronic interstitial nephritis with VUR d) Edema
renal
A 3 -year old boy is detected to have bilateral
Choose among the following the most important
74.
.rf.ir. Metabolic evaluation confirms the presence 82'
lab finding in nephrotic syndrome -
gN e5)
normal blood levels
oi*utf."a hypercalciuria with a) B-l protein
of calcium, m-agnesium, phosphate'
uric acidand
b) Hlperkalemia
creatinine. A diagnosis of idiopathic hypercalciuria
all' c) Hlpoalbuminemia
is made. The dietary management includes
- (AllMS MaY 0j' Nov 04) d) Hypertension
excePt syn-
a) Increased water intake 83' Most common infection in a child nephrotic
drome- MAHE 07' 08)
b) Low sodium diet
a) Spontaneous bacterial peritonitis
c) Reduced calcium intake
d) Avoid meat Proteins b) Pneumonia
and hematu- c) UTI
75. A child presents with abdominal colic
a stone 2'5 cm in diameter d) Cellulitis
ria. On oltroror*gtuphy is-
is seen in the renal pelvis' The next step in manage- 84. The commonest type of renal lesion in children
(rN es)
ment of this case is - (AllMS Nov 2000' Al 01) a) Lipoid nePhrosis
a) PyelolithotomY b) Nephroureterostomy bj frt.-U.u"o proliferative glomerulonephritis
c) Conservative d) ESWL c) Focal glomerulonePhritis
of renal artery stenosis in
d) Diffuse glomerulosclerosis
76. Most common cause of
children in India is - iAttMS Mav 07) 85' A year old child presents with four days history
3
TII
:Sallt;:i;l :;;t,l :'2:i,'r::.,..i 1:. ir' ::.'
ANSWERS
1. Ans. is 'a'i.e., One year of age
[Ref: paediaiics Urology, e"or rr"
"Normal adult kidnev can produce
urine with of greater than
.an,osmolality 1000 water. The healthy neu.
-m lsm/kg
';;;':!i::,:;?::::;r;;,";:xi;i':j!,:,i;i:i'1,i:,i;:;,'m.,ati,v
increases graituatfy a"ri"g'ri, .r.nty s00.700 m.sm / kg
i few months a;;;;e;r";;;':;:!r:J:;!":;:r'::r#";;";:r;
?;;:r"" one year
on the other hand' the newborn can dilute his urine to a minimum
of 50 mosm/kg much rike an order
child.
2' Ans. is t'i.e., Murticystic dysprastic Kidney,s
[Ref, o.p. Ghai 8th/e p. 468 {r vh/e p, 470)
"Multicystic dysplastic kidney is the most
common cause of an abdominal
mass in the new born, _ Nelson
CONGENITAL ANOMALIES
Ans' is t' i.e., unilateral renal dysprasia
[Rel sutton Radiorogy *th/e p. 11051
o The multicystic dysplastic kidney
is the commonest form of congenitar
complete uretric obstruction infetaf cystic renar dysprasia, and is due to
lrfr. Th, condition xLru,o,tti uilateral; bilateral disease is lethal.
4- Ans. is 'a'i.e., Autosomal dominant
fRef: Netson lgth/e p. 17061
' 7:i::::;,i;:t',i;';hi;";,i:::.sehas autosomat recessive inheritance,thererore
it is arso known as autosomat
5. Ans. is 'b'i.e., Hepatic cyst and fibrosis
[Ref Nelson tSth/e p. 2185]
o The,crinicar findings suggest autosomar recessive
porycystic kidney disease.
r Both kidneys are ma*eilly enlargedand
grossly siow innumeroui ryrtrthroughout
the cortex and medulla.
' H::ffiiff[|'u'"'.,ffi;il[* micro"cvsts radiating *,iuiro from to the iorixi;; primarily within the
o Liver involvement is characterize
d'by bile duct proliferation andectasia
as well asby hepaticfibrosis.
6. Ans. is t'i.e., Single Umbilical Artery
[Ref Nelson lVh/e p. t7B3; O.p. Ghai 6th/e p. 467]
Malformations associated with unilateral
renal agenesis
o Single umbilical artery o Controlateral vesicoureteric reflux
o Absent ureter o Absent Ipsilateral vas defrens
7. Ans. is t' i.e., All of the above
[Ref O.p, Ghai 8th/e p. 505 6 Vh/e p. 170; Nelson tgth/e p. 2221]
o Potter syndrome is characterized
by _
' :ii;if;:;;':r;;;:r:l:f1,';;::*.'whenmaternatutrrasonographvdemonstratesotigohydramnios,nonvisuatization
9. Ans. is'a'i.e., Potter syndrome
[Ref Nelson lgth/e ch, Sjfl
CnxFin.r
ECTOPIE URETER
NEPHROTIC SYNDROME
PATI.IOPHYSIOLOGY
l1 Afis. ig '{' n,*.,*4rypxr.albtu"mzyxt*wa'tal{li:-l': N*tls*w lN't'k: 1t. Jt92; {.}"1}" Gluti 7'}'le p. a50]
o Nephrotic syndrome is a group of disease having different pathogenesis and characterizedby -
1) Proteinuria (> 3.5 gm/day) 4) Hlperlipidemia
2) Hypoalbuminemia 5) Lipiduria -+ lipid casts
3) Edema 6) Hypercoagulabiiity
t2. Ans. is 'H i.e., Serum Fibrinogen lRe! Rabbin's Vh/e p. 978; tlanisaru trVh/e p. 1790; Nelsan 18th/e p. 21921
c Fibrinogen level is increased in nephrotic syndrome d/t increased hepatic synthesis of fibrinogen.
I i. t\tx*. isud i.*.,.{,qrw scr&fi:} *a\*izxwa f l{rl': .1lso it,c cl:'avL: t:xpluu*lion}
o In nephrotic syndrome there is hypocalcemia and secondary hyperparathyroidism as a consequence of loss of
cholecalciferol binding protein.
o Secondaryhyperparathyroidism causes hypophosphatemia by increasing renal phosphate excretion.
L4" Ans, is l.e.,Hypoalburninemia lRef : Diseases of kidney and utinary tract 4th/e p. 37761
'c'
e proteinuria in nephrotic syndrome leads to hlpoalbuminemia that results in decreased colloid osmotic pressure
which results in edema.
"The edema formation of nephrotic syndrome is secondary to increased sodium retention from intravascular
yolume depletion from low plasma oncotic pressure due to hypoalbuminemia."
cAusES
n'", is '&' r..{,,,W,lvzivuxa', *lzareg* dis*xse UtrtI: *.lt {ih*i &'t'/* t:.'}77 t::'?'t'i{' l}' 4571
i&arp.
o Minimai Change Disease is the most common cause of Nephrotic syndrome in children
*ty" k*s, ia"az' i.*., Millvlwz"*-tr *fueffiVp I{"S. llt$ t}{'ani 7't'le p. 45)
L7. Ans. is ob' i.e. NpHS-2 lRef : Robbinb vh/e p. 98i-984; Nelson tr
gth/e p. 2192, 21951
,t:,i;,t:idC1f[i
NPH52 1q25-3'l podocin slit diaphragm Steroid resi stant nephrotic syndrome
[8. Ans. is t' i.e", Nephrin lRef : Nelson 18'h/e p. 2192, 2195)
lo Ans. is ,d i,e.,No finding lRef: o,P. Ghai 9th/e p. 477 6 vh/e p. 452; Nelsan 1Yth/e p. 2190, 2192)
e Minimal Change Disease is the most common cause of Nephrotic syndrome in children.
o Minimal change disease has very good prognosis with excellent response to steroids.
c Pathological findings include
7. Light microscopy
-) No abnormality
2. Electron microscopy -+ Obliteration (loss) andfusion offoot processes
ofepithelial cells.
3. Immunofluorescence -+ No deposits of immune reactants
4. Serum complements -+ Normal levels
20. Ans. is 'b'i.e., Lipoid nephrosis
fRef: O.p. Ghai 8,h/e p. 479 dz Th/e p. 452; Nelson
r Minimal change GN is also referred to as lipoid
lyth/e p. 2193]
nephrosis.
r Minimal change GN has an excellent response
to steroids.
21. Ans. is 'b'i.e', IgG deposition in mesangium
[Ref: o.p. Ghai 8th/e p. 427 6 vh/e p. 4s1_452)
There is no depositon of immune reactants.
.,,,
Ans' is'a'i'e" No IgG deposits or c3 deposition
on renal biopsy [Ref Netson
This girl is having
r8n/e p. 2rg0-2r92]
i) Generalized swelling (edema)
ii) Grade 3 proteinuria
11i) Fatty casts (lipiduria)
iv) No hematuria
o All these features suggest the diagnosis
of nephrotic syndrome.
o Minimal change disease is the
commonest cause of nephrotic syndrome
r Minimal in chirdren.
change disease is characterized by absence
oiigc a.porr* andlo. comprement on immunofluorescence.
23. Ans' is 'b' i'e.l cyclophosphamide
rRef: o.p. Ghai 8th/e p. 479 6 Vhre p.
Ifa steroid dependent patient develops severe
452;.Nerson 18th/e p. 2193)
corticosteroid toxicity (cushingoid
and or growth failure), then alternatives toxicity, hlryertension cataracts
available are
a) Cyclophosphamide c) Tacrolimus e) Levamisole
b) Cyclosporine d) Mycophenolate
Treatment of Nephrotic syndrome
Nephrotic syndrome
+
Daily steroid (prednisone)
Remission Relapse
,,,
lnrrequent _ Frequent
Sternid d
+
Restart prednisone
Also know
Infrequent relapses -) If patient gets 3 or less relapses in a
a
year
Frequent relapses -) If a patient
has 4 or more relapses in a year
Steroid dependent -) When relapse occurs within 2 weeks
of discontinuation of drugs
Steroid resistant -) when patients do not respond to the initiar
t/t or respond to it transientrv
r. .'i::l':l:i
lelr 4BiI
Ans is'H i.e., Oral cyclosp otine lRef: Readbelowl
o The treatment options for steroid resistant nephrotic syndrome are:
(i) Calcineurin inhibitors (cyclosporine, Tacrolimus)
(n) IV or oral cYcloPhosPhamide
(lll) Levamisol
(iv) MycoPhenolate
(v)Pulse corticosteroid
r All above immunosuppressants are used along with corticosteriods (Prednisolone or methylprednisolone)'
t Cyclosporine and cyclophosphamide are most commonly
used'
therapy for steroid resistant nephrotic syn-
o Despite these options, there is lack ofconsensus on first line appropriate
drome.
o According to Indian fournal of pediatric (vot. 46, Ian 17 ,2009)
the efficacy of these durgs are (in decreasing order):
> IV cyclophosphamide + Prednisolone > Pulse Corticosteroids
Tacrolimus + prednisolone > cyclosporine + Prednisolone
+ Prednisolone'
(IV dexamethasone + orol ,yrloplrirphamide + Prednisolne) > oral cyclophosphamide
r So, amongst the given options, best answer is cyclosporine'
:5. Ans, is 'C i"e.,RBC casts in urine lRef: Nelson 18"/e p' 2169)
lPresenceofRBCcastsinurineisclassicalfeatureofnephriticsyndrome,
td' i.e., Hypocholestremia {Re! o.P. Ghai rth/e p. 471 & 7h/e p' 447; Nelson 18'h/e p' 21681
)6. Ans. is
affecting the kidneys, more specifically glomerular
r Nephritic sl,ndrome is a coliection of signs associated with disorders
hypertension, edema and oliguria'
disorders and is characterized by haematuria, protenuria,
27. Ans. is
,l
i.e.,Acute G.N. lRel O.P. Ghai yth/e p. 474 d, 7h/e p. 447; Nelson 18th/e
p. 21681
caused by acute
r Hematuria, hypertension and edema suggest the diagnosrs of nephritic syndrome
glomerulonePhritiq.
28. Ans is 'd i.e.,Increased IgA IR'l Nelson 18'h/e p' 21711
adult and is perhaps the most frequent type
r IgA nephropathy or Berger's disease affects children and young
of glomerulonephritis in children'
29. Ans. is'b' i.e., IgA Nephropathy [Ref.: O.P. Ghai \e/e p' 474 6 Vh/e p' 446; Nelson 18'h/e p' 2171)
and dysmorphic RBCi) 2 days after upper respiratory
r The patient is having glomerulo nephritis @ross hematuria
tract infection.
-+ IgA nephropathy, Post streptococcal glomerulonephritis, H'S' Purpura'
r Three conditions can manifest like this
IgANephroPathY
o Isolated hematuria
(no symPtom other
than hematuria)
47. Ans. is t'i.e. Posterior Urethral Valve lRef: Nelson lgth/e p. 22411
It is a case of Posterior urethral valve presenting with urinary tract Infection.
PUV is the most common cause of obstructive uropathy in a male child.
The keyto diagnosis are -
Age and sex of the patient
Urinary tract infection is rare in male child , greater than one year old and less than 5 years old. presence ofurinary
tract
infection in this age group suggests , presence of some obstructive uropathy. ( posterior urethral valve in this
case)
Presence of Suprapubic dullness
Presence of suprapubic dullness suggests urinary retention, which is seen in this case due to obstruction
caused by
posterior urethral valves.
48. Ans. is 'd i.e., Voiding cystourethrography lRef. Nelson 18n/e p. 22411
o Poor urinary stream since birth suggests urinary tract obstruction (risually infravesical).
o Most common cause of urinary tract obstruction in a male child is --> gtosterior urethral yalve.
o And the best diagnostic method for posterior urethral valve is voiding cystourethrogram.
OTHER CAUSES
49. Ans. is 'a' i.e., uretero pelvic junction stenosis fRef: Radiologla Brasileiral
o Most common cause of urinary tract obstruction in children -+ Posterior urethral valves.
o Most common cause of lower urinary tract obstruction in children -+ Posterior urethral
valves.
o Most common cause of upper urinary tract obstruction in children -+ PUJ obstruction.
r The most common presentation here is with an abnormal, obvious protruding mass from the sacral area. Out of
the 4 varieties known, only Tlpe iV which contributes 9.8 ie entirely pre-sacral and not visible externally
o/o
52. Ans. is 'H i.e., Vesicoureteric reflux fRef. O.P. Ghai 8th/e p. 506 6 Vh/e p. 456; Nelson 18th/e p. 2228-22331
"The most common abnormality seen in a child with UTI in a voiding cystourethrogram is vescioureteric reJlux.
It is identified in approximately 40% of patients"'
-5^r. Ans. is 'l i.e.,New born females lRe! Nelson 18th/e p' 22301
o Reflux is more commo nrnfemales and it is usually detected earlier in females so we can say that reflux is present from
birth but it is usually detected at 2-3 years of age but in females the age of detection is earlier.
54. Ans. is t' i.e., Vesicouretrial reflux induced pyelonephritis lR.ef: Pediatr Nephrol 1993 Aug; 7@) : 361' 4 The small
scarred kidney in childhood;. Risdon R.Al
'Reflux nephropathy is now a generally accepted term to describe small scarred kidneys discovered during childhood;
it recognises the close association between this renal lesion and vesicoureteric reflux (VURI.
Renal scarring is most commonly a result of chronic pyogenic infection of the kidney or chronic pyelonephritis.
Chronic pyelonephritis occurs only in patients with major anatomic abnormalities, such as obstructive uropathy,
struvite calculi or, most commonly, VUR (in 30 to 45% of young children with symptomatic UTI).
55. Ans. is 'a' i.e., Antibiotic prophylaxis lRef.: Nelson 18th/e p. 22331
r Since the age of the boy is less than 1 year we wili try medical management.
o See the below given tables from Nelson and the answer will be clear.
o Grading of VUR : is based on the appearance of the urinary tract on Micturating Cystourethrogram (MCU).
UTI
57. Ans. is '{ i,e,, E. coli lRef: Nelsan lSthle p. 2224-227; CpDTl6,h/e p.
715}
o 75 to 90o/o of all infections are caused by E. coli
followed by Klebsiella and proteus.
58. Ans' is 'H i'e" send urine for culture and sensitivity and
start I.v. antibiotics immediately
@/e p. 455 & 7"/e p. 456; CPDT L|th/e p. 63A; lRef a.p. Ghai
Nelson lgth/e p. 2225, 22261
' abdominal distension with 6-8 pus cells/hPf in urine
suggest the diagnosis of UTr, more specificaily
iiltJ;:p;1g'
o The investigation which almost confirms the.diagnosis
of u.T.I. is presenceo/6-g puscells / high power
e "The presence of pyuria (>5 white blood celk/ high power field.
field) is consktent with urinary tract infection.,,
e once U'T'I' is suspected, urine specimen - CPDT
Dorit wait for results of the culture.
is sent for culture and treatment started :
59. Ans. is ?' i.e., Suprapubic aspiration
lkef A.p" Ghai *le p. 484 & frle p. 456; N*an t*/e B. 2225; Cambell,s
Uralagy thle p. tS47]
o There are several ways to obtain a urine sample, some
are more accurate than others. These methods
l Midstream urine sample are -
r It is satisfactory in toilet trained children and in circumcised
boys. But in young infants and boys who cannot
'K::r{!.'- f"reskin, it is not reliable. Such samples will usuatly ieflect periuretilratand prepucial organisms
2' collection in an adhesive sealed sterile collection bag after
disinfection ofthe genitals
r Is a useful technique in infants, but potential contamination
from genitals and perianal area can occur.
3' urine specimen through catheterization or indwelling catheter
r Urine specimen through a catheter is less likely to ie
-
contaminated than the voided specimens as described
above' rf is also invasive than su?trapubic aspiration, but it is
less
not as sensitive as suprapubic aspiration.
r A catherized specimen is reliable if the first portion of the
urine that may contain urethral organisms is discarded
and specimen is taken from later flow through the
catheter, but it has the disadvantage of being
of potentially introducing urethral organisms into trqumatic and
sterile bladder.
r Suprapubic aspiration _
t suprapubic aspiration is best method to coilect urine specimen
t It is the most reliable method for curture.
r It can be performed safely in children and in premature infants by 2l
or 22 gaugeneedle.
r This procedure avoids any sort of contamination, however it is invasive.
So it is used only in infants and selected
patients.
o Note:
t The sensitivity of suprapubic aspiration is 99 %
t The sensitivity of calherization is 95o/o
RENAL FAILURE
63. Ans. is 'd i.e., Less than 0.3 ml/kg/hr fRef: Principles of pediatric and neonatal emergencies by panna Choudhury,
Arvind Bagga, Krishna Chugh, Siddharth Ramji 3dle p, 158)
o In children Acute renal failure is defined as either one or both of the following :-
i) Tripling of baseline serum creatinine.
ii) Urine output less than 0.3 ml/kg/hr for 24hrs.
64. Ans. is'a' i.e., Urinary sodium > 40 m.eq/L lRef Nelson l9th/e p. 22071
o Dehydration causes pre-renal azotemia.
r In pre-renal azotemia, urinary sodium is less than 20 m.eqlL.
65. Ans. is t' i.e., Severity of renal failure flnternet referencel
o Schwartz formula (for creatine clearance in child)
Creatinine clearance = K x height/creatinine
K = constant
r K depends upon -) Age, Muscle mass, Method of creatinine estimation
MISCELLANEOUS
BARTTER SYNDROME
66. Ans. is'a'i.e., Hyperkalemic alkalosis fRef: Nelsan l}th/e ch. S31l
r There is Hlpokalemia with metabolic alkalosis (not hlperkalemic metabolic alkalosis). Other options are correct.
67. Ans. is t' i.e., Bartter syndrome lRef: Nelson 18th/e p. 2201, 2202; O.P. Ghai 8*le p. 501 6 Zh/ep. 4691
Clinical features of the infant -+ Polyuria, Growth retardation, Medullary Nephrocalcinosis
Electrolyte abnormalities: -
t Decreased potassium (Normal j.5 - 5.0 meq/L) t Normal Bicarbonate (Normal 21-30 meq/L)
t Decreased sodium (I'{ormal 136 - 145 meq/L) t Increased pH (Normal 7.38 - 2.44 meq/L)
t Decreased Chloride (Normal 98 - 106 meq/L)
C/F and electrolyte abnormalities in Bartter's syndrome
t Hypokalemia t Polyurea and Nocturea (d/t hypokalemia)
t Metabolic alkalosis t Increased urinary chloride (cause Hypochloremia)
t Normal to low blood pressure t Hypomagnesemia (seen in minority of patient)
: Growth retardation . Hypercalciurea (causes nephrocalcinosis which is visible on ultrasound)
:r.rr"rr,,r.,l.i.::.:rli1,:.r:. r'r.l:r.tr....,. .1I......i'
iit:itr-.,_ltlt::r'i.',:i ::itlr:rr.t.r.rr:aa :'.:.::.:.: a :. . ..
;li1il.ttl.,.t:;:i..,1.::r:
1r*j-i::i:rrii.,:.i.rr1*:::ri:ii:j!1iiii;:t:ii:r;,:rj:rit?a::::,::....t',a:t|a:,.t:.:a:aa:.,::.:.,,1t!].r':f:,.ti.,-.:,....'
::. :.:.,::.:,..:
:' t:,
:..:.,: :.:..::
Causes of nephrocalcinosis
r Idiopathic hypercalciuria r Hlperoxaluria
o Distal renal tubular acidosis o Diuretics for preterm baby
o Bartter syndrome r Dent's disease
o Primary hlperparathl,roidism o Furosemide use
79. Ans. is 'd' i.e., 600-700 mosm/Litre lRef : o.p Ghai Sth/e p. 467 6 vh/e p. 4411
o A full term infant can concentrate his urine to a maximum of 700-g00
mosm/kg.
o An older child can concentrate 1200-1400 mOsm/kg.
o A newborn can dilute his urine to a minimum of 50 mOsm/kg much like
an older child.
82. Ans. is t' i.e., Hypoalbuminemia lRef : o.p. Ghai gth/e p. 477 d2 vh/e p. 4501
83. Ans. is'a'i.e., Spontaneous bacterial peritonitis [Ref : O.P. Ghai'yth/e p. 477-479
6 Vh/e p. 453;Nelsan lgth/e
p. 21esl
o Spontaneous bacterial peritonitis is the most frequent type of infection.
84. Ans. is 'a' i.e., Lipoid nephrosis lRef : O.P. Ghai p. 477 d2 Vh/e p.
Sthle 451; Nelson \gthle p. 21921
o Minimal change GN is also referred to as lipoid nephrosis.
85. Ans. is'a' i.e., Hlpokalemia
r It is a case of acute nephritic syndrome which can result in ARF.
o In ARF there is hyperkalemia (not hlpokalemia) and acidosis.
o Acute nephritic syndrome is also characterizedby hlpertension, So hlpertensive
encephalopathy may also occur.
86. Ans. is 'b'i.e., Posterior urethral valve [Ref : Nelsan lgthle p. 2241]
o The informations provided in this question are _
87. Ans. is'a'i.e., Dilatation of posterior urethra lRef : Nelson lgth/e p. 22a2 fig (54a141
Micturating cystourethrogram findings
i) Dilation of prostatic urethra
ii) Transverse linear
flling defect corresponding to the valves.
rrt
ilENTRAt NHEAV#LI h
{nqr{1 r-H- g: & 6
&X}AM1VA
SEIZURE ANSEPILEESY
FEBRILE SEIZURES
seizures are defined as seizures
r Febrile conr,,,lsions are the commonest cause of seizures during early childhood. Febriie
which occur during fever. Mostly occurs between 6 months to 5 yearsAuttssz).
c Theconuulsionsare notrelatedtoilegreeoftempraturel;se(AttMSeT)bvtarefrequentiftempraturerisesabruptlvabove
39" c.
e Spontaneous remmissionLilMseT) occurs with ro pastictal neurological deficit and EEG changes few days after
tbe
seizure is normal.
e Recurrentfebrile seizutes occur in 30-50% of cases('{i13"Arr-Mse7)'
Clinical features
* There are following tlpes of febriie convulsions :-
1) Simplebenign
Central Nervous System
IIt is more common. It lasts lbr less than 70 minutes@Gl00) and.is generalized in nature.
There is usuaiiy singl;
seizure in same day. No post-ictal neurologicat deficit occurs@Gt 0u
.
2) Complex (atypical)
I It lasts for more than 15 minutes and is focal in nature. More than one seizure
occur in same dav.
r Risk factors for recurrence offebrile seizures are :-
i) Positive family history@NB ls, At la, PGt 00) iv) Early onset (< I vear)(;r tot
Treatment
r Prompt reduction of temperatureby hydrotherapy (sponging) and antipvretics (paracetamole,
ibuprofen) is the
most important measure. If seizures lasts for more than 5 minutes, diazepa:nr. {r.ectal
or IV) is the anticonvulsant oi
clnoice(At 8-4). Phenobarbitone is an alternative.
I For prophylaxis (prevention of recurrence) of febrile seizures, intermittent prophylaxis
is used and the drug ot
choice is oral (or rectal) diazepam{D'vr 13'AttMS01'e6'PGI00) or other benzodiazepenes.
in faiied iliierr;riltent prophviaxis.
continuous prophylaxis is indicated by sodium valproate or phenobarbitone. carbamazepine
and phenytoin are
ineffectivefor prophylarcis[arse]. x'leasures to lower temperature like sponging and antipyretics
{paracetamal) have
no rale in prophylaxis(DNB 13' nrMs 1' e6' PGI 0a) .
0
r$YSCLONIC EPITEPSY
* It is characterized by brief rnuscular contractions with loss oJ bocty tone.Itmay be : (i) Infantile spasm; and (ii) )uvenile
myoclonic epilepsy.
a) Febrile seizure
b) Myoclonic epilepsy
c) Absence seizure
d) Grand-mal epilepsy
T
in morninglAltMs ou) after awakening. It can be provoked by sleep deprivation.Consciousness is usually preserved.
o It may be associated with generalized tonic clonic seizures(Pcl0s) and absence seizure (only in 7/3td cases(AilMs06)).
o It isbenign condition, although complete remission is uncommonqilMso6).
a
o EEG shows a 4-6 Hz irregular spike and wave discharges (fast spike).
e Family history of epilepsy is positive in most cases.
o Seizure respondswell('urusoc) 1o appropriate anticonvulsant.Valpraateis drugchoice(DNB13'A110'PGI07'05) aldis required
r0),
for lifelonglretoz'os). Other effective drugs are topiramate(Al lamotrigine, felbamate, clonazepam and zonisamide.
NEONATAL SEIZURES
a The most prominent feature of neurological dysfunction in neonatal period are seizures.
a Subtle seizures are the most commofl typs(uoo'ut*s07) and are characterizedby movement of upper limb ('boxing]
'hooking', 'swimrning') and lower limb ('bicycling'); sucking;lip smacking; and apnea. Other types of neonatal seizur*s
are focal, multifocal, myocionic and tonic.
a Focal seizures have better prognosis@Na t3) (afier subtle seizures which carries best prognosis).
a Causes ofneonatal seizures are :-
1) Hypoxic ischemic encephalopathy -) Most common cause (60oTolNnnzenusot:t .
ii) Intracranialhemorrhage
iii) Hlpoglycemia
iv) Hyponatremia(Pclog)
v) Pyridoxine deficiency{Attnsoe)
vi) Drug withdrawl
vii) Benign familial neonatal seizures
viii) Infection
ix) Hlpocalcemia, Hypomagnesemia
x) Disorder of amino and organic acid metabolism, hyperammonemia
xi) Developmental defects
xii) No cause found (idiopathic)
STATUS EPILEPTICUS
e It is defined as a condition in which the duration of one seizure is> i0 minutes or multiple seizures occur in 30 minutes
without gaining consciousness between seizuie episodes.
o Important causes are meningitis/encephalitis, head trauma, idiopathic, developmental neurological abnormaiities,
hyponatremia@Gl08), hypoglycemia, pyridoxin deficiency and drug intoxication.
o Initialdrugofchoicefortreatmentisivlora.zeparn@EEr'Alee)followedbyfosphenytoin(pheq.toin) andphenoiralhrl-orie.
CNS INFECTIONS
Signs
t Kernig's sign(,"'nt) -) Extension ofknee is resiricted to less thae I350, when tiie i:,j'o is in 9*i' ilrxqi.il ;r,,-i;
c Brudzinski sign -) On flexing the Neck, there ls flexion of the hips ancl krees.
a Tachy cerebrale -) If skin of the abdomen is lightlv scratched, flushing ilay b* seen.
a) Kernig sign
b) Brudzinski sign
c) Oppenheim sign
d) None
CSF findings
o Study of CSF shows :-
i) Markedly increased leukoclttes (neutrophits/polymorphonuclear leukocytes predominate)alus se)
ii) Markedly increased protein(AllMsee)
lii) Markedly decreased sugar\IlMs ss)
Neonatal nneninEitis
a GroupBstreptococcus(streptococcusagalactiae)isthemostcommoncauseofneonatalmeningitisoetoz,st,es,Ar0s,Arrlts
o'),
followed by E. coli as the 2d most comnnon cause@Gr 07, Ar 0s).
Other causative agents are Listeria monocytogenes(rl
0s),
klebsiellaecr0s), staphylococcus aureus and coagulase negative staphylococcus.
I Bacterial meningitis in the newborn and the first 4 to 6 months of life has
many aqpical features -
i) Neck rigidity and Kernig's sign are seldom prominent(orissass).
ii) Anteriorfontanel may of may not be bulginglorissass).
o Following arouse the suspicion of bacterial meningitis in a newborn -
i) Vacant stare vi) Poor cry
ii) Refusal to suck (Poor feeding)(orissa eB) vii) Fever or hypothermia
iii) Alternate irritability and drowsiness viii) Shock or circuiatory collapse
iv) Persistent vomiting with fever ix) Tremor or convulsions
v) Poor tone x) Neurological deficits of varying tlpes
Treatment of bacterial rneningitis
o For empericai therapy 3'1 generation cephalosporin (ceftriaxone or
cefotaxime) and vancomycin are used. After getting
the culture and sensitivity report, specific antibiotic is started :_
i) N' Meningitidis:Thirdgeneration cephalosporin (Ceftriaxone@Gt07) ar Cefotaxime@Gr07))
is the DoC. penicillin
G can be used in penicillin serusitive strainsGIIMS02).
ii) H. inJluenza : Third generatian cephalosparins(Al04) (Ceftriaoxone or cefotaxine).
rii) Streptococcus agalactiae : penicillin G or ampicillin.
l, ^, ; ; ;1' * i ; i ;;i;;*i;it
i:,
iti) Streptococcus pneumoniae : Penicillin G in sensitive strains or 3'd generation cephalosporin plus
t') Staphylococcu.s : Nafcillin for methiciliin sensitive strains and vancomycin for MRSA.
"""."-f.tr.
vi) Listeria: Ampicillin plus gentamycin.
vii) Pseudomonas, E. coli and klebsiella: Ceftazidim plus aminoglycoside.
- J BERCULAR
'WEN'NGlTI5
o Tuberculous meningitis usually arises from the formation of metastatic caseous lesions in the cerebral cortex or
meningitis that develops during the lymphohaematogenous spread of primary infection. This initial lesion increases
ln size and discharges tubercle bacilli in the subarachnoid space.
o This results in gelatinous basal exudateGl 0s' es' DPG 0e) which interferes in the normal flow of CSF, in and out of the
ventricular system at the level of basal cisterns leading to a communicating hydrocephalusLl 0s' ss, DPG 0e)
.
CSF in TB menimgitis
a LOW SU*AfGI 07' e4' AilMS e8)
Complications of TB menlngitis
o 'lherr. rnavbe i&farcts(nre') in ihe br':iir: ririr,.to v:.:r,-iJar oacir.i:;iur
o 1,'irious neuroiogical *;rnifustaiions see n ro;rtir f il:vi iitcrr_rrie :
x Hemiplegia (20o/o), qtadriplegia (19%), monoplegia (3Zo)
* Cranial nerve palsies (14%1r",ut
x Hemiballismus (117o)
x Tremors (6.1%)
x Midline cerebellar syndromes (4%)
a Ptosis(Ale7) & ophthalmoplegia
x Decerebrate Rigidity (3%)
x Decorticate Rigidity (3%o)
BRAIN TUMORS
Astrocytomas
o These are the most common brain tumors in children. They are usually located in posterior cranial fossa@rrs) and
most common site involved is cerebellum.
o Astrocytomas are divided into :-
l) Low grade astrocytomas (juvenile pilocytic astrocytoma, fibrillary infiltrating astrocytoma)
ii) High grade astrocytomas (glioblastoma multiforme, anaplastic astrocytomas).
o Mostofthechildhoodtumorsarelowgradeastrocytomas(aror)(especiallyjuvenilepilocyticastrocltomaldtts))and
occur infirst two decades6ros).
e Most common site is cerebellum, i.e. cerebellar astrocltoma.
o There is no sex predilectionc4ro8) and the prognosis is very good(Aroa).
Medultoblastoma
o Medulloblastoma is the most common PNET (primitive neuroectodermal tumoT)(etesl located in posterior cranial
fossa.
o It is the 2d most common infratentorial posterior fossa tumorates) (after cerebellar astrocytoma).
o It arises from midline cerebellar vermis thus presents as midline cerebellar swellingleuussat.It may extend into 4e
ventricle causing hydrocephalus.
o Males more commonly affected.
are
o Histopathology shows Homer Wright rosettes and positive reaction for synaptophysin.
o 17p deletion is associated with medulloblastoma.
o Chang staging is used for prognosis.
Craniopharyngeoma
c Craniophyngioma is the mos{Vommon supratentorial tumor in children^r B)
, lt is a suprasellar tumor\ItMs e5)
which
presents as cystic massarrMs es). AI eT)
CalcificationaltMses, is common.
o It arises from squarntrus epithelial cells crests of embryonic rathke\ pouch. ln children they present as -) visual loss,
growth failure, Bitemporal hemianopsiaailMs 04) .
o Craniopharyngeomq is the most common cause of suprasellar calcificationar eT, artMs ea) . Calcification is characteristic
midline and immediately above cells.
ENCEPHALOPATHY
r Encephalopathy are disorder of brain parenchyma, which may be static (cerebellar palsy) or progressive (e.9.
mitochondrial encephalopathy).tt can be caused by infections, toxins, hypoxia (perinatal) and metabolic disorders.
Microcephaly is commonly associated with encephalopathies.
o Cerebral palsy is defined as 'Static (non progressive)' 'Neuromotor disorder' of 'Cerebral origin'. CP is due to an
insult of developing brain which results in maldevelopment and disorderly anatomic organization of the brain. CP
may be classified into :-
A) Spastic CP
s It is the most commn type (65%) of Cpoer wt. There is spasticity(Pcr 0') and increased tendon reflexes. Mental
retardation and seizures may occur. It is divided into :-
1) Spastic hemiplegia
o It is due to large vessel (MCA ataxia) stroke. Spasticity is seen on one side ofbody arms>legs>face@NB
15)
.
r Seizures (in 1/3'd) and mental retardation (in 1/4'h) may occur.
2) Spastic diplegia
o It is due to premature birth. There is bilateral spasticity legs > arms@NB'5) resulting lagging of legs while
crawling (commando crawling).
r It is least commonly associated with seizures and mental retardation.
o Periventricular leukomalacia is characteristicallMs 0e).
3) Spastic quadriplegia
. It is due to birth asphyxia.There is spastic weakness of all 4 hmbs arms ) legs@Nn ts).
o It is most commonly associated with seizures (in 50%) and mental retardation@NB ").
r Scoliosis may occurutusez).
o It is the most severe type of CP@NB
1s).
B) Ataxic CP
r It is the secondmost commontype. There is ataxi"{rcrra), h14>otonia and nystagmus. Forebrain is more commonly
involved than cerebellum.
:
It is commonly associated with other form of CP, e.g. spastic hemiplegia (mixed CP(PGr05)).
C) Hypotonic (atonic) CP
r There is marked hypotonia(Pc' to (floppy child or Jlaccid paralysis(Pcr oa)), normal or brisk tendon reflexes and
extensor Babinski response.
r Severe mental retardation is there.
r Forster sign (flexion ofhip and leg on holding the baby verticle) is positive.
D) Extrapyramidal (or athetoid) CP
: There is dyskinesia such as athetosis(Pct0s), dystonia, choreiform movements, tremors and rigidity@Gr05).
r Mental retardation, seizures and hearing defect may be seen.
r Extrapyramidal CP due to peripartum total asphlaria{om r:r ir associated wi.th bilateral symmetrical lesions@NB
13)
in posterior putamen and ventrolateral thalamus, and appear to be carrelate of neuropathologic lesion called
status marmoratus(DNB'3) in basal ganglia. These lesions have marbled appearan6s@Nrr:).
E) Mixed type
r There is diffuse neurological involvement of mixed Qp e@Gt
0s)
.
M ITOCHONDRIAL ENCEPHALOPATHIES
o These are a group of disorders caused by mitochondrial DNA mutation. The various disorders are htlELAS (mitochondrial
encephalopatlry,lactic acidosis and stroke), MER&F (myoclonic epilepsy with ragged redfibre), Leigh subacute necrotizing
encephalopathy, LHON (Leber Hereditary Optic Neuropathy), kearns-sayre syndrome (KSS), and NA RP (Neurogenic
0e).
weakness with ataxia and retinitis Ttigmentosa)@IlMs Mitochondrial disorders are always maternally inherited.
One important acquired mitochondrial encephalopathy is Reye's syndrome.
Reye's syndrome
o Reye's syndrome is a metabolic mitochondrial disorder characterized by:-
r) Fatty infltration ofliver
ii) Encephalopathy(Pclos)
lii) Sometimesfatty infiltration of kidney.
o So, it so also known as Encephalopathy withfatty degeneration of viscera.
o It is an acute self limiting metabolic insult resulting in generalized mitochondrial dysfunction due to inhibition of
fatty acid oxidation. Precipitating factors -
t Viralinfection@Gro3,uPs7)) Influenza B * S{xeratass),Yaricella (Herpes tlpe 3(Kerotaes)),Echovirus-2, Adenovirus(("'"/'
rsl, EBV Coxsackievirus A
: S alicylates (Aspirin{Nnnr' ur sz ;1
HYDRAT{ENCEPHALY
relatively intact.
o The cause ofhydranencephaly is unknown, but bilateral occlusion ofthe internal carotid arteries during early fetal
development would explain most of the pathologic abnormalities.
a Affected infants may have a normal or enlarged head circumference at birth that grows at an excessive rate
PostnatallY(errs).
a Transillumination shows an absence of the cerebral hemispheres(Arr5).
a The child is irritable, feeds poorly, develops seizures and spastic quadriparesis, and has little or no cognitive development.
a A ventriculoperitoneal shunt prevents massive enlargement of the cranium.
a Porencephaly is considered a less severe degree ofthe same pathology.
DEVELOPMENTAL DEFECTS
I{EURALTUBE DEFECT
I NTDs account for most congenital anomalies in CNS. It results from failure of neural tube to close spontaneously
between 3'd-4th week of in utero development.
o NTDs have multiple etiological factors -
r Maternal diabetes
r Maternal exposure to alcohol, radiation, valproate, carbamazepine
t Zinc and folate deficiency
r Trisomy 13 and 15
r Maternal malnutrition is an important risk factor for development of NTD. There is decreased maternal
folate
levels in NTD affected pregnancies -+ Periconceptional folic acid supplementation decreases the occunence of
es).
NTD(AIee,
r NTDs allow excretion of fetal substances like alpha-fetoprotein and acetylcholinesterasear ee)
into amniotic fluid,
as prenatal biochemical markers for diagnosisal ss) .
which are rsed
r Neural tube defect may be divided into :-
A) Spina bifida : Which includes :-
i) Spinabifida occulta
r It is the mildest and most common type. Commonest site is lumbosacral region, S, being the commonest.
There is bifid spinous processes of the vertebrae.
ii) Spinabifiila aperta
r Commonest site is dorso-lumbar region The defects are meningocele, meningomyelocele (myehmeningocele)
(Ar 01),
syringomy elo cele and my elocele.
B) Others:Theseareencephalocele{Aloa),anencephallqlry4),dermalsinus,tetheredcord,diastematomyeliaandlipoma
involving conus medullaris.
Meningocele
o There is protrusion of meninges through a defect in neural arch. This contains only CSF. There may be associated
genital tract abnormalities, e.g. vaginal septa and rectovaginal fistula.
'eneprrn 8 CentrclNervous Systefi
* Hydrocephalus is seen commonly(Alee) and is associated wlth chiari rualformati*tt tytrte II.
Treatment includes surgical repair of clefect (ivithin 3 days) to prer.,ent infection. lliis is ibllo..t'eil b,v shuirt
* placr:;:tei'i
1i ) q0
for hydrocephalus. If there is cSF leak, csF and blood sample should be send .for culture a*.*! sensitivid,'i'1rr'u's
that perioperative antibiotic can be changed accordir.rg to sensitivity.
Eneepka!oeeIe
* Thereisprotrusionofbraintissue(cerebralcorter,cerebeilumorbrainstem) ttiroi.rgiracranii'rltieiect(craniun:bi:.,'l;i;:)'
Most common site is occipital region" Eiydrocepliaius cail !rccur due to aqueductsi stewosis, chiati tm*lf,eww*'tiait *r
D andy-Walker syndrorne.
&r'lencepl'la!y
* There is failure of develcpment of cerebral i"remispheie and cerebellum. It is associated r',ith cJefrpal*l:e art'l {lI-*Fs it
(r\rrEr L).
is the earliest anomaly which can be detect by antenatal {tsG (at 10-11 weeks} "r-I
a) Tuberous sclerosis
b) Spina bifida occulta
c) Meningocele
d) Meningomyelocele
4) Holoprosencephaly{eroat
r It is caused by defective cleavage ofporencephaly.
cRANTOSYNOSTOSTS
DANDY.WALKER MALFORMATION
r Itischaracterizedbyhypoplasiaorabsenceofcerebellarvermis(,{rrsdrMses)withcysticdilatationof4thventriclein
posterior fassa(Ar '5 ArMs e8). There is hydrocephalus(' r.I,, /,Ms es), agenesis
of corpus callosum and increased head size
with prominent occiput.
o Dandy-walker malformation can be differentiated from congenital
aqueductal stenosis by normal size of posterior
fossa in the later('{rr'AzMs02) (posterior fossa volume is increased
in Dandy-Walker malformation).
r Most common site is sylvian fissure. It may be associaed with Dandy-Walker syndromeGeo,t).
4) Holoprosencephaly{tt ut
r It is caused by defective cleavage ofporencephaly.
cRANTOSYNOSTOSTS
i) Scaphocephaly(Dolichocephaly)
t Commonest type and chatacterizedby early closure of sagittal sutures
with anteroposterior elongated skull.
ii) Brachycephaly
r Early closure of coronal suture(,u,rse& e7)
withanteroposterior flattened skull.
CHAP?ER
iii) Trigonocephaly
r Early closure of metopic suture.
iv) Plagicephaly
r It may be associated with Chotzen syndrome. It is of two types :
a) Frontal plagicephaly is lhe 2d most common craniosynostosis (after scaphocephaiy) and involves early
fusion ofcoronal and sphenofrontal sutures.
b) occipital plagicephaly is characterized by early closure of lambdoid sutures.
v) Turricephaly
r There is cone shaped skull due to early closure of coronal, sphenofrontal and frontoethmoidal
sutures. It is
associated with Ffeffir syndrome.
I.IYDROCEPi.IALUS
c Hydrocephalus is charac terizedby an increased volume of CSF in association with progressive yentricular dilatation
(v entriculomegaly ){ ou n t : t .
t Papilledema does not occur in infants because separation of sutures and open fontanelle compensate for increase
in the intracranial pressure. However, if ICT rises very rapidly papiliedema may occur.
o Macewan or ctacked pot sign occurs after sutures and
fontanelle haye closed (not in neonate)$uMs s7).
o Projectile uomiting
a Headache -+ Particularly in early morning
c Diplopia 6 sixth nerve palsy
o Sun set sign{AttMseT) -+ Eyes deviate dorvnward because of impingement of the dilated suprapineal
recess.
e X-ray shows "beaten silver" appearance of skull due to increased convolutional markilg.
Pseudotumor cerebri
o-Pseudotumor cerebri is characterized'by increased
intracranial pressuretilMssz) inthe absence of an identifiable
intracranial mass or hydrocephalus. cardinal features of pseudotumour
cerebri.
t Headache, Clinically resembling that of brains tumor
t Normal cerebrospial fluid
t Normal or small ventricular sizeLilMssz)
t CT & MkINormalaIIMSez)
t No focal neurological deficisLttus szt
t Transient visual obscurations and papiiledema with enrarged blind spots.
MENTAL RETARDATION
Mental age
lQ @PG os, Kdata ss,
= x I 00
--------
Chronological age
CrurrEn I
o A child with IQ < 70 is called rnentally retardation [4re3)
(Pct02)
Normal intelligence > 90
Mental retardation
(AltMsos,ss)
MiId MR 50 - 69
Moderate MR 35-49
Severe MR 20-34 6GPG.ol)
Profound MR 0-19
(DpG PGI 02)
o An average normal trQ is considered to be IOO . However, the range actually extends from 90- 109.
Causes
o Important causes of mental retardation are :-
A) Maternalfactors: Advanced age,poor socioeconomic status(Pcl06),consanguinity, lbxemia, placental insufficiency,
teratogenic drugs, radiation exposure.
B) Metabolic : Phenylketonurit(Pu ot), galactocemia, hemocystinuria@cl 08), mucopolysaccharidosis, histidinemia,
organic aciduria.
c) Chromosomal disorders : Dowm syndrome(Pct 08' Keatuto e4) (most common genetic cause), fragile X-syndrome@Gt0s)
(2d most comman lenetic cause, but most common inherited cause@EBr)), Klinefelter.
D) Endocrine : Hypothyroidism and cretinism(K""'to e') are Ttreventahle causes of Mp,Nntr' u ss)
.
NEUROFIBROMATOSIS
a) Neur*fibromatosis
b) Tuberc'.;"ssclerosis
c) VHL disease
d) Tr.rberous scierosis
na'i"e,,
Ans, is Neuro&hr$ma*osis
a This chiid is having cafe-au-lait spots (flai pigmented spots) + neurofibromatosis type-1.
a) Neurofibromatosis
b) Tuberous sclerosis
c) VE{L disease
d) Tuberous scierosis
Elr mertrin,
oJ)
Periu.rrgrral fi hror*easi-t+'n"' (Koenerr.s trirror).
,li lrleru;-rlasrns : - Subepencivmal gi;'.ni cetr1 asti-cci'toma, eperidymona, rhai:etrofi:1y*ri1a$,r,rf fu,1666('it';o), angiq:rirr.:;:;:l:.
oi rr:,r iiirlnel,, iiver, irdrenal and paricreas.
a) Ependymoma
b) Rhabdcmyoma of heart
c) Angir:mvoma of kidney
d) SCC of lung
CHeprsn 8
a) NF-1
b) NF-2
c) Tuberous sclerosis
d) Sturge-Weber sYndrome
bv classical
of vHL gene on chrornasome3' It is characterized
a It is an atrtosomal dominant disorder due to mutation s')' other associated features
triadof cerebellar hemangioblastoma(Atea), retinal angioma arrd rew:$ eli c&rcinowta\l
arepheochromoc}tomaandcysticlesionsinvariousorgans(k!rlrrer,.iir,er,pancreas).
r$r56EI"!'&&!&QUS
t
:.l:
?.
b
Cnaptr,n 8 Central Nervous Systr,m'':'
!{ilportafit pasteriorfossat*mars in children..cerebellar astrocytoma {rnc), medulloblastoma (2''d mc), brarnstern giioma, ependyn'loma'
1,4*stcammansuprasellarcystlemsssinchildren:Craniopharyngicrrna
Mas! comrnan cause of suprasel!itr t*icificatian in chiidren: craniophatynEioma
ly'!ost com mon supratentorlal tu mar i n chi ld ren : Crariiopharyngioma'
tv4osl common tvpe cf cerebral prrirv : Spastic CP
Type of cerebral palsy commcnly csscciated with scoliasis: spastic quadrip!egic cP.
?!ue {}ba!.tt r3*tus mari.naratus: Seen iii athetoid CP, biiateral, <jue to asphyxia, in basal ganglia, marbled appearance'
r a s i'E :6 ;;rlvet;triru!ar !eukomalacia: Spastic dipleEla'
{leurai tube deleits are prevented by: Folic acid'
^+;. +: rlcetyicholinesierase
,ira*r,irhnlinc<ior:s, anci a!pha-fetoprctein in anrniotiC flUld
s dural
Markers for titbedeiecr
ilW*rE,R 8: cerrrrar Nervous system
&xe
eHAF,TE&.
QUESTIONs
3, % of children with simple febrile seizures developing t2. Most common cause of convulsion on the First day
epilepsy is - (All lndia Dec.14 Pattern) of life in a newborn is - (NEET Dec.12 Pattern)
a) l-2o/o b) 2-5Vo a) Anoxia b) Head Injury
c) 5-l0o/o d) I0-20o/o c) Hypoglycemia d) Hlpocalcemia
4. Which of the following is not associated with in- 13. Most common cause of seizure in newborn is -
crease in the risk of seizures in future in a child with (AIIMS MaY 08)
febrile seizures - (Ar to) a) Hlpoxia induced ischemic encephalopathy
a) Developmental delay b) Hypocalcemia
b) Late age ofonset c) Metabolic abnormality
c) Complex partial seizures d) Sepsis
d) Family history positive 14. Which vitamin deficiency is responsible for neonatal
5. Most important risk factor of recurrence of fetrrile seizure - @llMS i{ov 09)
selzure ls - (CET Nov 15 Pattern) a) Pyridoxine b) Vitamin C
a) Age ofonset <2years c) Thiamine d) Cobalamin
b) F'amily history 15. l.leonatal seizure carries best prognosis ifthe cause
c) Seizure at time of fever peak 1S- (All India Dec.13 Pattern)
d) Long prolonged fever prior to seizure a) Idiopathic b) Hlpocalcemia
6. A yr. old child with acute onset of fever of 1040 F
6 c) Infection d) Asphlxia
developed febrile seizures and was treated. To avoid 16. Commonest type of seizure in newborn -
future recurrence of seizure attacks what should be (At 08, AIIMS Nov 07)
grven - (CET Aug. li Pattern, AIIMS May 01)
a) Clonic b) Tonic
a) Paracetamol 400 mg + Phenobarbitone daily c) Subtle d) Myocionic
b) Oral Diazepan 6 hourly
t7. Drug of choice of Neonatal seizure is - (AIIMS Feb 97)
c) Paracetamol 400 mg 6 hourly a) Phenytoin
d) I.V. diazepam infusion over 12 hrs b) Phenobarbitone
c) Diazepam
MYOCLONIC EPILEPSY d) Sodium valproate
a) Hlpernatremia b) Hyponatremia
a) Grandmal epilepsy (CE1- Nov. 14 Pattern)
b) Petitmal epilepsy
c) Hlperkalemia d) Hlpokalemia
c) Myoclonic epilepsy 19. Best prognosis of neonatal seizures is in ?
(CET June 14 Pattern)
d) Reflex epilepsy
a) Myoclonic b) Tonic clonic
o
o. drug ofchoice for infantile spasm is-
(All India Dec.1i Pattern)
c) Focal d) Opsoclonus
a) Vigabatrin b) ACTH
c) Ethosuximide d) Carbamazepine ABSENCE SEIZURES
9. Which one of the following in the characteristic
feature of juvenile myoclonic epilepsy - (AIMS May 06)
20. All are features of absence seizures except - @l al)
/
MENTAL RETARDATION MISCELLANEOUS
89. A male child of 15 years with a mental age of 9 years 99. Yeung child with taughing spells. Diagnosis -
has an IQ of - (At oi) (All India Dec15 Panen
a) 50 b) 60 a) Hlpothalamic hamartoma
c) 70 d) 80 b) Tetralogy offallot
90. IQ between 50-70 indicates - (Ar 9s) c) Nitrous oxide poisoning
a) Mild mental retardation d) None ofthe above
b) Moderateretardation 100. Decortieatc child - Flase statement is -
c) Severe retardation (NEET Dec.12 Patten
d) Profoundretardation a) Acute Brain injury
91. \{hich is MC genetie cause of mental retardation - b) Susthalamic, CT & frontal iobe lesion
(NEET Dec.12 Pattern) c) More dangerous than decerebrate lesion
a) Tirberous sclerosis d) Flexion of arm & extension of lower limb
b) Cri-du-chat syndrome I01. Anterior funtanelle closes at - (CET July 15 Patten
c) Fragile-x-syndrome a) 2-3 months
d) Angel's syndrome b) 4-7 months
92. Which of the following is a preventable cause of c) 9-12months
mental retardation - (Ar es) d) l9-24months
a) Hlpothyroidism b) Down syndrome lW^ Closure of the anterior funtanelle is ddaned in aItr
c) Cerebral palsy d) All of the above except - (All India Dec.14 Pattem
93. Preventable cuse$ ofmental retardation are - a) Down's syndrome
(All India Dec.14 Pattern) b) Osteogenesis imperfecta
a) Downs b) Phenylketonuria c) Hlpogonadism
c) Cretinism d) Cerebral palsy d) Hlpothyroidism
94. Mental retardation can be proved if delayed mile- lO3. klost comrmon vir,atr ealrse of ac.qqired aquednctal
stones and slow or retarded growth seen upto which stenosis is ? (CET Nov.13 Paternl
age (tn year)- (All India Dec15 Pattern) a) Rubella
a) t2 b) 16 b) Mumps
c) 18 d) 20 c) Toxoplasma
d) Enterovirus
!
REYE'S SYNDROME 104. True about infantile tremor syndrome - (pGr Noy. i5)
-,9. A}year old child is trrought by parents lYith history 116. Which of the following has the worst prognosis -
of seizures and developmental delay. He has multi- $PMERaL)
ple hypopigmented macule$ over the baek. What is a) Rolandic epilepsy
the rnost probable diagnosis - (At 1o) b) Versive epilepsy
a) Neurofibromatosis tlPe 1 c) Absence epilepsy
b) Tuberous sclerosis d) Infantile spasm
c) Sturge weber's sYndrome ll7 " Most severe papilloedema is caused by- (Kerola 95)
d) Linear Sebaceous nevus syndrome a) Pituitary tumor
I 10. A 10-yr old male child was presented to the b) Frontal lobe tumor
pediatrician for evaluation ofa seizure disorder' On c) Posterior cranial fossa tumor
exarnination a vascutrar plaque was found along the d) N{edulloblastoma
ophthalmic and rnaxillary divisions of the trigem- 118. The common type of ceretrral palsy seen in hospitals
inal nerve. The mother informed the pediatrician is- (CUPGEE 95)
that the lesion was Present since birth and there was a) Spastic b) lv{onoplegia
no change in rrorphol.ogy.The most likely possibil- c) Quadriplegia d) Diplegia
rty is -
(AIIMS May 12)
119. Scapocephaly is due to premature closure of the -
(Orissa 99)
a) Sturge Weber sYndrome a) Coronal sutrue b) Metopic suture
b) Inlantile hemangioma c) Sagittal suture d) Lambdoid suture
c) Congenital hemangioma of
d) Proteus sYndrome
120. The following are recognised signs any symptoms
raised intracranial tension in a 9 month old infant,
111. A newborn presents with congestive heart failure, (sGPGt o5)
except -
on examination has bulging anterior fontanellae a) Bulging fontanel b) Diplopia
with a trruit on ausculation. Transfontanella usg c) Papiiloedema d) increase in head size
shows a hypoechoic midline rnass with dilated later-
121. A 2 year old child without fever develops bone pain,
al ventricles. Most lillely diagnosis is -(AIIMS Nov .l.1, 06'
vohiting and features of increased intracranial pres-
AI A7)
sure following excessive medication. The drug most
a) Medulloblastoma
likely to be responsible for this is - (UPSC e8)
b) Encephalocele b) Phenothiazine
a) Vit A
c) Vein of Galen malformation d) vftD
d) Arachnoid cYst c) Phenl'toin
ll2. Known to prevent intreventricular haemorrhage
122. The normal concentration of protein in CSF at 4
(PGr 96) weeks may be as high as- (PGI 8a' Delhi sa)
when given antenatallY -
a) 500mg % b) 25mgo/o
a) Phenobarbitine
b) Vitamin K
c) 50mg% d) Z5mgo/o
a) Hydrocortisone b) Prednisolone
c) Dexamethasone d) Betamethasone
QUE5TIONS OF VARIOUS OTHER EXAMINA-
L24. Banana sign seen in the foetal brain suggests -
TIONS (Comed 05)
III
b) Pyogenic septicemia d) Multifactorial
c) Cerebral abscess 127. Acquired extra - cranial infection that causes Aque-
d) Encephalitis ductal Stenosis is - (UqSC 04.,
126. Neural tube defects have which one of the following a) Bacterialendocarditis
inheritance patterns ? - (UPSC-il 09) b) Mumps
a) Autosomal dominant c) Measlbs
b) Autosomal recessive d) Staphylococcalsepticemia
c) X-linked recessive
lrl
CHAPTE.R iB
ANSUfERS
EPILEFSY
TEBRII.E CONVUI.SION
Ans. is 'd i.e., R.ecurrent in nature fRef: A.P. Ghai I'h/e p. 556 6 Vh/e p. 528; Nelson l?th/e p. 245fl
o Febrile convulsions are the commonest cause of seizures during early childhood.
o Mostly occurs between 6 months to 5 years.
o The convulsions are not related to degree oftemprature rise but are frequent iftemprature rises abruptly.
e Spontaneous remmission occurs with no postictal neurological deficit and EEG changes few days after the
seizure is normal.
a Recurrentfebrile seizrxes occur in 30-50% ofcases.
Ans. is 'd' i.e., 25-50o/o lRel llekon 18th/e p. 2457; O.P. Ghai Vh/e p. 52Bl
o Recurrent febrile seizures occur in 30-50% ofcases.
Ans" is 'b' i.e., Late age of onset fRef: CPDT tr}'h/e p" 720; Ctinical Paeddatric 3d/e p. j90; Op Gbai }th/e p. 5561
b. Ans. is 'b' i.e., Oral Diazepan 6 hrly fRef: CPDT 1|th/e p. 726; O.P. Ghai 8'h/e p. 556-557 6 Vh/e p. 528; Nelson 18th/e
p. 24s81
Prophylaxis in febrile seizures
Prophylactic anticonvulsants are not given routinely in febrile seizures. They are required when -
i) Febrile seizure is prolonged or complicated
ii)Medical reassurance fails to relieve family anxiety.
Prophylaxis may be continuous or intermittent
lntermittent prophylaxis
o It is currently the desirableform oftherapy
a It is used during episodes of fever
o Indicated during first three days offever.
o Drugs that are used are - Diazepam and other benzodiazepenes (these drugs are used because they attain desired
lewls quickly) --> Diazepam is given oral or rectal.
Continuous prophylaxis -
o It is used when
e Intermittent therapy has failed s Recurrent atypical seizures
t Central neryous system disease a Family history of epilepsy
o Drugs used are -+ Sodiumvalproate or phenobarbitone.
Note - Carbamazepine and phenytoin are ineffective for prevention of recurrence.
;l,xi,l6&r.
MYOCLONIC TPILEPSY
.A.ns. is 'c' i-e., Mlrcdonic epilepsy lRef: O.P. Gh*i */e p. 559 & fr/e p. 531)
r Hysparrhl'thmic pattern of EEG is seen in infantile spasm (a type of myoclonic epilepsy).
8. Aa:s is'd Le,, Yigabatrin :lRef:,O.P. Ghai */e p-.559 & Ple p. sjll
t Vagabatrin is the DOC Now.
9" Aas" is'a" i"e., Myoclolric seruillr,es frequentlyocqrr ia morning [Re! Hatison lVh/e p. 2500)
o Juvenile myoclonic epilepsy is seen mostly in morning. Complete remission is uncommon, it respond well to
anticom.ulsant and is associated with absence seizure only in 1/3.d cases.
1,0- Ans. is t'i.e., Va$roate {Ref, Nelson 1,*/e p. zaffil
r Valproate is the drug of choice for myoclonic epilepsy and is required life long.
ll" A:rs" is '|t' i.e", Carbamazepine {Ref: Hawison 1*/e p 2507, 2508; trnternet)
Drugs used in myoclonic epilepsy
c Valproate (DOC) t Topiramate r Clonazepam
r Lamotrigine . Felbamate r Zonisamide
I{TONATAL SEIZURTS
lL Ans. is ',a" i.e-, Aaoxia :l&ef D"P, Ghai#/e p- S5S &'*/e p. 531; Nelson t*/e p. 212)
r The flve major causes ofneonatal seizures are -
1) Hypoxic ischemic encephalopathy (hypoxia, anoxia) --> most common 4) Meningitis
2) Hypocalcemia 5) Polycythemia
3) Hypoglycemia
13" Aas" is A'i.e., Hypoxia induced ischemic encephalopathy [eef O.2 Ghsi */e p. S5g-55g d" 7/e p. 531; C.p.D.T.
1*/ep" 621
15. Ans. is lb' i"e", ffirmalcernia Leel A:P. ,Ghai 6"/e p. t77l
r Hypocalcemic seizures carry good prognosis.
o Idiopathic seizures have bad prognosis.
BSENCE SEIZURES
). Ans. is t' i.e., Fost ictal confiIsion lRej: Ila*ison l7*le p" 2499, 25A0; AP Ghai Sele p. 558j
-J welJ 'Absence seizures are characterized by sudden brief lapse of consciousness without loss of postural control. The
seizure typically lasts for only seconds, consciousness returns as suddenly as it was lost and there is no post ictal
confusion". --- Harrison
1. Ans. is 'a'i.e., Spike and dome [Rel Harrkon 17h/e p. 2499, 25AA]
c The EEG hallmark of typical absence selzure is a generalized symmetric 3 Hz spike and slow wave discharge.
)2. Ans. is'-r- i.e., Absence seizures lRef: A.P. Ghai 8e/ep. 558 & Tele p. 5301
r Absence seizure is characterized by a few seconds of impairment of conciousness without loss of postural control
There is associated eye blinking or staringwhich may occur as clustered events.
Ans. is t' i.e., Petitmal epilepsy tRef O.R Ghai *'h/e p. 558 6 Thle p. fiA\
---==--"' o Absence seizures are also called petitmal or minor epilepsy.
c Generalized tonic clonic seizures (GTCS) are also called grand mal or major epilepsy.
c Complex partial seizures are also called temporal lobe epilepsy or Psychomotor epilepsy.
* Simple partial seizures are also called cortical focal epilepsy.
TREATMENT OF SEIZURES
C.PD.Z
24. Ans. is ? i.e., Ethosuximide lRel O.P; Ghai Sthle p. 559,6 7h/e p. 5j2l
,.;;
c Absence seizure c Valproate * Lamotrigine
acid r o
Ethosuximide Clonazepam
: :EG
25. Ans. is'b'i.e., Carbamazepine [R{ GhaiTh/ep. 53)
* DOC for partial seizure -+ carbamazepine / oxcarbazepine
26. Ans. is 'a' i.e., Lorazeparn lRef O.P. Ghai #h/e p. 559 & Vhle p. 5251
c Drug used are )Lorazepam, Clonazepam, Diazepam, Phenltoin, Phenobarbitone, Thiopentol, Propofol, Midazolam.
e Lorazepam i.v. is now the preferred initial choice.
77 Ans" is t' i.e., Sodium valproate fRef: Harrison lVhle p. 2507, 25A8; Leurence */e p. 416\
Petit mal seizures are synonymous with Absence seizure
Now DOC for absence seizure is valproate (previously it was Ethosuxamide).
CNS INFECTIONS
LO. Ans" is 'b' i.e., 50-80 rnrn of HrO fRef; Nelsan t9'hle p. ch. 6a2 ftable 1))
e Normal CSF pressure in children is 50-80 mm HrO (5-8 cm HrO).
BACTERIAL MENINGITIS
29. Ans. is 'b' i.e., Acute bacterial meningitis [Ref O.g Ghei Sele p. 564 & Vhle p. 5i6]
c Three important signs of acute bacterial meningitis are Kernig's sign, Brudzinski sign and Tache cerebrale.
30. Ans. is t' i.e., Poor feedingfRef O.P. Ghai 9th/e p. 56j 6 Vh/e p. 517, 537; Nelson 18th/e p. 25151
r Among the given options, poor feeding is a common symptom.
o Neck rigidity and Kernig\ sign are seldom prominent
o Anterior fontanel may or may not be bulging
31. Ans. is'b'i.e., Seizure lRef: A.P, Ghai 9th/e p. 561 6 7h/e p. 536-5i7; Nelson 18'h/e p. 25161
o Seizure is the commonest complication of meningitis in children.
32. Ans. is'd i.e., ABER lRef: O.P. Ghai 8th/e p. 564 6 7h/e p. 5j7)
o AfterH.influenzameningitissensorineuralhearinglossoccursin5-10%of patientsduringlongtermfollowup.
o Therefore Auditory Brain Stem Evoked Response is done to check the peripheral auditory system.
NEONATAL MENIN6ITIS
34. Ans. is t' i.e., Streptococcus Agalactiae fRef Nelson 18th/e p. 2513, 79n
r Group B streptococcus (strep agalactiae) is the most common cause of neonatal meningitis.
J:t. Ans. is 'b" i.e", Streptococcus Agalactiae fRef: Nelson 18th/e p. 25131
'Group B streptococci are the commonest gram positive agents responsible for eaily onset neonatal pyogenic
infections and are usually clinically apparent within the first 24 hours of life'. Nelson
t Presence of hemolytic colonies on blood agar
-
(p hemolysis) and gram positive cocci in smezrs is almost diagnostic
of Group B hemolytic streptococcii infection (streptococcus agalactiae).
36. Ans. is 'H i.e., E. coli lRef : O.P. Ghai 8th/e p. 56j 6 7h/e p. 536; Nelson 18h/e p. 25131
"Group B streptococcus followed by E.coli are the two most common causes of neonatal meningitis".
Nelson lSthle 2513
So,
-
Most common cquse of neonatal meningitis -+ Group B streptococcus (Str. agalactiae)
Second most common cause of neonatal meningitis -+ E.coli
37. Ans. is t' i.e., N. Meningitides [Rel O.P. Ghai 8th/e p. 563 b Vh/e p. 5j6l
Causes of neonatal meningitis
r Group B-streptococcus (str, agalactiae) r Listeria monocfogens r Streptococcus fecalis
t E.coli r Staphylococcus aureus
r Klebsiella r Coagulase negative staphylococci
38. Ans. is t'i.e., Streptococcus pneumoniae lRef: CPDT 18th/e p. 1089, 26231
.
R EATTMEN{T OF BACTEM'AL MEr{'&!6IT'5
:-a Ans. is ne'i"e", Third gemeration eephalospeirins fRef: Nelson LEh/e p. 2519; Nwrrison l7th/e p. 26261
* DOC for H. influenzae meningitis Cs -> Third generation cephalosporin.
4, Ans" is 'e' i.e", Fenicillire {Ref: {}"P" Ghai I'h/e p. 565 d* vt'/e p. s3g; tr{s.rcisow lrhle p. 2626}
a The clinical presentation of fever, altered sensorium and purpuric rashes, is highly suggestive of meningiococcal
meningltis.
o Purpuric rash in quite characteristic of meningococcemia.
a I.V. Penicillin is the treatment of choice for meningioccal inf. among the given options.
* The DOC for meningiococcal infection is
x IIIrd generation cephalosporin e.g. Cefotoxime, Ceftriaxone.
+f, Ans. is t' i"e., l0 days fRet': Ghai Vh/e p. 539; Nelson t9,h/e ch. 6A2]
* Child with bacterial meningitis shows improvement in 10 days and rarely necessary beyond l4 days.
16. Ans, is na'i.e., Mycobaeteriurar Tuhereulosis flTef: Nelsan igthle p. 124g, l24g)
* Insiduous / gradual onset offever over a duration of two weeks, with features of raised intracranial tension in the
form of vomiting and altered sensorium with characteristic basal exudates and hydrocephalus on cranial CT
scan are almost characteristic of tuberculous meningitis.
od'
47. Ans" is i.e., Farkinsonism IRe,f O"F. Ghsi Vth/e p. 567 & Vh/e p. S4A)
* Parkinsonism is not a complication of tubercular meningitis.
18" Ans. is'tr'i"e", tr ow saagar + High protein, and Lynephoeytosis {Ref Has been explainecll
CSF im TB memingitis
e Low sugar * Predominant cel1s -+ Lymphocltes * Opening pressure is elevated
* High protein e Very low chloride
49. Ans. is 'd' i.e", Tuhererdous meeningiti s fRef: Nelson 17t'/e p. 2a39, See previous cluestions also)
o Typical signs of meningitis (Fever, convulsion and neck rigidity) with increased CSF protein and decreased sugar
level and decreased chloride level associated with lymphadenopathy suggest the diagnosis of tubercular meningitis.
E'Ve €pHA!-t?"t85
50. A*rs. is 'd' i,e.o Enterovirus {Ref: Nelson 18th/e p. 2521; E"F. Gkai Eh/e p. 56g}
"Enteroviruses are the most common cause of meningoencephalitis,, ------ Irlelson.
@&ANt\! YW&1&m5
<1 A.ns" is 'a'i.e., &dostly is infra-tentorial [Re/ Nelsom x.gtt'/e p. 2129]
o Brain tumors are the second most common malignancy of childhood next only to leukemia.
* Otter two-thirds of brain tumors are infratentoterial.
o Most of these tumor occur near the midline -) commonly obstruct CSF circulation and cause hydrocephalus early
in disease. These can also cause t ICt and papilledema (In infants papilledema may be absent because of open
s uture s and b ulging fo ntanelle ).
ffi{ffi ii: i:i:i;i:;, ;,, :::;*:.:' :' :n
:
"The classical triad of headache, nausea and vomiting, and papilledema is associated with midline or infratentorial
tumors", Nelson 18th/e 2129
-
58. Ans. is t' i.e., Medullablastoma lRef O.P. Ghai 8e/e p. 571 & Vh/e p. 545; Nelson 18th/e, p. 21j41
rMidline swelling arising from cerebellum in a child favour the diagnosis of medulloblastoma.
tRobbin\ states
r "In children medulloblastomas are located in midline but in adults they are found in lateral locations'l
Note -
. Astrocltoma is also a posterior fossa tumor, but it does not commonly present as midline mass.
59. Ans. is ? i.e., These tumors are more common in females [Ref. O.P. Ghai Bth/e p. 571 6 Zh/e p. 545; Nelson lgth/e
p.2130,213s1
o Cerebellar astrocltomas do not show any clear gender predilection and are equally common in both males & females.
r Lowgrade astrocltomas are more common in children than adults. The predominant group of astrocytomas is childhood
are low grade astrocytoma.
o cerebellar astrocltomas develop most commonly during first two decades of life.
o Most common type of astrocl'toma in children is fuvenile pilocytic astrocltoma, which has very good prognosis.
CRANIOPHARYNGIOMA
50. Ans. is 'd i,e,, Craniopharyngioma [Ref: O.p. Ghai B*/e p. 572 6 7/e p. 546; Nelson 18e/e p. 2135]
r Most common supratentorial tumours in children is - craniopharyngioma.
51, Ans. is'H i.e., Craniopharyngioma {Ref: O.p. Ghai B*/e p. 522 6 Vh/e p. 546; Nelson tyn/e p. 2135)
o craniophyngioma is the most common supratentorial tumor in children,
r It is a suprasellar tumor which presents as cystic mass.
62. Ans. is 'a' i.e., Craniopharyngioma {Ref: Sutton */e p. 1609; O.P. Ghai 8h/e p. 572 6 Vh/e p. 546; Nelson 18th/e p.
21 3s1
"Presence of Suprasellar
midline calcification immediately suggests the diagnosis of craniopharyngioma".
Craniopharyngioma is the most common cause of suprasellar calcification.
Crrn rr,rBa I
CEREBRAL PATSY
63. Ans. is'a' i.e., Spastic diplegia lRef Nelson l$hle ch. 598)
Involvement of limbs
o In spastic diplegia -+ Legs > Arms.
c In spastic hemiplegia and spastic quadriplegia -+ Arms > legs.
64. Ans. is 'd i.e., Diplegia is weakness in upper arm more than leg. lRef: Netson l&hle ch. 59a|
o In spastic diplegia, legs are involved more than arms. Other options are correct.
65. Ans. is 'a' i.e., Spastic quadriplegialRef: Tachdiian Pediatric orthopaedics p. 397\
"scoliosis is common, occuring in 15 to 25 percent of the total body CP (spastic quadriplegia CP)" Tachdjian
-
66, Ans. is 'b' i"e., Microcephaly lRef :O.P. Ghai S'hle p. 582 6 7h/e p. 559-56A1
o Hypotonia and flaccid paraiysis is seen in hlpotonic (atonic) CP. Ataxia is seen in ataxic CP.
67. Ans. is'd' i.e., Unilateral lRef: Nelson l$hle Chapter 598,99.5\
r Extrapyramidal cerebral palsy secondary to acute intrapartum near-total asphlxia is associated with bilaterally
symmetric lesions in the posterior putamen and ventrolateral thalamus.
c These lesions appear to be the correlate of the neuropathologic lesion called status marmoratus in the basal ganglia.
o These are present in fuli-term infants of basal nucleus lesions resulting from acute total asphpria.
o The lesions have a marbled appearance caused by neuronal loss and an overgrowth of myelin in the putamen, caudate,
and thalamus.
68. Ans. is 'a' i.e., Spastic diplegia lRef: O.P. Ghai 9th/e p. 582 dt Vh/e p. 5591
o Spastic diplegia is commoner in preterm babies and is associated with periventricular leukomalacia.
69. Ans. is 'b' i.e., Folic Acid lAeT: O"e. Ghai 8th/e p. 576 6 Vh/e p. 5511
o Maternal malnutrition is an important risk factor for development of NTD. There is d.ecreased maternal folate levels
in NTD affected pregnancies -+ Periconceptionalfolic acid supplementation decreases the occurtence of NTD.
70. Ans. is'b' i.e., Folic acid lRef: Nelson 18'h/e p. 96.81
o The figure in question is showing neural tube defect. Which is prevented by folic acid.
71. Ans. is 'a'i.e., Open Negral Tube Defect lRef O.P. Ghai Sthle p. 576 & 7h/e p. 551; Nelson l8tule p. 244j]
o In intra embryonic life, neural tube is open at both end and freely communicate with amniotic cavity. Failure of closure
of neural tube results in persistant of this communication. This allows excretion of following fetal substances into
amniotic cavity -
l) Alpha - fetoProtein
2) Acetylcholinesterase
o These serve as biochemical marmkers for NTDs for prenatal diagnosis.
72. Ans. is 'd' i.e., Holoprosencephaly lRef: a.P. Ghai 8th/e p. 576 (t Vh/e p. 550; Nelson 18'h/e p. 244j1
Holoprosencephaty is a developmental disorder of the brain that results from defective cleavage of the
prosencel)halon. lt is thus a malfurmation of cortical development and not a neural tube defect.
73" Ans is'c'i.e., Vascular Lesions due to degenerative vessel disease and Head Injury fRef: Nelsan 18'h/e p. 2449)
porencephaly Refers to the presence of cysts or cavities within the brain, that may results from
1. Developmental defects (True porencephalic cysts).
2. Acquired iesions of infarction of tissues. (i' e. Vascular lesions) AV malformation or infarcts or (Pseudo-
porencephalic cysts).
74. Ans. is'b' i.e., Cerebral infarction fRef: See above explanationl
75. Ans. is 'a' i.e., Spasticity of the Lower Limbs is seen lRef a.p. Ghai I'h/e p.
576 dz vh/e p. 5511
o The neural tissue may be the spinal cord or the Cauda equina.
t In a sacrql meningomyelocele, howeuer, the neural tissie involved would be the cauda ecluina,
the inuolvement oi
which would results in a lower neuron picture and not an upper motor
neuron picture (ie. as in the inyolvement
of spinal cord)' spasticity would thus not be a
feature of-iacral Meningomyelocele. spasticity is a feature oJ
u'M'N' lesion and would thus be a feature of meningomyelocele occurriig higher
up, ii the lumbar as dorsal
region, where neural tissue involvement is that of spinil cord. (l,{ote:
Cauda equina are nothing but spinal
nerves which haue left the spinal cord' but yet have to leaie the vertebral
column, ie. the) are lower motor neurons)
a Bladder & Bowel incontinence may be seen.
a Hydrocephalzs is an important and frequently
associated finding with meningomyelocele.
/6. Ans is 'a' i.e., Blood-culture and sensitivity [Ref: Pediatric nursing care plans 4th/e p. 44g]
o Most cases of meningocele are recommended for treatment as
soon after birth as possible.
o In the case of a sac which is leaking fluid, the treatment is most
urgent.
o Generally, treatment includes a surgical procedure to close and .ei-ro,re
the soft tissue covering of back.
o As there are chances of bacterial meningitis and sepsis due to
csF leak, csF and blood saipte should be send
culture and sensitivity andperi-operative antibiotics (broad spectrum) can for
be changea to trr. ,p..lfic antibiotics after
the blood and CCF culture and sensitivity report.
77. Ans. is 'd i.e., Congenital anomaly lRef Nelson lSth/e p. 2452; Op Ghai Bth/e p. 5741
78. Ans. is t' i.e., Aqueductal stenosis lRef Nekon 18th/e p. 24521
congenital hydrocephalus is most commonly of obstructive or non communicating
type. Abnormalities of the Aqueduct
(Aqueduct stenosis) are the most common cause of obstructive hydrocephalus.
Aclueductal stenosis therefore can be termed as the most ,o**i, cous"
of congenital hydrocephalus.
As obstructive hydrocephalus are more common cause for conginitat hydroiephalus than non - obstructiye
hydrocephalus, aqueductal stenosis is the single best answer.
'7() Ans. is 'a'i.e., Post inflammatory obstruction lRef: Read text berow)
r MC cause of obstructive (non-communicating) hydrocephalus --> aqueductal stenosis.
r MC cause of non-obstructive (communicating) hydrocephalus -) subarachanoid hemorrhage.
r But, amongst the given options best answer is option .a1
80. Ans. is 'd' i.e., All of above lRef: Nelson l8,h/e ch, 592.1)
o Non-obstructive(communicating)hydrocephalusisduetoobliterationofsubarachnoidbasalcisternsormalfunction
of arachnoid villi. There is enlargement of all ventricular cavities aswell
as subarachnoid space.
75. Ans. is'a' i.e., Spasticity of the Lower Limbs is seen [Ref: o.p. Ghai B,h/e p. 57d 6 Th/e p. 551)
o The neural tissue may be the spinal cord or the Cauda equina.
e In a sacral meningomyelocele, however, the neural tissue inuolved
would be the cauda equina, the involvement of
which would results in a lower neuron picture anrJ not an upper motor neuron
picture (ie. as in the inyolvement
of spinal cord). spasticity would thus not be a
feature of-iaual Meningomyelocele. spasticity is a feature of
u'M'N' lesion and would thus be a feature of meningomyelocele occurriig higher up, ii the
lumbar as dorsal
region, where neural tissue involvement is thot of spinal cord. (l{ote: C"aud"a
,quiro are nothing but spinal
nerves which have left the spinal cord, but yet have to leave the vertebral
column, ie. the) are lower motor neurons)
o Bladder dz Bowel incontinence may be seen.
t Hydrocephalus is an important and frequently associated finding with meningomyelocele.
76. Ans is 'a' i.e., tslood-culture and sensitivity lRef Pediatric nursing care plans 4th/e p. 44Bl
e Most cases of meningocele are recommended for treatment as soon
after birth as possible.
r In the case of a sac which is leaking fluid, the treatment is most urgent.
o Generally, treatment includes a surgical procedure to close and rerirove
the soft tissue covering of back.
c As there are chances of bacterial meningitis and sepsis due to CSF leak,
CSF and blood ,rnipte shoulil be send
culture and sensitirtity andperi-operative antibiotics (broad spectrum) can be changed for
to the specific antibiotics after
the blood and CCF culture and sensitivity report.
HYDROCEPI.IALUS
77. Ans. is 'a' i.e., Congenital anomaly lRef: Nelson lgth/e p. 2452; Op Ghai gth/e p. 574]
/o. Ans. is t' i.e., Aqueductal stenosis [Ref Nelson 18th/e p. 2452]
congenital hydrocephalus is most commonly of obstructive or non communicating type.
Abnormalities of the Aqueduct
(Aqueduct stenosis) are the most common cause of obstructive hydrocephalus.
Aqueductal stenosis therefore can be termed as the most ,o**i, crus, of ,ongenital
hydrocephalus.
As obstructive hydrocephalus are more common cause for congenitat hyaroiephalus than non - obstructive
hydrocephalus, aqueductal stenosis is the single best answer.
79. Ans. is'a'i.e., Post inflammatory obstruction [Ref Read text berow)
o MC cause of obstructive (non-communicating) hydrocephalus -+
aqueductal stenosis.
o MC cause of non-obstructive (communicating) hydrocephalus -)
subarachanoid hemorrhage.
e But, amongst the given options best answer is option hi
'A common cause of acquired hydrocepahalus, is post inflammatory obstruction. Bacterial
and tuberculous
meningitis have a propensity to produce thick tenacious exudate that obstructs the basal cisterns,,.
80. Ans. is'd'i.e., All of above lRef: Nelson lgth/e ch. 592.1)
r Non-obstructive(communicating) hydrocephalusisduetoob/iterationofsubarachnoidbasalcisternsormalfunction
ofarachnoidvilli,Thereis enlargement ofallventricular cavitiesas well as subarachnoid
space.
Cnep rsn 8, , Cenfral ilbrV:ousrffs{stti
Ans. is t' i.e., Crack pot sign; ?' i.e,, Depressed fontanell efRef:O.P. Ghai 8'h/e p. 574 6 7h/e p. 549;Nekon 18't'/e p. 2453]
e "Cracked Ttot or macewan sign indicates raised intracranial pressure afier sutures and fontanels have closed"
o Fontanelle is wide and bulging (not depressed)
Ans" is t' i.e., Aqueductal stenosis {Ref: t{illiaw's 22n/e Ckapter 16; Nelsan 18th/e Chapter 592.11)
* Hydrocephalus is characterized by an increased CSF volume with progressive ventricular dilatation (ventriculomegaly).
* Obstructive or noncommunicating hydrocephalus/ventriculomegaly develops most commonly in children because
of an abnormality of the aqueduct or a lesion in the 4th ventricle.
* Obstruction of the aqueduct is the single most common cause offetal and neonatal hydrocephalus/ventriculomegaly,
* Nonobstructiye or communicating hydrocephalus most commonly follows a subarachnoid hemorrhage, which is
usually a result of intraventricular hemorrhage in a premature infant.
83. Ans. is'c' i"e", MRI [eef {liruicsl wewrolagy 3'dle p. 318}
* Investigation of choice for hydrocephalus is MRI because is can demonstrate the extent of hydrocephalus and
uderlying cause.
84. ,{ns. is'd'i.e,, .A.ll of above [Rel Nelsow tr9't'le Chap. 2$fl
c Hydrocephalus, meningomyelocele and syringomyelia are found in chiary malformation type II.
85. Ans. is 'd'i.e., ,4,I1 are true {Ref: Nelson 18th/e ch, 5921
a It is charact erizedby hypoplasia or absence of cerebellar vermis with cystic dilatation of 4th ventricle in posterior
fossa. There is hydrocephalus, agenesis of corpus callosum and increased head size with prominent occiput.
s6. "Ans. is t' i.e., Cerebral eortex are deficieney/hypoplastic in hyrlranencephaly {Ref: Nelsan 18'h/e ch. 592.11)
PS E["'B8T[-N&4OR CHMEMR'
37, Ans, is'b'i.e., CT scan sleows punctete hypodense areas ["&rf CPWT X.8t1'/e p. f4A; 0.P"Gkwi 9'h/e p" 575 6
Vhle p" 55A; NelsoYt l*tkle P. 25251
* There is raisedlCT,normai ventr icular size, normalCT scan and no focal neurological deficit in pseu dotumor cerebri.
:3, Ans" is'a' i"e., Salicylic eci&l*ef: CPWT tr8'h/e p" 741; Nelsan tr&il'le p. 25251
* Salicylates do not cause pseudotumor cerebri. Tetracycline, nitrofurantoin and nalidixic acid can cause pseudotumor cerebri.
ryIKNYAL mFY&mmpr'0rx
89. Ans. is'b' i.e., 60 tRe"f 0.P. Ghai I'hle p. 584 & 7t'le p. 5621
Mental age
IQ= x 100
Chronological age
q
lQofthischild=' -x 100=60
15
90, Ans. is 'a' i.e., l\{i}d rnenta} retardation [l]'ef: A.P. Gkai 8'h/e p" 584 b Vhle p' 562)
Classifi eation of nnental netardation
o A child with lQ< 70 is called as mentally retarded.
51-70
36-50
21-35
92. Ans. is'a'i.e., Hypothyroidism [Rel O.P. Ghai 9th/e p. 585 6 Vh/e p. 562]
o Adequate care for prevention of hypothyoid state can prevent mental retardation in hypothyroidism.
r Down's syndrome and cerebral palsy are congenital causes of mental retardation and prevention of mental retardation
would be possible only by prvention of the syndrome itself.
93, Ans. is t' i.e., Cretinism IR.ef: O.P. Ghai 8'h/e p. 585 6 Vh/e p. 5621
o Cretinism is due to deflciency of Iodine, which can be preventable.
94. Ans. is t' i.e., 18 year fRef: Nelsan 18'h/e p. 38.2)
his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home
living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work,leisure,
health, and safety.
c) The onset is before age 18 years.
REYE',S SYNPROME
95. Ans. is 'b' i.e., RSV IRel Nelson 18th/e p, 1i94, 1695; CPDT 18th/e p. 663)
o Precipitating factors for Reye's syndrome : Salicylates (aspirin) and viral infection (influenza, echovirus-2, Aenovirus,
EBV vericella (HSV-3), coxsackievirus-A)
96. Ans. is 'd' i.e., Deep jaundice is present lRe! A.P. Ghai 9'hle p. 570 6 Vh/e p. 54i; Nelson 18th/e p. 1697; CPDT 18th/e
p.663]
o faundice is infrequent in Reye's syndrome -) Bilirubin is not raised.
Q7 Ans. is'a'i.e., Reye's Syndrome lRel Nelson l9thle Chap. j58l
98. Ans. is 'a'i.e., Aminoaciduria [Ref CPDT 18th/e p. 663]
Laboratory findings of Reye's syndrome
t Ilypoglycemia o Mixed respiratory alkalosis and metabolic acidosis
o llypoglycorrhoea-+ t CSF glrrot, o On liver biopsy -
. tpt t Microvesicular fatty changes
o t scor,
sGPT, LDH t Absence of inJlammation
t Normal alkaline phosphatase t Depleted glycogen stores
o Normal bilirubin o Kidney
. Hyperammonemia t Swelling and fatty degenration of PCT.
MISCELLANEOUS
99. Ans. is 'a' i.e., Hypothalamic hamartoma lRef lournal of neuropsychiatric dis,l
Laughing spells (also know as Gelastic seizure)
o Gelastic seizures are epileptic events characterizedby bouts oflaughter. Laughter-like vocalization is usually combined
It
with facial contraction in the form of a smile. Autonomic features such as flushing, tachycardia, and altered respiration
are widely recognized.
r Gelastic seizures have been associated classically with hypothalamic hamartomas.
lital o Hlpothalamic hamartomas are rare congenital lesions presenting with the classic triad ofgelastic epilepsy, precocious
puberty and developmental delay.
e Electrophysiological, radiological, and pathophysiological studies have confirmed the intrinsic epileptogenicity of
the hypothalamic hamartoma.
c Currently the most effective surgical approach is the trancallosal anterior interforniceal approach.
1 00. Ans. is'e' i.e", ffiqys &a* gero;ws *L*fr. dec*rebrate lesion
Decortieal Posture
o Also known as flexor posturing or Mummybaby
o Arms flexed/bent over chest, hand fisted, leg extended & rotated inward
o Damage to area in cerebral hemisphere, internal capsule, thalamus & upper part of brain.
r Decorticate posture is ominous sign of severe brain damage.
Decerebrate posture
r Also known as extensor posturing
o Extension of upper limb & lower limb (ELBOW EXTENDED)
for o Indicates brain stem damage (Below level of red nucleus)
o Decerebrate posture is more ominous than decortical posture
e, I 01. Ans" is'&' i"e., 18*24 m**ths lR$ Crey Anet&rry p- 1967
e Closure of anteriorfontanel -+ 1.5 years (between 1 to 2 years).
c Closure of posterior fontanel -+ 2-4 months.
f06. Ans. is ? i.e., Optic nerve glioma [Ref Nelson tfle p. 2a$l
o Optic glioma is one of the diagnostic criteria for neurofibromatosis tFpe-I.
lA7 . Ans. is ? i.e., )uvenile myelomonocytic leukernia facars in oncolagt p. j3l
lRef : Hemetopaietie growth
'Among leukemias, Neurofibromatosis - 1 is associated with nonlymphocytic leukemia particularly IMML and
my elo dy splastic sy n dro m e".
108' Ans' is 'b'i'e., Tuberous screrosis rRef: o.p. Ghai Yth/e p.
586 6 vh/e p. 564-565; Nerson lvh/e p. 2017, 20ls]
o Seizures' mental retardation and adenoma
sebaceum are seen together in Tirberous sclerosis.
109' Ans' is 'b'i'e', Ttrberous sclerosis
rRef a.p. Ghai 8'h/e p. 586 6 Vh/e p. 564; Crinicar paediatric 3dre p. 5391
' ff:::L"r:tT[:t and multiple hlpopigmented macules over
the back (ash leaf patch) suggest the diagnosis
of
I10. Ans. is 'a' i.e., Sturge weber syndrome
lRef: Roolc vh/e p. 39.20]
o This child has :
i) Seizure disorder
ii) vascular plaque along the ophthalmic and
maxillary divisions of trigeminal nerve
iii) Lesion presenting since birth and not chonging
i" ;";h;i"gy
o The diagnosis is sturge weber syndrome.
II l. Ans. is t, i.e., Vein of Galen malformation
veinofgalen.co.ukl
[Rel Ne/s on lgth/e p. 19gg; www.emedicine.cam/neuro/topic53g.htm;
wwu,.
I Midline intracranial mass with bruit on ausculation
and features of hydrocephalus and congestive
All point towards Vein of Galen Malformation. heart failure -
Vein of Galen Matforrnations(VGM)
r The vein of Galen is a large deep vein at the base of
the brain. It is located under the cerebral
drains the anterior and central regions ofthe hemispheres and
brain into the sinuses ofthe posterior cerebral
r vGM results from an aneurysmil malfurmation with fossa .
an arteriovenous shuntingof blood.vGM
heart failure in the newto tn resulting usually causes
ffi|"tO"t flom the decreased resistaic) and high blood flow in the
t include cerebral ischemic changes such as sfrokes or steal phenomena that resurt in progressi'e
f.tffiT:Srfndings
r The malformation may result in mass
effects, causing
malformation may cause obstruction of the rroqlelfve neurological impairment. Alternatively, the
cerebrospr,ii nr'ia (CSF) outflow arJ *.rr,
c Loud intracranial bruit maybeheard in hydrocephalus.
becaus" of tfr. utooJ turbulence in vGM.
a
o The vein of Galen abnormality is the
most freqr"nt oiii*nous malformation inneonates.
ll2. Ans. is'b'i.e., Vitamin K[Ref: Nelson l}th/e p.
712]
"Intravenous vitamin K should
be given before deliuery to all women receiving phenobarbitone or phenytoin
during pregnancy, to prevent intraventiicular
hemorrhage,,. '
Nelson
--
ANSWERS OF VARIOU5 OTHER EXAMINATIONS
I18. Ans. is 'a'i.e., Spastic [Ref : O.p, Ghai gth/e p" Sg2 & Vh/e
p. 559)
I19. Ans. is t' i.e., Sagittal suture fRef: O.p. Ghai 6th/e p. 602]
120. Ans. is 'c' i.e., papilloedem a
[Ref : O,p. Ghai gth/e p, SZ0 &. 7,/e p. 544)
l2l, Ans. is 't i.e,,Vit A [Rel Has been explained]
o It is a case of pseudotumor cerebri.
CHrt?,H,iar,8.,
122. Ans. is 'd' i.e., 25 mg% lRef: Meharban Singh 3'd/e p. 3161
r It is 15-40 mg%.
Premature
sit:.:r:
47 mga/o DayT
:i.si*+,,._-_-& =..=,.....jil1i,.;ti.i:il..i
123. Ans. is t' i.e., Dexamethasone [Rel O.P. Ghai 6th/e p. 520 6 7h/e p. 541]
r Dexamethasone is Preferred.
124. Ans. is t' i.e., Spina bifida lRef : William's Obstetrics 21"/e p. 982)
I25. Ans. is t'i.e., Cerebral abscess fRef: O.P. Ghai 8'h/e p. 573 6 Thle p. 410)
r Brain abscess is frequent complication ofcyanotic congenital heart disease, TOF.
t26. Ans. is t' i.e., MultifactoriallRef : Dutta 6'h/e p, 492; Hollend and Brew's 16th/e p. 216; Ghai 6'h/e p. 531)
ITI
xvx&y,&eotrc
mxsffiKm&K
1) Type I glycogenosis -+Glucose - 6 - phosphatase deficiency (Von Gierke disease)at ts, Nnnr).
ii) Type III
glycogenosis -+ Debranching enzyme d.efetrc'Ntnrt
lCori's disease/Forbe disease/limit dextrinosis)
iii) Type IV glycogenesis -+ Branching enzyme def (Anderson's
disease).
iv) Type VI glycogenosis -+ Liver phosphorylase def (Her,s disease(NEEr)).
Liver olycogenoses
Type-l Glycogen storage disease (Von Gierke,s disease)
o It is caused by deficiency of glucose-6-phosphatase in liver, kidney and intestinal mucosa.
o It is an autosomal recessiye disorder.
o Type la GSD is due to deficiency ofglucose-6-phosphatase and Type lb GSD is due to defect in translocase,which
transport glucose-6-phosphatase across microsomal membrane.
o It is charact etizedby hepatomegaly with recurrent hypoglycemia which is unresponsive to glucagon or epinephrine(Al
13' e3).
Other features are seizures, renomegaly@Gl01, Arse),short stature, hyperlipidemia(Ar 8s),
hyperuricemia(Ar Be),
and
e3).
lactic acidosis@ct
Liver glycogenoses
+
Hepatomegaly Cirrhosis
I
Y
Renomegaly No renomegaly Type IV (Anderson)
Hlpoglycemia unresponsive Hypoglycemia corrected (Abnormal glycogen
to glucagon/epinephrine by glucagon/epinephrine structure)
i
I
+
Vm Gierke's disease (\pe 1) Abnormal Normal
(Normal glycogen structure) glycogen structure glycogen strucfure
+ +
Tpe III (Cori/Forbe/limit dextrinosis) Tpe W (Hers)
Muscle glycogenoses
r Both present with exercise intolerance with muscle cramp(Pct "), myoglobinemia, myoglobinuria
PGt e8)
rhab domY olY sis( .
Galactosemia
o Galactosemia is a group of metabolic disorders which occurs due to defect in metabolism of galactose.
o There is inability to metabolise galactose which may be caused by deficiency of any of the following enzymes:
r) Galactose-l-phosphate uridyl transferase (most common)@Gt 01' AilMS eB).
01 )
111) Galactokinase(Pcl
o The defect in galactose metabolism results in accumulation of galactose-L-phosphate and galactical that are thought
to have direct toxic effect on the liver and other organs.
Clinical features
r Infant appears normal at birth, however, becomes symptomatic a few days to weeks after initiating galactose containing
feeds. Due to accumulation of galacticol, damage to nerve tissue and liver occurs which causes:-
t Hepatic parenchymal disease- jaundice, hepatomegaly and ascites@IlMse&). t Acidosis
t Mental retardation(PGl 01 ) t Seizures
: Vitreous hemorrhage : Splenomegaly
s Cataract : Hypoglycemia
o The accompanying GI symptoms are poor feedings, vomiting and diarrhoea.
o Fanconi syndrome (Aminoacidiuria, proteinuria, phosphaturia) may occur.
t There may be sepsisuttMseg),
c Glucagon has no effect on hypoglycemia of galactosemiaailMs 04)
.
Diagnosis
o Urine shows reducing sugarwhich can be detected by?uttstol
i) Benedicts reagentqllMs 10)
o After intake of fructose (e.g. sugar cance juicearlMs0t)) the child presents withhypoglycerniaGltMs 'r), jaundice,
hepatomegaly^ilMs0l), hemorrhage, vomiting andfructose (reducing sugar) in urine(urtrsott.
9lsoRDERS OF METABOLTSM OF pHENYLALAN|NE
Alhinism 1
I phenylalanine (_) I
-t
I hydrotylase <- Phenvleketonuria
l,-r t J
I
DOPA
l
Tyrosinase ' ,
Phenylacetic acid
I
+ I
Transaminase
Melanine I J
p-hydroxy phenylpyruvic acid Phenylacetyl glutamine
I p-hydroxyphenyl (-)
Tlrosinosis
It
I
pyruvrc ondase
Homogentisic acid
It Honogentisic (-)
.. .. <l- Alkaptonuria
iI
aud oxttl$e
Maleyl - acetoacetic acid
t
I
Phenylketonuria
r It is an autosomal recessive disorder due to deficiency of phenylalanine hydroxylassrarrr;.
o As a result phenylalanine is not metabolizedby hydroxylase, and metabolism
is shifted to alternative pathlway and
there is increased concentration of phenylalanine, phenylpyruyateal\o), phenylacetate
and phenyl-lactate.
r Because phenylalanine is not converted into tyrosine, tyrosine becomes an essential amino acidat 10).
o Classial phenylketonuria is due to deficiency of phenytalanine hydroxylasefaiio,. Milder form
may be caused by def -
ciencyofdihydrobiopterln reductase that produces tetrahydrobiopterin,a cofactorfor phenylalaninehydroxylase.
Clinical presentation
o The babies arc normal at birth but may present with vomiting. Gradually
mental retrardation6r07) andgrowth
retardation develop. Baby ha slight complexion withblue iris1llT).Other feature s arc
microcephaly(Arr7),rash, hlpertonia,
seizures, exaggerated tendon reflex(uesc o<) , wide spaced teeth, enamel hypoplasia(upsc oq)
andhlperactivity.
o There is musty or mousy sf,6svNnr7 'uee) of urine and other body secretions
due to presence of phenylketones.
r Pregnant females with increased pheynlalanine (maternal phenylketonuria) may cause mental retardation,
mi c r o c eph aly,' gro w th r et ar d ati o n an d CHD s in b ab iesLilM s e s)
.
Diagnosis
r Elevated phenylalanine levels
o Elevated blood tyrosine level
o Presence of urinary metabolites of phenylalanine
o Guthrie's Test -+ It detects the presence of phenylalanine in serum
o FeCl. -> lt detects the presence of phenylalanine in urine. FeCI, is added to
patients urine. If it contains phenylalanine,
it will turn green&Enr).
c 2-4Dinitrophenol hydrazine -+ gives yellow precipitate with old urine.
Treatment
t Administration of low phenylalanine is the mainstay of treatment (but phenylalanine should not be completely
restricted
as it is necessary for growthat00)). Tetrahydrobiopterin can be used in milder form.
Alkaptonuria
o It is an autosomal recessive disorder. It is due to deficiency of enzyme homogentisic oxiilase. Large amount of
homogentisic acid is accumulated in body and excreted in urine.
Clinical manifestations
r Clinical features consist of -
i) Ochronosis -+ Dark spot on the sclera or ear cartilage.
ii) Arthritis -+ Spine, hip, knee.
r But both these occur in adulthood.
t The only sign of disease in children is a blackening of urine on standingluoz). This is caused by oxidation and
polymerization of homogentisic acid.
r High incidences of heart disease (mitral and aortic valr,rrlitis, calcification of heart valves, MI) have been noted.
o Inthedegradationo fessentialbranchedchaina*)ooriar(Valine,leucine,isoleucine),theintermediatemetabolites
are all organic acids.
r Thus deficiency of any enzyme (except transaminase) in the metabolism of these amino acids cause accumulation of
organic acidbefore the enzlrmatic block.
r Therefore, these disorders are called organic acedimia/organic aciduria.
r Important types of organic acidemia are :-
i) Methylmalonicacidemia
ii) Propionic acidemia
i11) Isoavleric acidemia
iv) Maple syrup urine disease
v) Qombined (multiple) carboxylase deficiency
vi) Glutaric acidemia
vii) Ketothiolas e deficiency
o Most of the clinical features of these disorder are same and include : refusal to feed, v otnitinglArtMs0o), neurological damage
(mental retardation, seizuresarlMs00), lethargy), metabolic acidosis (lactic acidosisarlMs00)),hyperammonemiaurrMs0o)
developmental delay, neutropenia and hypoglycemia.
o However, some manifestations are specific and help in the diagnosis.
Note :- (Irea qtcel m4tme defects also present with features of organic aciduria, but there is llyperammonemia wilhout
. kaoacidosis and there is no lactic acidosis.
Alkaplenuna
r It is an autosomal recessive disorder. It is due to deficiency of enzyme homogentisic oxidase, Large amount of
homogentisic acid is accwulated in body and excreted in urine.
Clinlcal manifestations
r Clinical features consist of -
Note :- Urea qtcel enqtme defects ulso present with features of organic aciduriu, but there is Hyperammonemia without
ketoacidosis und there is no lactic acidosis.
Crlrprrii
Alkaptonuria
r It is an autosomal recessive disorder. It is due to deflciency of enzyme homogentisic oxidase. Large amount of
homogentisic etcid is accumulated in body and excreted in urine.
Clinicai manifestations
r Clinical features consist of -
i) Ochronosis -) Dark spot on the sclera or ear cartilage.
ii) Arthritis ) Spine, hip, knee.
r But both these occur in adulthood.
o The only sign af disease in children is a blackening of urine on standing!'ar 07). This is caused by oxidation and
polymerization of homoqentisic acid.
r High incidences of heart disease (mitral and aortic valvulitis, calcification of heart valves, MI) have been noted.
r In the degradatiorr of essential branched chain amino acids (Valine,leucine, isoleucine),the intermeiiiate metabolites
are all organic acids.
r Thus deficiency of any enzyme (except transaminase) in the metabolism of these amino acids caLtse accumulation of
crganic acicibelore the enzymaiic block.
r Therefore, these disorders are called organic acedimia/organic aciduria.
o Important tlpes of organic acidemia are :-
r) Methyhnalonic acidemia
ii) Propionicacirlemia
lli) Iso avleric acidemia
iv) Maple syrup urine disease
v) Combined (multiple) carboxylase deficiency
vI) Glutaric acidemia
vii) Ketothiolase ilefciency
r Most of the clinical features of these disorder are same and include : refusal to feed , vomitinglAilMs 00),
neurological damage
(mental retardation, lethargy), metabolic acidosis (lactic acidosisGIIMS00)),hyperammonemia(AIIM|00)
seizures(AIIM9o0l,
developmental cielay, neutropenia and hlpoglycemia.
r However, some manifestations are specific and help in the diagnosis.
J
tlInt,t99t
t Methyl melonic acidemia deltcrcncy
Acy I- C oA de hy- dr ogen as e Urea cycel defect
c Ketothiolas
deficiency
3-hydron 3-merhyl glutaric
ac idu ria (glfi ar i c aci d emi a)
Note :- Ureu cycel enq)me defects also present with features of organic aciduria, but there is Hyperammonemia without
ketoucidosis and there is no lactic acidosis.
Multiple rarboxylase defi ciency
o It is an autosomal recessive disease due to deficiency
of holocarboxylase synthase (required for synthesis of a-
carboxylases) or biotinidase (required for biotin metabolism,
a coenzyme for all carboxylases).
r Thus there is functional deficienc y of multiple carboxylases (acetyl coA carboxylase,
puruvate carboxylase, propionrl
CoA carborylase, methyl crotonyl CoA carborylase).
r child present with refusal to feed, vomiting, lactic acidosis(ArlMsee),hlpoglycemi a, seizuresarruseer,
failure to thrir-e.
hypotonia, generalized rash with exfoliatipn (exfoliative dermatitis)(ArrMsee)
arrddevelopmental delay.
o The urine has peculiar smell of tomcat urine.
o Biotinidase deficiency is also associated with features
of biotin deficiency (i.e. dermatitis, ataxia, and SNHL), in
addition to above features.
e Diagnosis is confirmed by enzyme assay in lymphocytes.
o The mainstay of treatment is biotin administration(Ar 07)
.
C'I{n$.T,E,lii
organelles become large and numerous enough to interfere with normal cell functions, giving rise to the lysosomal
storage disorders.
(Ar 13)
o All lysosomal disorders are hutosomal recessive' except for Hunter's syndrome and Fabry's disease, which are
X-linked recessive. Thus Hunter's syndrome and Fabry's disease affect only malesqttMs 08) .
Sphingolipidoses
e GM1, gangliosidosis p-gaiactosidase GMl ganglioside
r GM2 gangtiosidosis
l) Tay-sachs disease
ii) Sandoffdisease
Gtycogenosis Type II
o Pompe disease
Mucopolysaccharidoses
o MPSIH(Hurlefl a-L-Iduronidase Dermatan sulfate
c MPS ll (Hunter)
Iduronate sulfatase Heparan sulfate
r Niemann-Pickdisease presents with hepatosplenomegaly, and delayed milestones. Type A involves CNS and Tlpe B
involves lungs. There may be childhood cholelithiosis(A[Ms e8). Histiocltes shows PAS positive diastase resistan ceAilMs
inclusion which on microscopy shows concentric or parrallel lamellar arrangement@ItMs 04) .
0a)
r Fabry Disease presents with angiokeratomas and neuropathic pain. Lipid inclusions with "Maltese crosses" are seen
in urinary sediment.
r Metachromatic leukodystrophy presents with feature s of white matter degeneration. There is mental retardation(rN
03),
muscle wasting, decreasedtendonreflexes(rNost, optic atrophy(rN03) and genu recurvatum. Inclusion bodies are
positive for PAS and alacian blue.
r Krabbe disease presents with optic atrophy, opisthotonus, seizures, with radiological increased densilv in thalamusarMs
07)andlow density in areas in white matter.
v) Others: Coombs negative hemoftic anemiaullMser), fanconi syndrome (amino aciduria) and cardiomyopathy.
Diagnosis
c The gold standard for diagnosis is liver biopsy with quantitative copper assay -) concentration of copper in a
liver biopsy sample > 200 mglgdry weight.
o Other tests qre -
ii) KF rings@Nar'urct
ll1) urine colp)er excretion -+ 13, Ar lo)
increased@NB
iv) DNA Haplotlpe analysis.
Leukodvstroohv
e Leukodystrophy refers to progressive degeneration of the white matter of the brain due to imperfect growth or
development of the myelin sheath, the fatty covering that acts as an insulator around nerve fibre.
I Myelin which lends its color to the white matter of the brain, is a complex substance made up of at least ten different
chemicals.
e The leucodystrophy are a group of disorders that are caused by genetic defects in how myelin produces or
metabolizes these chemicals.
o Each of the leucodystrophies in the result of a defect in the gene that controls one (and only one) of the chemicals.
Cxunurla
r Metabolic disorder of autosomal recessive inheritance(irrs).
r Defect in transport of cystine and some other aminoacid across renal tubular cell & interstitial cellar
15)
e Selective increase renal clearance of cystine and other basic aminoacid in urine.
r High urinary cystine leads to radio - opaque hexagonal crystal(Ar Is).
c Crystal is soluble in alkali.
o Treatment -+ formation of stone can be reduced by irlkalization of urine.
.-
.. , ...
:l:i
- ,,,. -,...,r' '..-. , -l
o CT scan in Krabbe's disease disease shows increased density in thalamus(/I.MS07) and low density areas in white
matter.
r CT scan in Metachromatic leukodystrophy shows diffuse symmetrical attenuation of cerebellar and cerebral white
ic
matter.
r CT scan in Alexander's disease shows degeneration of white matter, most prominant in frontal lobes.
r CT scan in Canavan's disease shows diffuse white matter degeneration mainly in cerebral hemisphere'
7. Hyperoxaluria - Pyridoxine
8. Tyrosinemia - NTBC, Liver transplantation
Slunu{ta rs''
o Metabolic disorder of autosomal recessive inheritance(Ar
Is)
o f)efect in transport of cystine and some other aminoacid across renal tubular cell & interstitial cellar
c Selective increase renal clearance of cystine and other basic aminoacid in urine'
rs)'
r High urinary cystine leads to radio - opaque hexagonal crystal(Ai
c Crystai is soluble in alkalfl
c Treatment -) formation of stone can be reduced by blkalization of urine.
(type-'l
a Recurrent hypoglycemia attack with hepatomegaly tvon-Gierke's disease
a Hypoglycemianotrespantdingtoepinepi'hrine/glucogon:von-Gierke'sdisease'
a Not a liver glycogenosis: Pompe's disease (type-ll glycogenosis)'
a Giycigen staragediseases,with predomlnant musle involvement: Type ll, V Vll.
a Glycogen storage diseases with predominant liver involvement :lype l, lll, lV Vl, lX, Xl.
'
a Muscle,cr*nps with'myagilobinuna : Mc Ar.dlet'dlsease {!ypeV glycogenosis).
(type ll glycogenosis)'
o Coarse facies, hepatosplenomegaty and tatl QRS complex : Pompe's diseae
a Vo.mitifig, distended abdamen, diarrhea and reducing sugar in urine in a neonate : Galactosemia' :
ln Wilson's diseose : Reduced ceruloplasmin, increased serum copper, increased urinary excetion of coppel increased liver copper.
Hartnup diseose is characterized by: Massive aminoaciduria of multiple neutral amino acid without increase in neutral amino acid
in blood.
III
QUESTIONS
3 LYCOGEN STORAGE DISEASE itive forbenedicts test for reducing substance. The
substance in urine is - (AILMS Nov 10)
All are liver glycogenosis except- (NEET Dec.12 Pattern) a) Sucrose b) Glucose
a) Von Girke disease c) Galactose d) Fructose
b) Hers disease 9. An 8 days old child presents with yellow selera,
c) Tlpe III glycogenosis whitish stool and turmeric colour urine on 3rd day
d) Pompes disease of septicemia on broad spectrum antiboitics, the
Glycogen storage disease with predominant muscle likely diagnosis is - (AIIMS lune 98)
r.lation
of,insid, descement membrane. Most likely diagnosis is - b) Methyi-malonic-acidemia
_: f I
.Vor,. 14 pafter ; Fabry's disease (Al o1) c) Cystathioninuria
: ) Wilson's disease d) Xanthurenic aciduria
;) Glycogen storaSe disease 43. Cystinuria is characterised by - (ALLMS 83)
d) Acute rheumatic fever a) Generalised aminoaciduria
:
True about wilson's disease - -(AI 10) b) Systemic acidosis
a5e _
a) Increase in urinary copper and increased serum c) Deposition of cystine crystals in Renal tubular cells
::.., Dec.l3 pafteh:
ceruloplasmin and copper d) Recurrent urinary calculi
:lnidase
b) Increased serum ceruloplasmin levels with 44. Cloudycornea is a feature of- (MH u)
ise
increased urinary copper a) Hurlert disease
: ILTIS t4q,08t c) Elevated hepatic copper leVel and increased serum b) Morquiot disease
ceruloplasmin levels c) Maroteaux Lomy disease
d) Increased in urinary copper and decreased serum d) All of the above
ceruloplasmin
45. All are seen in metachromatic leukedystrophy
True about Wilsons disease is? (cET Aug 13 Pattern)
except-
l-rlre re- a) Increased serum ceruloplasmin a) Mental retardation (IN 03)
b) Decreased liver copper b) Optic atrophy
;. 06, Nov
03) c) Increased urinary copper excretion c) Decerebrate posture
d) Decreased urine copper excretion d) Exaggerated tendon reflexes
W"ilson disease all are true lxcept - 46. Which one of the following is not a feature of
a) AR (All India Dec15 Pattern) Phenylketonuria? (uPSCo4)
b) KF ring a) Severe mental retardation
rbdorn_ c) Raised copper level b) Reduced tendon reflexes
rj calcifr- d) Raised ceruloplasmin level c) Enamel hlpoplasia
rsi d) Vomiting in early infancy
,r.l 10, 09)
M!SCELLANEOUS 47. Guthrie test can be used for the diagnosis of -
a) Tyrosinemia (UPSC t la)
18. Features ofcystinuria are - r4ll lndia Decl5 Pattern) b) Galactosemia
a) Impaired proximal tubular reabsorption of cystin c) Alkaptonuria
b) Autosomal recessive d) Phenylketonuria
c) Recurrent renal stone 48. Which is nnt a feature of wilsons disease in a child-
d) All of above a) Fanconi syndrome (AtrMS e1)
sYn- 19. Features ofRefsum disease are all except - b) Sensory changes
't.v 0g)
a) Ataxia (All India Decl5 Pattern) c) Hemolltic anemia
b) CCF d) Chronic active hepatitis
c) Ichthiois 49" Which glycogen storage disease doesrt't a{fect
d) Retinitis pigmentosa muscles ? (APPG 08)
-10. 2-5 year old child with DM, target HbA, C is - a) type I
. (All lndia Decl5 Pattern) b) type 2
a) <8% b) <7% c) tlpe 3
t7) c) <9 d) <60/o
o/o
d) tlpe 4
50. Massive arninoaciduria without a corresponding
increase in plasma amino acid level is characteristic
QUESTIONS OF VARIOUS OTHER EXAMINA. of which one of,the following diseases ?
TIONS a) Homocystinuria (UPSC-| 08)
b) Hartnup disease
41. Large doses ofpyridoxine are ofvalue in some cases c) Tyrosinemia
of- (PGr 7e,81, 87) d) Maple syrup urine disease
a) Phenylketonuria
rrtr
ANSWERS
GLYCOGEN STORAGE DISEASES
1. Ans. is 'd' i.e., Pompes disease [Ref : Nelson tSth/e p. 60j, 604]
J. Ans. is 'l i.e., Von Girke's disease lRel See above explanation)
r Amongst the given options only Von Girke's disease presents with hepatomegaly and hlpoglycemia.
'A diagnosis of type I glycogen storage disease (Von Girke's disease) should be suspected whenever there is
hepatomegaly withlrypoglycemia that is unresponsive to glucagon or epinephrine".
4. Ans. is 'd i.e., Von Gierke disease [Ref : Nelson 18th/e p. 603, 604, 605; Harison lVh/e p. 2458; O.P. Ghai 9th/e p. 657
dr Vh/e p. 6361
Liver glycogenoses (Liver glycogen storage disease)
Presence of hepatomegaly and hypoglycemia alongwith absence of an increase in blood glucose upon administration
of glucagon suggets the diagnosis ofVon Gierke disease.
In Von Gierke disease, administration of glucagon or epinephrin results in little or no rise in blood glucose.
Mc Ardle disease is a Muscle glycogenoses and does not characteristically present with hepatomegaly and
hypoglycemia. Mc Ardle\ disease can hence be excluded.
Cori and Forbes are liver glycogenoses grouped under glycogen storage disease type lll. Although they present
with hepatomegaly and hypoglycemia, the administration of glucagon in these conditions provokes a normal
increase in blood glucose (Nelson 18th/e 605). The child in question does not show an improvement in hypoglycemia
afier administration of glucagon and hence is unlikely to have Cori or Forbe\ type III GSD.
McArdle's disease
o This is due to deficiency of muscle phosphorylase,
o Lack of this enzgne limits muscle ATP generation by glycogenolysis, results in glycogen occumulation.
o Clinical manifestions -
r Develop in late childhood or adult
s Exercise intolerance with muscle cramp
e It is important to note that two types of activity tend to cause symptoms:
i) Briefexercise ofgreat intensity such as sprinting
ii) Less intense but sustained activity, such as climbing stairs or walking uphill.
r Moderate exercise, such as walking on level ground, can be performed by most patients for long periods.
r Many patients experience a characteristtc "second wind" phenomenon -+ If they slow down briefly at the lst
apperance of muscle pain, they can resume exercise with more ease.
o There may be exercise - induced myoglobinuria secondary to rhabdomyolysis.
o This can lead to acuterenalfailure.
o Serum creatine kinase is elevated.
Ans. is'H i.e., Von Gierke's disease lRef : Nelson 18th/e p. 603, 604)
o A11 the given options are liver glycogenoses which present with hepatomegaly and hypoglycemia.
o Among the given options renomegaly is a feature of Von Gierke's disease.
e One important fact require specific mention. In type-III (Cori's) and tlpe-IV (Anderson's) glycogenoses, deposited
glycogen has abnormal structure. Where as in other glycogenoses, glycogen has normal structure. Thus option c
and d can be exciuded easily as glycogen deposited in question has normal structure (further these two do not have
renomegaly).
c Hert disease (t1pe-Vl) has deposition of glycogen with normal structure, but there is no renomegaly.
Ans. is 'b' i.e., Glycogen storage disease type I[ lRef: Nelsoru 18th/e p. 6A7)
a Hepatosplenomegaly, characteristics E.C.G. findings and coarse facies are seen in Glycogen storage Type II or
pompet ds.
o Hurler's and Hunter syndrome are mucopolysaccharidosis that presents with hepatomegaly and coarse facies, bul
characteristic ECG pattern of Pompes disease clinches the diagnosis in favour of Pompe's disease.
8. A.ns. is 'c' i.e,, Galactose {Ref: I'{elsan 18thle p. 609-61A; O.F. Ghai B'h/e p. 656 6 Vh/e p. 634, 6i5l
a Characteristic symptom i.e., vomiting, distended abdomen and diarrhea along with the presence of reducing substance in
the urine suggests the diagnosis of galactosemia
9, Ans. is t'i.e., Galactose l-4 phosphatase uridyl transferase deficiency lRef: A.P. Ghai E'hle p. 655 6 7h/e p.
534-535; Nelsan 78th/e, p. 609, 6101
e Feature of conjugated bilirubinemia on the 3rd day accompanied by sepsis in a neonate suggests diagnosis of Ga-
lactosemia.
e Inabilitytometabolisegalactoseoccursingalactosemiawhichmaybecausedbydeficiencyofgalactose-1-phosphate
uridyl transferase, UDP-Galactose-4-Epimerase and galactokinase.
e Out of three, most common is Galactose = l-phosphate uridyl transferase deficiency.
ob'
10. Ans. is i.e., Aldolase E IRel' Lippincat's Biachewistry 2dle p. 128; Nelsan tr8'h/e p. 511)
c Symptoms of hypoglycemia, hepatomegaly develping after ingestion of excessive fructose intake (sugar cane juice
contains the major dietary source offructose-Sucrose suggest the diagnosis ofhereditary fructose intolerance.
11. Ans. is 'd' i.e., Multiple Carboxylase Deficiency fRef: Nelson 18th/e p. 6141
o The patient in question has symptoms of organic aciduria. Among the given options Propionic aciduria and multiple
carboxylase deflciency are organic aciduria. But skin manifestations are found in multiple carboxylase deficiency (not
in propionic acidemia).
o Urea cycle enzyme defect also presents with clinical features similar to organic aciduria. But in urea cycle defect there
is no ketoacidosis (patient in question has increased ketone bodies, i.e. ketoacidosis).
Acidosis No acidosis
I
I
+
O rg an i c ac i d e m i u,/ucida r i a (Irea cycle defectl
13. Ans' is'H i.e., urea cycle enzyme deficiency lRef; Ghai vhre p. 6jj, 6i2, 62s)
o There is hlperammonemia without any acidosis -+ urea
cycre defect.
19. Ans" is 'H i.e., Phenyl ketonuria [Re/: o..e Ghai 8,h/e p.
652 & vh/e p. 629; Nelson rrth/e p. 5291
20. Ans' is'd i'e', Microcephaly, mental retardation congenital heart
p. 609; Nelsan l8thle p.
disease tRef o.p. Ghai grh/e p. 652 6 @le
5i1)
children born to phenyl ketonuria mothers have following features (Note
: mother is phenyleketonuric not child)
o Mental retardation t Growth retardation
t Microcephall c CongenLtal heart disease
't') Ans. is 'a'i.e., Maple Syrup urine disease [Re/; Harlter 26h/e p. 259; Nekon lg,h/e p. S4A, 54ll
r Maple syrup urine disease (MSUD) is d/t defect in enzyme - a-keto
acid dehydrogenase.
r It is a mitochondrial, enzyme complex consisting of
t a-ketoacid decarboxylase . Dihydrolipoyr rlehydrogenase and s Transacyrase
23. Ans. is'H i.e., Blue [Ref: Nelson l#le p. 54Il
o Ferric chloride gives navy blue colourwith the patients urine.
r
I
Ans. is 'a'i"e., Alkaptonuria [Re/; Nelson trth/e p. 534; O.p. Ghai B,h/e p. 653 & 7h/e p.
Cnerrrn 9 .Metubolk*iioi r
630; Lippincott 3d/e p. 222\
o Theonlysignofdiseaseinchildrenisablackeningofurineonstanding.Thisiscausedbyoxidationandpoll.n-rerization
of homogentisic acid.
Ans. is U'i.e., cerebroside [Ref : a.p. Gkai Bth/e p, 661 6 vh/e p. 6jg; Nelsaru la,t/e p, Sgs, sg6]
c In Gaucher's diseases, there is accumulation of cerebroside (glucocerebroside, i.e.
glucosylceramide).
-n. Ans. is 'b'i.e., Hexosaminidase [fiel l,lelsan l9th/e p, p. 638l
595, 596; A.F. Ghai Vt,/e
o The enzyme deficient in Tay-sach disease is Hexosaminidase-A (i.e., cx-subunit
of Hexosaminidase)
18. Ans. is 'd' i.e., Gaucher's disease [Ref: Netsan tgth/t p. 5g5, 5961
'Enzyme Reltlacement therapy is the treatment of choice
for significantly afltected patients - Harrison
'cerezyme' a recambinantly produced acid p grucosidase is being currently used.,
29. Ans. is 'b'i.e., tr{oXman disease IRef : Netson llthle p. 23s6, z3sn
e Hepatosplenomegaly, jaundice, abdominai distension and anemia, along with adrenal
calcification is the characteristic
presentation of Wolman's disease.
LEUCOEYSTROPHY
Canavan's disease
l Autosomal recessive disorder
c Caused due to deliciency of the enzyrne N-Aspertoacylase.
e This leads to accumulation of N-Acetyl aspartic acid in brain and urine.
o It is characterized. by the clinical traid of -> Hypotonia, Head lag, Macrocephaly.
31. Ans. is t' i.e., Krabbe's disease fRef: I,{etson lgtt,/e p. 25021
Krabbek disease
W!LsON'S DISEASE
36. Ans. is t'i.e., Increased urinary copper excretion lRef: See above explanationl
-7,/ . Ans. is'd'i.e., Raised ceruloplasmin level lRef: Nelson l\th/e ch. 354.21
MISCELLANEOUS
Refsum disease
r Peroxisomal disorder.
r Defective enzyme - phltonoyl CoA oxidase.
r Clinical feature includes :- Impaired vision (retinitis pigmentosa), Icthyosis, Peripheral neuropathy & Ataxia.
40. Ans. is t' i.e., < 9o/o fRef: Nelson 18'h/e ch. 590)
o In children below 5 year of age, target HBA,C is 7 .5 - 9o/o.
180-250 7,s-9,0
42. Ans. is 'b' i.e., Methyl-malonic acidem ia lRef: Nelson lfth/e p. 2202]
o For methyl malonic acidemia, Vit B12 is given.
43. Ans. is t' i.e., Recurrent urinary caliculi lRef: Nelson 18th/e p. 22021
Cystinuria
o It is an autosomal recessive disorder.
o The disease is caused by a defective high afinity transporter for L-cystine and diabasic amioacids present in the
proximal tubules.
o It is characterizeby recurrent kidney stone formation.
44.Ansist'i.e.,AlloftheabovelRef:A'P'Ghai9'hlep'661("7h/ep'63fl
+
Hurler/lH
Scheie's/l5
+
Hunter/ll
5anfliPo/itl
+
Morquio/lV
+
Maroteaux-LamY/Vl
+
Sity//ll
rvhich
.d, i.e., Exaggerated tendon reflexes [Rel; o.P. Ghai 8'h/e p. 662 & Thle p' 639, 561; Nelson 77'h/e p'
;15. Ans. is
2Ai2l
Ghai rth/e p' 652 d? Thle p' 629; Nelson 17h/e P. 399,40t)7
46. Ans. is.H i.e., Reduced tendon reflexes [Rel:"o"P'
e Reflexes are hlPeractive'
47. Ans.is1d'i.e.,Phenylketonuria[RefA.P'Ghai8'h/ep'652drVh/ep'6291
Sthle p' 320-321 & 7hle p' 6411
48. Ans. is'H i.e., Sensory changes tRef O'P' Ghai
Clinical features of wilson disease in children o KF ring
rr# o Acute or chronic liverdisease
i.#
::.:*** o Psychiatric disturbancesparkinsonism, 'e Hemolytic anemia
rta
lrc
cF{rlffie€ffiffire
t:rlY T& ,f laT.} f
AU rVtugq.*
r Common childhood tumors are leukemias (AML, ALLlrea 08), lymphoma, rhabdomyosarcom&@'tr), brain
tumors@Gtot), neuroblastoma(Pct08), bone tumors, Wilm's tumors@G[08) and retinoblastomaNEEr), Most of these tumors
occtr in first 4rrr6rr*iu't, except for lymphoma which is uncommofl before 14 years@NB 12) .
t Most common childhood tumor is leukemia^'07' ee), especially acute lymphoblastic ieukemia.
c Second most common childhood tumors and most common solid childhood tumors are brain tumors.
t Third most common tumor of children is lymphoma.
o Fourth most common tumor of children and most common tumot in infancy is neuroblastomaqllMse3).
Fifth most common tumor of chiidren is Wilm\ tumor.
"
o Most common tumor infetus and neonate is sacrococcygeal teratoma6ll2),
: Most common abdominal tumor in children is neuroblastoma.
ts).
c Most common GI malignancy in children is lymphoma{et
c Acute lymphoblastic leukemia (ALL) encompasses a group of neoplasms composed of immature, precursor B (Pre-B)
or T (Pre-T) lymphocytes referred to as lymphoblast.
r Majority (85%) of all ALLs are precursor B-cell tumsls@crra) 1[ru1 tlpically manifest as childhood "leukemia'' with
extensive bone marrow and variable peripheral blood involvement. The less common precursor T-cell ALLs tend
to present in adolescent males as "lymphomas" often with thymic involvement@Ies'e4).
r Peak incidence of Pre B-cell ALL is evident between 3-5 years and ALL is the most common childhood cancer. Pre
T-cell ALL occurs in adolescent male.
c Tumor cells (lymphoblasts) contain cltoplasmic aggregates of periodic acid schiff (PAS) positive meterialare3).
Clinical rnanifestations of ALL
r Symptoms related to depression of normal marrow function.
r An accumulation of neoplastic blast cells in the bone marrow suppresses normal hematopoisis by physical crowding
and competition for growth factors. This results in : -
c Anemiaqlli) -+ Fatigue, Pallorat oEt
o Neutropenia(At") -+ Infection, intermittentfeyeratq4)
o Thrombocytopenia -+ Bleeding, p etechiaeql 0o),
ecchgnoses, epistaxis.
t These are the most common sign dr symptoms,
Cellular <lassifcation
r French-American-British (FAB) system divides ALL into three morphological subtypes :-
1) L,lymphoblasts
t It is most cammon type and has better prognosis. Cells have scanty cltoplasm and inconspicuous nuclei.
2) Lr lymphoblasts
I Cells arelarge and more pleomorphic in size with abundant cl,toplasm and prominant nucleus.
3) Lr lymphoblasts
r It is least common type. It is identical to Burkitt's lymphoma, i.e. Mature B-cellsat0T).
Prognostic factors in ALI-
fyp.. Ll l111S.,lmNr:rsa..
Cytogenetics Hlperploidy{Dr: ts) Hypoploid/DNB 12' AI a7' AtlMS 02)
> 50 X l0e/L(A,
tt D\B 12 \tt4sae'02)
T{,C 'a I 26.x1{Ot/lir}r3
15}
(-) (+)
LprphadenoPathY,
HepatosplenomegalY
{..}. . " - .'.. (+)
ldaniilgeal intolv€meet',, ,.
(-) (r)
Mediastinal mass
Early,ple'' $...ce
p7s -'8,:TslfAt!71'. . : :: l
Treatntent ofALL
betwe en 2 and 2% years'
c Treatment of ALL is divided 4 stages. The total duration of treatment ranges
1. Induction of remission
is used to attain remision, i.e., to eradicate the
leukemic cells fiom bone marrorv'
r Induction therapy s4)
Anthracycline. Duration of therap,v
r Drugs used are ) Vincristine\t ts), preilnisolone, L - Asparginase(Ales. ,
is 4-6 weeks. .
1 r-hl€ *1"r.,-ny
i.iiJ +!r!4."r/
3. Intensification
into remission, the next step is to intensify the therapy
fcr a short period"
x Ifthe Patient goes
. Epipodophyllotoxin' Cyclophosphamide\I,o), Cytarabirct"
r Drugs used are -) Methotrexgte, L Asparginase,
4. Maintenance theraPY
atrd
on maintenance threrapy to maintaine the remission state
After consolidation, the patient is generally put
a
r
prevent re[aPse'
Predruisolane, Vincrist;ine,Duration of maintenace therapy
x Drugs used ar e - > 6-mer captopurine' Methotrexate'
is 2-2.5 vears.
(2 qnd testis'
lete remission ore t Bone marrow tmc), CNS mclNEEt)
* The common sites of t
Etiology of AML
o AML has bee associated with Down Synd.romeql0T'Ke/ata14), Klinefelter syndrome\ror), Patau syndrome\I0T), Fanconi
anemia, Bloom syndrome(Kerata04), Ataxia telangiectasia(Kerata04), and Kostman syndrome. Other etiological agents are
radiation, chemicals (benzene, ethylene oxide), and drugs (alkylating agentsat 1s), topoisomerase II inhibitors).
s Neonates with down syndrome may develop'transient myeloprolifurative disorder'6r04) which may mimic AML.
elassification of AML
* FAB classification divides AML into eight types Mo to Mr.
* This scheme takes into account : -
i) The degree of maturation (M0 to M3)
i, The lineage of leukemic blast (M4 to M7).
;
]
Nonspecific esterase (+) ve{il07) l Monoblastic
Ans.isU'i,e"; M4AML
o Gingival hyperplasia is more common in M4 & M5 AML.
Treatrnent of AML
c The most commonly used chemotherapy regimen is combinatron of cytarabine (cytosine arabinoside) and anthro-
cycline (Doxorubian or daunorubicin).3-4 cycles are given.
o Patients who fails to attain complete remission after two induction courses should immediately procee dto an allogenic
stem cell transplant (SCT).
o DOC far Promyelocytic AML is Tretinon (retinoic acid).
Treatment of relapse
r Patients etigible for allogenic SCTshould receive transplant expeditously at the first sign ofrelapse.
r If SCT is not possible :
4) Cltogenetics : - AML prognosis is currently separated into three broad categories based on cltogenic results:-
l) Favourable: inv (761{dnmsozt, t (15:17), t (8:21).
ii) lntermediate: Normal(ArMsoz), 1 8, + 2L, +22, del (7q), del (9q), Abnormal 11q23.
il) Unfavorable: - Monosomy 5 or 76ItMs07), complexes with > 5 chromosomes involved, del (5q), abnormal 3q,
abnormal 17p.
5) Type : Mo, M6, & M7 types have poor prognosis (Mr, Mr(o"t), M. are associated with good prognosis).
BADPROGNOSIS
hI&EJROBLASTOMA
r Neuroblastoma is a malignant neuroendocrine tumor arising from any neural crest element of s1mpathetic autonomic
nervous systern(ruto).
r It is the most common malignancy of infancyqtqs), the most common abdominal cancer in childrenAltMs e7' AI e6' e4),
ls' 0e).
and most comrnon extracranial solid tumor of childhb/odur
10'oB))' ott1,
e Sites of involvement are adrenal medulla (mast commorr(Pcl pelvis, cervical area (neck(o"' posterior
o8),
mediastinumlea and paravertebral retroperitoneum.
e*inical features
o Clinical features are :-
l) Due to mass: Abdominal (flank) mass@EEr'A1e4) (most common presentation(Pcre3)), often crosses midline and
displaces the kidney downwords without comptressing collecting system@G108); cervical tumor may cause Horner
syndrome.
ii) Due to metastasis: Orbital proptosis@Gles), Raccoan eyes (wllateral or bilateral periorbital or eyelid ecchymosis),
fever, bone painar e4)
in skull with sutural diastasisat es' rcr rs), spinal cord compr'ession.
, lytic lesions
1i1) Due to catecholamine secretion by tumor: Tachycardia, headache, sweatindNEEr), episodic diarrhea@EEr'Ate4),
JlushinglAlea).
iv) (Incommonfeatures: Ogtsoclonus /opsotnyoclonusQcres), myastenia gravis.
r Metastasis is present in 6U-70o/oar0e) atthe time of diagnosis. Commonest site of metastasis is skeletal system@Gtqs) and
06' 02).
neuroblastoma is the most common childhood malignancy metastasizes to bonear Other sites of lnvolvement
are liver, lymph nodes and skin, Lung metastasis is uncommonqr 0e)
. Encasement of abdominal aorta and IVC may
i
occllr6los,Pclos).
c Bilateral periorbital ecchymosis ip metastatic neuroblastoma -+'Raccoan eye$'.
e It is the most common malignant tumor of kidney in children Most cases are sporadic. l-2o/o cases may have family
history.
r Familial predisposition is inherited in autosomal dominant manner. Mutation occurs inWilms tumor (WT-1) gene
on chromosome-7761"), CTNNB-1 gene encoding for protooncogene beta-catenin, and p53 gene.
r Wilms tumor is associated with three distinct syndromes :-
1) WAGRsyndrom e:Wilmt twor,Aniridia@Gl08'AilMse7'AIea), Genitourinary abnormalities@clq8) (includingllorse-
shoe kiilney(uPsc I0), Mental Retardation.
2) Beckwith Wiedemann syndromeqllMseT'AI e') : Enlargment of body organs (e,g. macroglossia(ot"'))
hemihypertrophy(rd08'Auussz'uea), renal medullary cyst, adrenal cltomegaly, and hypoglycemia.
3) Denys-Drash syndrome: Gonadal dysgenesis (Male pseudohermaphrodite), nephropathy with renal failure.
e Other associations with wilms tumor are Frasier syndrome, Sotos syndrome, Perlman syndrome, Simpson-Golabi-
Behmel syndrome, and Von-Willebrand diseasb.
c Heamaturia (10-25o/o)
r Fever (200/o)
r Anorexia and vomiting
Prognosis
e Tumor stage at the time of diagnosis is the best prognostic indicator(4r06).
e Good prognostic indicators are stage 1 & 2, favourable histology, small tumor (< 500 gm) and age < 2yearc.
e Poorprognostic indicators are stage 3 &4, unfavourable histology, large tumor (> 500 gm), age > 2 years, hlperdiploidy
and renal vessel or capsule invasion.
Cnep:rrn.
e Poor prognostic factors are age > 1 year; stage 3 and 4, N-myc amplificational14'
PGI00)
' deletion of chromosome I and
* It is the most common malignant tumor of kidney in children lr'Iost cases are sporadic. 1-2% cases may have family
history.
* Familial predisposition is inherited in autosomal dominant manner. Mutation occurs in Wilms tumor (WT-1) gene
on chromosome-17(o,tn), CTNNB-1 gene encoding for protooncogene beta-catenin, and p53 gene.
c Wilms tumor is associated with three distinct syndromes :-
1) WAGR syndrorre : Wilnis ttmor, Aniridia?Gl0s' AilMSe7' Atsa), Genitortrinary abnormalities(Pc'0t) (including I{orse-
shoe kidney(uosc r0), Nlental Retardation.
08))
2) Beckwith Wiedemann syndrotneallMs e7' At ea) : Enlargment of body organs (e,g. macroglossia(Pcl
meduilary cyst, adrenal cytomegaly, and hypoglycemia.
hemihypertroqthy@Gt08,AttMss7'Atsa)n renal
3) Denys-Drash syndrome: Gonadal dysgenesis (Male pseudohermaphrodite), nephropathy with renal failure'
c Other associations with wilms tumor are Frasier syndrome, Sotos syndrome, Perlman syndrome, Simpson-Golabi-
Behmel syndrome, and Von-Willebrand disease.
A) Favourable histology
r It is the usual form and carries good prognosis. It compries blastoma, epithelial and stromal (mesenchyme)
0a)
elements. Metastasis to lung may occur btfi brain and bone metastasis is rareAilMs .
B) [Jnfavorable histologY
r There is anaplasia. Clear cell sarcoma subtype metastasizes to bone\rtMs 04)
.
Prognosis
* Tumor stage at the time of diagnosis is the best prognostic indicatorGl06).
* Good prognostic indicators are stage 1 & 2, favourable histology, small tumor (< 500 gm) and age < 2 years.
c Poor prognostic indicators are stage 3 & 4, unfavourable histology, large tumor (> 500 gm), age > 2 years, hyperdiploidy
and renal vessel or capsuie invasion.
Treatment of Wilm's tumor
o Treatment of wilm's tumor consists surgical resectionfollowedby chemo and ratiotherapy,
Wilms tumor
+
Surgical resection
I
Stage III
Stage I & II I
Stage IV I
I
V
iI
Vincristin + +
Yiqcristin +
Vincristin Vincristin
+ + +
Ductinmycin
Dactinomycin Dactinomycin Dactinomycin
+
(actinomycin-D) + +
Doxorubicin
+ Doxorubicin Doxorubicin
+ +
Ratiotherapy to
Ratiotherapy to Cyclophosphamide
tumor bed
all sites -+ tumor bed + known +
sites for metastasis Radiotherapy to all sites
.l:.,,,.,3ii315;"i.]..'":,.,.:,.. J.
Age,:,... 1.:',:,,'".'::::,:.iilil:. :r, t.i rr', ;.. rr.r..::'.:.:.,.:,,
Clinical features Unilateral fl ank mass (asymptomatic abdominal Abdominal mass, GI or genitourinary obstruction, prop-
mass), abdominal pain, hematuria, hyperten- tosis, fever, bone pain, spinal cord compression, diarrhea,
sion, fever, anorexia, vomiting. flushfnS, olro:lor'.1 *I::1or'*: h"rdu.h...
..
Less common (15%) ;,lEEstc'r fs$j& ,i.,:;*1,{t1:.,, .
c'11.:rm*r::e11s in
each are d,erived from dendritic cells and e.*press S-100. CDla(zr''!'rtrr/ an,3 i"II-r!-1-rF,,'iir,. lrre:.trr,,-
of Birbeckgranules(ArMs03'PGI01) in the cltoplasm is characieristic. r-.rnder 1[s 6]r,;1;11r-:,1 yiir:lr:sr:,-'Ra, !rrL.r:!:- f!t:t:,..:1:::i
have a penta-laminar, rodlike, tubular apperance and sornetimes a dila"ied termirrai ei"d it*npis . ra.r:l:.-r 3:",ii.ir:1i!rir::i
1.) Skeletal involvernent :- It is seen in 80% of casss (75a/a cases lu'e -eent u'ith s*lii.rtr:, !.t,tic l.e siu.i. Skl,!r ,s tl: r*irqr
common site of involvement (Presents with solitary lytic l€.9i:3s\itiE'Er':r1{'s 'rt). l:r..:ol:rriirl,:iir. cl'spi:re l; ,1-,; 1.1 r;1-e!!:;;:5.;
of vertebral body and compression of spinai cord. In fiat long brories the lesicn is r:r!l<;4;11-{!11r ' :',''
tability.
Treatment
o Localized (single system) disease is treated by intralesional corticosteroid, curettage or local radiotherapy.
o For Multisystem disease etoposide or vinblastin is given along with prednisolone.
o Refractory (unresponsive) cases are treated by cladaribine\ltMs0s), imatinib, cyclosporine, IFN-cr or stem cell
transplantation.
::: .:..,::
,',:a,' ,..1
.,:,t::,, ,.
: ,1::.: '
OTHER PEDIATRICTUMORS
t Teratoma
a Yolk/sac (endodermal sinus) tumor(PGt0e)
Rhabdomyosarcoma
: The most common sofi tissue sarcoma in children is rhabdomyosurcoma@Glee). The common site of involvement are: -
t Head.6 Neck (25o/o) -+ Most commorx(Pclqe)
t Genitourinary (22%) -+ 2nd most common
r Extremities
r Retroperitoneum
r Rhabdomyosarcoma is the most common nonocular orbital tumor is young children and is most common urinary
e7).
bladder malignancy in children(AllMs
o There are four histological rhabdomyosarcoma :-
i) Embryonal tyPe (60o7olrtctoat l
ii) Botryoid type is a type of embryonal form
J
Corn,ro., in childhood
iii) Alveolar tlpe (15%)
iv) Pleomorphic type (adult form) is rare in childhood and accounts for only 7%o of cases@Gt
os)
.
CHaptrn
I Stem c:
:s), Gern:
ierm cells
Lri'e gerru
:.n cells.
.i. Extra-
cofttlttotl
! l't !1f,!-tl )
x.t:* ChildhoadTamors
tauses of abdominal mass calcification in children: Cysts of adrenal gland, neuroblastoma, Wilm's tumor, pheochromocytoma ,-:f
adrenel, adrenal cortical carc!noma, ganglioneuroma.
& Mast cammon inherited malign*ncy in childhsod: Retinoblartoma.
& Differentia! diagnasis of lytic lesions of bone in children: Brown tumor, metastasis (neuroblastoma, leukernia), histiocytosis.
Highest are ra{e of solid tumor in children : Retinoblastoma, ::
I]I
I
:jl6-i &,,,e*,,1-a Childhaod rumors
rtl
Cnlpre B"ro
QUESTIONS
a) Megakaryoclticleukaemia NEUROBLASTOMA
b) Lymphocyticleukaemia
c) ErFthroleukaemia 32. The most comrnon malignant neoplasm of infancy
d) AML is-
23. Non specific esterase is positive in all the categoriee a) Malignant teratoma (AI0s)
c) ALL a) Neuroblastoma
d) Non Hodgkin's lymphoma b) Wilm's tumor
c) Medulloblastoma
25. A child with acute myeloid leukemia presents rryith
d) Pheochromocltoma
hyperleukocytosis. Treatment includes all of the
following except - (Ar oe) 34. Most common presentation of neuroblastoma is -
a) IV fluid a) Lltic lesion in skull with suture diasthesis
b) Allopurinol b) Lung metastasis (At e8)
26. All of the following syndromes are associated with 35. 4 years old child having palpable abdominal mass &
AMlexcept - @to7) hlryertension wit}t sweating & diarrhea is due to -
a) Down's syndrome a) Neuroblastoma (NEET Dec.12 Pattern)
a) Thrombocytopenia
in neuroblastoma associated - 6t 04)
a) Diploidy
.. :r'i:r.r..-...rrr:'..::.r..,,.i:ir.I
. ...: j:r.1,r.;::4.::r:t,.,tt:j:r
..
. -r.......,.1:1......,::;..:.::t.-
CH:$tiEa;,ililg
e) Pleomorphicrhabdomyosarcoma b) Neuroblastoma
c) Wilms tumour
62. Most common urinarybladder tumour in chifdhood
d) Rhabdomyosarcoma
1S- (AIIMS lune 97, AI 92)
a) I{aemangioma 73. A 2 day old newborn baby presented with micro-
cephaly, macroglossia, visceromegaly and a blood
b) Rhabdomyosarcoma
glucose level of 20 mg/dl. What is the most likely
c) Transitionai cell carcinoma
d) Squamous cell cdrcinoma diagnosis
a) Prader-Willi syrrdrome (orissa 98)
63. Commonest sarcoma in children is -
b) Beckwith Wiedman syndrome
a) Rhabdomyosarcoma (All lndia Dec.14 Pattern)
c) Werner syndrome
b) Lipoma
d) Cockayne syndrome
c) Angiosarcoma
d) Fibrosarcoma 74. Wilms'tumor is associated with the following except
64. Which of the following is the most common inherr"t-
a) Aniridia (UPSC-r 1o)
ed malignancy - (AIIMS May 0s)
b) Horse-shoe kidney
a) Infant leukemia b) Retinoblastoma
c) Hemihypertrophy
c) Wilmt tumour d) Neuroblastoma
d) Opsoclonus
65. A 10 years old child has lytic lesions in upper fe.mur,
75. Most common benign tumours during infancy is-
the differential diagnosis can be all except-
a) Lymphangioma b) Hemangioma (UP 07)
(AIIMS Dec 97)
c) Cystic hygroma d) Lipoma
a) Plasmacltoma b) Browns tumour
ITI
ANSWERS
1. Ans. is 'c'i.e.,Neuroblastoma arises in the first 4 years [Rel Nelson 18th/e p. 2097; Ghai 8th/e p. 616 & Vh/e p.
seal
Childhood malignancies
i)Most common tumor in childhood is leukemias especially acute lymphobiastic leukemia.
Second most common tumor -+ Brain tumors
ii)
iii) Third most common tumor -) Lymphomas
iv)Fourth most common tumor *) Neuroblastoma
v) Fifth most common tumors ) Wilms tumor
o Most of these tumors occtr below the age of 5 years except for lymphomas, rvhich is uncommon before 14 years of
age.
,,
Ans" is'l i"e.,I-eukemias lReJ Nelson 18th/e p. 2097; O. P. Ghsi 8'h/e p. 599 d* 7h/e p. 58Al
3. Ans. is'il i.e.,SacrococcygealTeratoma
c Sacrococcygeal Teratoma (SCT) ,s the most common neoplasm in the fetus and neu'barru.
'sacroccocygeal Teratoma (SCT) ,s the most common neoplasnl in the .fetus ond newlrarn with an estimated
prevalece of 1:30,000- 1:40,000 and with a 3:1 female preponderance.
- Handbook of Fetal Medicine by Shailesh Kumar (Cambridge [Jniv, Press) 2t]10/87
4" Ans. is'd' i.e., Ameloblastoma [fiel O.P" Gh&i 9th/e p. 599 & Vh/e p. 59a]
years old.
r Hodgkint lymphoma is the most common malignancy in adolescence.
r It is uncommon before 14 years of age.
6. Ans. is '*
i.e., B-cell origin lRef: O. P. Ghai 8th/e p. 600 & 7/e p. 5801
r Majoritp(85o/o) of all ALLs are precursor B-cell tumors that typically manifest as childhood "leukemia" n'ith
extensive bone marrow and variable peripheral blood involvement.
7. Ans. is'a' i.e., Acute leukemia lRef: O.P. Ghai 8th/e p. 601 6 Vh/e p. 5811
r Pallor (anemia), petechial spot (thrombocltopenia), fever (infection due to neutropenia) with splenomegaly suggest
the diagnosis of acute leukemia.
r Further, presence of splenomegaly eleminates aplastic anemia and ITP as the possibilities
"splenomegaly and lymphadenopathy are extremely uncommon in ITP and their Presence should lead one to
consider other possible diagnosis". - Robbini
"splenomegaly is characteristically absent in aplastic anemia and if present the diagnosis of a plastic
anemia should be seriously questioned".
r Hypersplenism' is a condition characterised by splenomgally and cytopenias with a normal hlperplastic marrow
and response to splenectomy..
Although cl,topenias resulting from hypersplenism may give rise to most manifestations mentioned in the question
these are more likely with massively enlarged spleens and not with minimally enlarged spleen as in the question
above (2cm below costal rnargin in a 2 year old child).
8. Ans. is'd' i.e., All of the above fRef: O"F. Ghai Vh/e p. 58A; Nelson L8'h/e p. 2115-21251
9. Ans. is t' i.e., ALL lRef: O.P. Ghai 8th/e p. 601 (t Vh/e p. 581)
"T cell vaiant of ALL presents with a wide mediastinal mass" - Ghai
10. Ans. is 'i i.e., Mature B cells tRef: O.P, Ghai Sth/e p. 600 b Vh/e p. 581; Robbins 7"/e p. 6771
r Lrmorphology is identical to Burkitt's lymphoma cells i.e., mature ts cells with surf'ace immunoglobuiin positive.
11. Ans. is ? i.e., Hypodiploidy lRef: o.p. Ghai 8th/e p. 600-601 6 Th/e p. 581; Nelson 18th/e p. 2120; Wintrob's
1lth/e p. 2145, 242)
. Poor prognostic cytogenetic abnormalities of ALL: Hlpodiploidy; pseudohlpoploidy; t(4:11); t(9:22) i.e., BCR-ABL;
t(8:14); t(1:19).
t2. Ans. is 'c' i.e., Pre B-Cell ALL {Ref: O.P. Ghai Bth/e p. 600-601 6 Vh/e p. 581; Wintrobe's llth/e p. 2145, 2421
o Pre B cell ALL has poor prognosis.
13. Ans. is t' i.e., Age > l0 years [Ref Devita's 6rt,/e p. 224A; Nelson 17h/e p. 1695; Wintrobe's clinical her,mtalagy
lLn/e Table 80.2)
r Age more than 10 years has bad prognosis.
14. Ans. is 'c' i.e., Testicular involvement fRef: Nelson 18e/e p. 2120; Wintrobe\ llth/e p. 2145; O.p. Ghai
8th/e p. 600-6011
o Testicular involvement is a poor prognostic factor.
15. Ans. is t'i.e., t(9;22);t (a;f l); t (1;f9) fRef: O.p. GhaiB,h/ep.600-6011
16. Ans. is t' i.e., ALL lRef: O.P. Ghai Bth/e p. 60i & fl/e p. 582; Nelson IBh/e p. 21191
o Induction therapy is used to attain remision, i.e., to eradicate the leukemic cells from bone marrow.
r Drugs used are -+ vincristine, Prednisolone, L - Asparginase, Anthracycline
17. Ans. is'a'i.e., CNS
o The common site of relapse of ALL --> (1) Bone marrow (most common - 200/o), (1i) CNS (5o/o) (iil) Testis (3ot6)
18. Ans. is'a' i.e., ALL fRef: O.P Ghai 8th/e p. 60j & Vhle p. 583)
o Most children with leukemia have subclinical CNS involvement at the time of diagnosis.
r Treatment include -+ rntrathecal methotrexate plus cranial radiation.
19. Ans. is t' i.e., Vinblastine {Ref: Ghai Ze/e p. 582)
o Vincristine, cyclophosphamide and firethotrexate are used (see text of the chapter)"
20. Ans. is t' i.e., Acute promyeloblastic leukernia (M.3) tRel Ghai fl/e p. 584; Nelsan 1re/e rh. 49Sl
o {)apd ltrognosis : M, (AML with maturation), N{. (acute prornyelocl.tic ieukernia), Mn (acute myeloplonocytic
leukcmia).
c Faor prognosls : Mo (ririnilnaiiy diferentiated AML), Iv{u (acute er1.thro1eu.l:,mia), M, (acute megakaryocytic).
23. Ans. is 'd' i.e., Mu[Ref : Hematology Basic Principles and Practice by Hoffman, Benz et al4th/e p. 10g0)
r Non-specific esterase is seen in AMLs which have monocltic Lineage (M, & Ms ).
r In M. AML, usually non-specific esterase is usually not seen. But some cases miy show non-specific esterase
" Acute promyelocytic leukemia shows immature cells that are strongly myeloperoxidase positive, but some cases may also
show not-specific esterase positivity". --- Textbook ai lllustrated pathology
l Aees. is'a' i.e", Ae{L tRd.' A.F. Ghai }tt'/e p. 506 {, 7t'/* p' 584; trlabbin's Thle p. 694}
r Chloromas (granulocytic sarcomas or myeloblastomas) are localize masses composed of myeloblasts in the absence
of marrow or peripheral blood involvement in Mn & Mu AML.
25. Ans. is'd' i.e., Irnmediately start induction chemoth erarpy
o Treatment of hlperleukocltosis includes :-
1. Immediate leukoreduction (cltoreduction)
r Immediate leukoreduction is required to lower the blast cells'
r This can be achieved by leukopharesis or by administtation ofhydroxyurea.
2. Induction chemotheraPy
r Induction chemotherapy is initiated early, but only after attempts at leukoreduction (not immediatly) as immediate
administration of induction chemotherapy carries a high risk of acute tumor lysis syndrome.
r So, early induction chemotherapy is advised but not immediately.
3. Supportive/Prevention of complications
r Supportive therapy is given to prevent/reduce the metabolic complications of tumor lysis syndrome.
r It includes IV hydration, allopurinol and alkalinization of urine,
26. Ans. is 'd' i.e., Turner's syndrome lRef: O.P. Ghai 9th/e p. 6A5 6 Vh/e p. 584; Harrson 16h/e p. 6j1l
Etiology of AML
1. Hereditary -
Down syndrome, Klinefelter syndrome, Patau syndrome, Fanconi anemia, Bloom syndrome, Ataxia telangiectasia,
Kotsman syndrome.
2. Radiation
3. Chemical and other exposure
Benzene, smoking, ethylene oxide, paint, herbicide and pesticides.
4. Drugs
Alkalating agents, Topoisomerase II inhibitors, Chlorarnphenicol, phenylbutazone and less commonly chloroquine,
methoxlpsoralen can result in bone marrow failure that may result in AML.
Note: Turner syndrome also causes leukemia - Nelson 18th/e p. 2117 table 495.1
But I am not sure, whether it causes AML or not.
27. Ans. is'None' fRef: O.P Ghai 8n/e p. 605 6 7h/e p. 584; Nelson 18th/e p. 21171
28. Ans. is'b' i.e., Down's Syndrome lRef: Nelson 18'h/e p. 2122)
'Neonqtes and infants with Down's Syndrome may have a condition known as 'transient myelopraliferative
syndrome' which mimics congenital leukemia'
25" Ans" is'a' i.e", Down $yndrome [Ref Nelson 18't'/e p. 21221
JUVENILE CML
31. Ans. is 'd i.e", |unenile Ce{L tftef A.p. Gbai S,hle p. 6AS & f,le p. 5S6l
NEUROBLASTOMA
34. Ans. is 'i i.e., Lytic lesions in skull, with sutural diastasis lRef O,p. Gh*i */e p. 616 & Vh/e p, s90; Nelson tffh/e
p. 2137, 21j81
e Most frequent site of metastasis from nueroblastoma is bone : where metastasis occurs very early.
o Lytic lesions in skull and suturai diastasis are manifestations of bony metastasis to skull, and hence the
earliest feature,
amongst the options in the questions.
Ans. is'a'i"e., Neur*blastnmalR.ef: A"p Ghsi gtt,/e p. 6]6 6 Vt'/e p" S9A]I
e Atrdominal mass and hypertension can occur both in neuroblastoma and wilm's tumor.
r But, sweating and diarrhea favour diagnosis of neuroblastoma.
36. Ans. is 'b' i.e., NeuroblastomalRel O.p. Ghai I'h/e p. 616 d, Vh/e p. 59a|
'Metastasis present in 60-700/o of children at time of diagnosis
are usually ta the skeleto*, characteristicaLly to the
fctcial bones and the skull and to the bane marrow and nodes'
37. Ans. is 'c' i,e,, Lung metastasis are comtnon [Ref Nelson lgele p. 21jg]
o Neuroblastoma is most common extracranial solid tumor of children.
o Lung metastasis is rare in neuroblasioma.
.liiiir 11: ,..r,... :irrl.. ;ni..:::iui
"
crrip irn r :o
"c*l*iiiild
metaslasis is skeletal
r Metastasis present in 60-700/o of chilclren at the time of diagnosis, and the most frequerut site af
system. Other common sites ate liver, lymph nodes and skin'
r Encasement of abdominal aorta and inferior venacava by turnor is common.
ntl' p' 2137, 21381
.&ffs. is i.e",Nemroblast*tt;:'al%ef Nelsaw 18th/e
o Neuroblastoma can present as paraneoplastic synrlrenne of autoimune origin mani&sling as ataxia or opr-rsti:voclr"'Lrs
(Dancing eyes and dancingfeat).
o In such cases primary tumor is in the chest or abdomen and the brain is negative for tum<lr'
r Some tumor produce catecholamines that can cause sweating and H'IN a'rd sotne relrase vasoactive
peptide (VIP) causing secretary diarrhea'
i9. Ans. is 'd' i.e., Trk A expression lRef: Robbin's Vh/e p' 7631
40. Ans. ist' i.e., Hyperdiploidy tnef Robbin's Vh/e p' 763)
{1. Ans. is t' i.e., Neuroblastomit[Ref: o.P. Ghai 8th/e p' 616 dt vh/e p' 590]
infitst two years of life l{euroblastoma
e The commonest intra-abdominal tumor
t l'fe Wilru's tumor
The commonest intra-abdominal tumor between 2d to 5'h yeat af
-
.a,
i.e., Neuroblastorna [Ref Nelsor 18th/e p. 21i7, 21i8; o.P Ghai 8th/e p. 616 dv 7h/e p. 590]
12. Ans. is
of neuroblastoma'
o proptosia, bony metastasis and sutural separation (due to skuil rnetastasis) suggest the diagrrosis
WILM's TUMOR .
6 p'
Ans. is t' i.el, Polycystic kidney p. 591; Nelson 18th/e 214a1
14. lRef: o.P. Ghai }th/e p. 617 Vh/e
Wilmttumor
e Wilm,s tumor, also known as nephroblastoma, is the most comlnon malignant tumcr of kielney in cirildren'
Etiology
o Most of the tumor ate sPoradic.
o I - 2 Vo rnaY have familY historY.
o r-amilial predisposition to wilm's tumor is inherited in at autosomal dominant lnanner'
o Mutation of the foilowing genes are seen in wilms tumor'
r) Wiims tumor gene (WT 1) on chromosome 1l
ii) CTNNB.I gene encoding the protooncogene beta-catenin'
iii) ps3.
Witm's tumor is associated with three distinct syndromes :
45. Ans. is 'c' i,e., clear cell sarcoma fRef: a"p. Ghai B'h/e p. 617 6 vh/e p. 592; Nelson rgthle p. 214a, 2141)
o Clear cell carcinoma is a histological subtype of Wilm's tumour which frequently metastasize to bone (In
conventionai wilms's tumour bone metastasis is rare).
46. Ans" is'a'i.e., As asymptornatic abdominal mass lRef: O"P, Ghai B,t,/e p. 61g & Vhle p. 592; Nelson rgth/e p. 214tr1
Presentation of Wilm's tumor:
e Asymptomatic abdominal mass (most common) r Heamaturi a (10 -25o/o)
o Abdominal pain (30%) t Fever (20o/o)
c Hypertension (25o/o) e Anorexia and vomiting
47 . Ans. is 'd i.e", Stage of dis ease lRef: Rudolph 29th/e p. 164l
r Tumor staging at the time of diagnosis is the most important prognostic factor.
48. Ans. is 'b' i.e., Open Nephroureterectomy fRef. Sabiston |Bth/e p.20L2l
o The treatment of choice for Stage I Wilm's tumor is Transperitoneal Radical Nephrectomy (Radical
Nephroureterectomy) followed by chemotherapy with or without radiotherapy depending on tumor histology,
49. Ans. is 'd'i.e., Torres syndrome fRef: O.P. Ghai yth/e p. 620 & 7h/e p. 595; Nelson lsthle p. 2159, 2$a; Robbin\ Tt,le p.
7o1l
o Histocltosis X is characterized by proliferation of Langerhans histiocytes (tissue macrophages).
o It is subdivided into three categories : (i) Letterer - Siwe syndrome, (ii) Hand -Schuller-Ciristian
disease,and (iii)
Eosinophilic granul oma.
50. Ans. is'c'i.e., Lagherhan's cell histnqtosis [Rel A.P. Ghai 9th/e p. 620 6 Vh/e p. s9S; I{elson tyth/e p. 21s9, 2rca}
r Seborrhic dermatitis, polyuria, hepatosplenomegaly and discharge suggests the diagnosis of Langerhans cell his-
tiocytosis.
51. Ans. is 'b' i.e., Langerhans cell histiocytosis [RS o.p. Ghai Btble p. 62a 6 Thle p. s9s]
52. Ans. is'c' i.e., Histiocytosis X [Rel a.p Ghai yth/e p. 62a d, vh/e p. 595; Robbins vh/e p. 7a1, 7021
o Osteollfrc lesions in a child involving all the bones of the body points towards the diagnosis of Histiocl,tosis X.
o The bony lesions in Histiocytosis x can present as a single lesion or as a wide spread iir.ur. involving virtually
any
bone ofthe body.
o The iesions are osteolytic and the common sites of involvement are -+ Skull, Vertebrae, Ribs 6 Clavicle.
About other choices
o Metastasis from Wilm's tumour It can be easily be excluded as the metastatic from Wilm\ tumour
--) does not involye bones.
e Neuroblastoma Though it can inyolye any bone of the bocly, but simultaneously
--) inyolvement of all the bones of the body without any common
manifestation is very unlikely to be neuroblastoma.
o Metastasis from Osteosarcorna Metastasis from osteosarcoma commonly goes to lung not bones.
--)
53. Ans. is 'a' i.e., Birbeck granules in the cytoplas m l&ef: a.P. Ghai &thle p. 62a-621 dr Vh/e p. 595-595; Nelsorc try*/e p
2159, 2160; Robbin's 7h/e p. 7011
r Hepatosplenomegaly, presence of histiocytes with PAS postive suggest the diagnosis of langerhans cell histiocltosis.
o Diagnosis of LCH:
Cn,r,prra
::.r:,grii:F
t The hallmark of LCH is clonal proliferation of cells of monocyte lineage.
r The presen ce of Birbeck granules in the c1'toplasm of tumor cells is characteristic of LCH.
dite) r Birbeck granules are tennis racket shaped bilameliar granules.
r As Birbeck granules are not seen in all tumor cells by election microscopy, the detection of S-100 and CDla
expression by immunohistochemical techniques makes the definitive diagnosis.
Ans. is'a' i.e., CDla fRef: Nekon 18th/e p. 2159, 2160; Robbin's Vh/e p. 701)
o The presence of Birtreck granules in the cltoplasm of tumor cells is characteristic of iangerhans cell histiocltosis.
r As Birbeck granules are not seen in all tumor cells by electron microscopy, the detection of 5-100 and CDla
expression by imrnunohistochemical technique aids in the diangosis.
re (In Ans. is 'a'i.e., Can be associated with diabetes insipidus; t' i.e.,Birbeck's granules in langhan's cell; 'd' i.e.,
Proliferation of antigen presenting cells; 'e' i.e., Associated with specific HLA DR fRef: Privious explanationsf
111 o Hand-Schuller-Christion disease (a tlpe of histiocltosis) is characterizedby triad of : -
i) Claviral bone defects n) Diabetes insipidus iii) Exophthalmos
r There is proliferation oflangerhans histiocltes (antigen presenting cells)
r LCH is associated with HLA-DR, S-100, CD1a.
o Birbeck granules are present in the cl,toplasm of tumor ceiis.
lical
MISCELLANEOUS
Ans. is'-n* i.e-, Lpnphorma llltJ: Nelsorz n9't'/e C:. 491,,192, 3421
t Lymphoma is the most common malignancy of the gastrointestinal tract in children. About 30% of children with non-
ep. Ilodgkin lymphoma present with abdominal tumors.
lls- 59. Ans. is 'b' i.e., Leydig cell tumor [Ref: CPDT l*'h/e p. 965, 966, Nelson 18th/e p, 2153, 2154)
o Germ celi tumor are : -
t Seminoma/dysgerminoma t Embrybnal carcinomat Yolk/sac (endodermal sinus) tumor
s Choriocarcinoma t Teratoia
60. Ans. is'a' i.e., Rhabdomyosarcoma lRef: O.P. Ghai \th/e p. 618-619 & 7h/e p. 593; Nelsan 18th/e p. 21441
r The most cofirmon soft tissue sarcoma in children is rhabdomyosarcoma.
n), r Head & Neck (including face) are involved most commonly.
61. Ans. is t' i.e., Pleomorphic rhabdomyosarcoma fRef Nelson 18th/e p. 2144)
o Pleomorphic type (adult form) is rare in childhood and accounts for only 7o/o of cases.
62. Ans. is'b' i.e., Rhabdomyosarcoma fRef: O.P. Ghai 6th/e p. 575; Nelson 18th/e p. 2144)
Retinoblastoma 97o/o
ffi!,6s"
Rhabdomyosarcoma
67. Ans. is'b' i.e., Leukaemia lRef: O.P. Ghai Bth/e p. 599 & Vh/e p. 550)
68. Ans. is'b'i.e., Brain tumour lRef: O.P. Ghai 8th/e p. 5gg d, Vh/e p. 545, Sg0)
69. Ans. is'a'i.e., ALL[Ref : O.P. Ghai 8,h/e p. 599 d2 7h/e p. 5811
70. Ans. is'a'i.e., Presence of mediastinal mass lRef : o.p. Ghai gth/e p. 6a0-6u & Thle p. 5gll
71. Ans. is'a'i.e., Down syndrome lRef O.P. Ghai Bth/e p. 638 6 Vh/e p. 5g6l
o Patients with Down syndrome are more prone to develop juvenile type of cML.
74. Ans. is t'i.e., Opsoclonus lRef: O,P Ghai 8n/e p. 617 & fhrc p. iOZl
75. Ans. is'H i.e., HemangiomtfRef: Nelson l9th/e p. 21451
o Hemangiomas, the most common benign tumors of infancy, occur in 10% of term infants.
El,r.r .,...iiP
HEE{AT*I#GY
r Erlthropoiesis is the production of red blood cells (er1'throcl'tes). Er1'thropoiesis begins between 10-14 days of
gestation. The predominant site of er1'thropoiesis varies with age.
* 24 weeks - till birth (myeloid stage) e Bone marrow throughout the skeleton
* After puberty (after 1 6-1 8 years) Q Bone marrow of vertebrae, ribs, sternum, skull, pelvis,
and proximol ends of humerus & femur
ANEMIA
r Anemia is defined as a decrease in the amount of red blood cells or hemoglobin concentration in the blood.
DISORDERS OF HEMOGLOBIN
r Hemoglobin molecule is made up of four subunits, each containing a protein part (globin) and a non-protein part
(heme).
o The heme part is same in ali qpes of hemoglobins.
r The protein part (globin) is different in different hemoglobin, which is made up of two pairs of poilpeptide chains.
Different pollpeptide chains are o, P, y, 6, e, (. Different hemoglobins (depending upon there pollpeptide chains)
are HbA or adult hemoglobin (c"r} r), Hbf or fetal hemoglobin (a;y ,), HbA, or minor adult hemoglobin (o-16 ), Gower-l
(e y
), Gower-2 (are) and Portland ((7 ).
ls' AIrMS 83) upto 8th week; these
o In early fetal lifu three hemoglobin Gower- 7, Gower-2 and portland are synthesized@I
are called embryonichemoglobins. After that predominant hemoglobin is fetal hemoglobin (HbF) upto 36 weeks@rlMs
0s'04)
after which synthesis of hemoglobin switches from HbF to HbA (adult hemoglobin)Gnusos'oa). After birth, adult
values of HbA are achieved by 6 months to 1 years.
THALASSEMIA SYNDROME
o Adult hemoglobin is a tetramer, composed of two cr globin chains and two p globin chains. Thalassemia is an inherited
autosomal recessive disorder. In Thalassemia, the gentic defect results in reduced synthesis of one of the globin chains
of hemoglobin.
e p-Thalassemiaiscausedbydeficientsynthesisofp-chainwithnormala-chainsynthesis@IlMsol), cr-thalassemiais
caused by deficient synthesis of ct-chain with normal B-chain synthesis.
e Molecular defect in pathogenesis are :-
A) B-thalassemia
r It is mostly due to point mutation which changes an amino acid codon to a stop codon (non sense mutation).
Rarelyit may also occur due to deletion orinsertionwhich results iny'ame-shift- mutation(Pcrql).These mutation
0r)
can cause defect at different steps of p-chain synthesis : (i) Aberrent splicing (catled splicing mutation(Pcr :
most common); (ii) Premature termination of translation (chain terminator mutation); or (iii) transcription
defect Qtromotor region mutation).
B) o- thalassemia
r The mostcommon cause of reduced o-chain synthesis is deletidn of cr-globin genes. Rarelynonsense mutation
may also cause o-thalassemia.
p- thalassemia
o The abnormality common to all B-thalassemias is diminished synthesis of structurally normal p-globin chains,
coupled with unimpaired synthesis of cr,-chain4llus01). As B-chain is absent, there is compensatory increase in
production of o, y, and 6 chains, resultinginincreased amount of HbA2 (o-16r) anilHbF (o-ryr)(Nnnrmut06'PGt04).
r There are three forms of B-thalassemia :-
1) Thalassemia major (Cooley's Anemia)
r It is in individulas homozygous for p-thalassemia gene. It is severe transfusion dependent anemia.
seen
r Severe Anemia manifests at 6-9 months after birth. There are prominent frontal and cheek bones, jaundice,
hepatosplenomegaly(a['uso6),increased risk of pigment stone due to extravascular hemolysis, iron overload and
secondary hemochromatosis.
CHeptsx
r Perpheral blood smear shows anisocl,tosis, poikilocltosis, microcytic hypochromic anemiaqllMsa6), target
cellsqllMs 06) , bosophilling stippiing and fragmented RBC'
r HbF is markedly raised (60-90o/o)@Gt04). There is JUCV JtrriCU, JITACUC, t.errrm iron, tserum ferritin,
tpercentage saturation , and Jtotal iron binding capacity.
r Bone marrow examination shows marked erlthroid hlperplasia, and reversed myeloid to erlthroid ratio (normal
is 3:1).
r fragility of RBCGIIMS06).
There is deueased osmotic
r X-ray skull shows crew cut appearnaceGrs:), and hair on enil appearance(Pcle7'AIIMSe') (Hair end appearance is also
seen in sickle cell anemia(Pcls7'Air'trsrz), hereditary spherocl'tosis and G6PD deficiency).
(such
Blood picture of beta thalassemia includes microcytic hypochromic RBCs; anisocltosis and poikilocytosis
as ovaiocytes, schistocyte); talget celIs, basophilic stippling and nucleated RBCs (NRC).
Alpha - thalassemia
o people who do not produce enough alpha globin chainhave alpha - thalassemia@EED. Alpha globin chain is made by
four genes, each gene contributes to 25o/o of the cr-globin chains'
r The severity of cr,-thalassemia varies greatly depending on the number of cr-globin genes affected
-
Clinical features
r The clinical manifestations of sickle cell anemia are -
1. Chronic hemolysis
t Ineversible sickle cells have rigid, nondeformable cell membranes that lead to dificultyin negotiating the splenic
sinusoids, sequestration, and rapid phagocytosis. This results in extra - vascular hemolysis. Some intravascular
hemolysis may also occur because of increased mechanical fragility of severely damaged ceils.
Cuepren tr HematologY
Vasoocclusive sYmPtorns
t molecules and are abnormally sticky that
Reversiblesickle cells express higher tiran normal levels of adhesion
lungs, spleen and penis'
is responsible for occlusion of microcirculation especially of bones,
qre fhe most common manifestations of sickle cell anemia. They commonly manifest as -
I
r) Pairuful bone crisis?
ii)Hand-footsynd'rome@Ni15)+Dactylitisofbonesofhands/feet.
III) Autosplenectomy@Gra0)-+predisposestoinfectionbyencapsulatedbacteriae'g.H.influenza&pneumococcus'
iv) Acute chest syrrdrome
This is the most dangerous crisis'
v) Sequestration crisis -+ ,\cute painfui enlargement of spleen'
vi) Aplastic crisis -+ due infection by parvovirus - B19
vii) CNS symptoms -> Seizure, stroke
8)
viil) P r i ap i sm6tt
MS e
and infarction of p enis
line
oil. lnvestigation
I3r 1s)'
o peripheral smear shows sickle cellshl
13)
, target cells('{r and Howell - lolly bodiesql
:ie
in most of other anemias ESR is increased)'
e ESR is ilecreased(only important anemia in which ESR is decreased,
metabisulfite'
::.\'. o There is positive sickling test with a reducing substance like sodium
trait?Gl s8) (40% HbS & 50% HbA) and one
o Hb electrophoresis shows firyo bands in heterozygous state/sickle.cell
eor bands in homozygous state (only HbS). Hbs is slower
moving than ItrbA towards pasitive electtodeqttMson) '
lCs r Bone changes on X-raY show :-
1) Fish mouth vertebtae@Glnt)
sst
ii) Crew hair cut (hait on end) appearance of skull{eu '
,Hair on end appearance' is also seen in thalassemia, hereditary spherocytosis and G6PD deficiency'
]a\'
:lltre peripheralblood smear shou'ing sickle cells, target cells, and Howelljallyo'odies'
I
: illC
-iar
Besides hemoglobin S, there are other hemoglobinopathies due to point
mutation in beta globin chain of hemoglobin.
There are HbC (in ltalians and Black); HbE (prevalent in BengalrPctro),
tusam & East lndia); and HbD {in Funjabisrdrs, & Gujratis).
s Enzyme deficiency causing hemolytic anemia: G6PQ pyruvate kinase, aldolase and hexokinase.
OTHERTYPES OF ANEMIA
Clinical features
o Pallor(Aro') is the most important sign. Other features are fatigue, pagophagia (eating of inedible substances like clay),
irritability(Ar0'),anorexia, decreased attention span, decreased alertness(Pcr0e), litharryut04), tachycardia, cardiac
dilatation and systolic murmur.
lnvestigations t
o Bloodpictures:Microcytichypochromicanemia@Gt|s),ring(pessary)cellstueat,poikilocltosis,Targetcells(unusual).
o Bone marrow : Hypercellular marrow, erythroid hyperplasiaAr 0a), depleted bone marrow iron (bone marrow iron
decreases earlier than serum iron@Glos)).
o Parameters:Decreasedserumferritin(eailiestchange)@Gloe'Als6'ss),reducedserum iron,increasedtotalironbinding
capacity (TIBCyoe'ost, reduced percentage saturation, increased transferrin receptors, increased red cell porphyrin
and increased hepacidin level.
o Red-cell distribution (RDW) width is increased@Gton).
o There is decreased MCVt(Ar0a),MCH and MCHC.
,es+prnr. tr Hemat&gy
. H'ypochromicmicrocyticanemiawithwideningofcentralpallor> 1/3oftotatRBcdiameter.
dr$f
-- rr
Treatment
I Oralironsaltsaregiven 6mglkglday.Treatmentisgiven tillSweeksafterachieymentofnormalHbleveltoreplenrs::
iron stores. The dose of iron can be calculated by a formula, i.e. 3x body weight (kg) x Hb deficit gm/dl.
c The earliest response is rapid subjective improvement, e.g. increased appetite, diminution of fatigue,
and. decreased
irritability(NEEr) (within 24 hours). Earliest hematological response is increase in reticulocyte countar 06) (within
i :
days).
r Peripheral smear in megaloblastic anemia showing hypersegmented neutrophif w1th nine lobes.
COAGULATION DISORDERS
II
iii) Partial thromboplastin time (PTT)
I0). prolonged PTT can results from deficiencl
r It tests the intrinsic and common coagulationpathwaysqnms So, a
os)), lX, X, XI, XII, prothrombin or fibrinogen.
of factor V VIII (factor Vlllc, Von willebrand faessvqr
t Thus in common coagulation pathway defect both PT and PTT are elevatedailMslo).
Hemophilia-A
r Hemophilia A is due to deficiency of factor VIIIGGL ' eT)
At
BT and platelrl ,ounltod
oa'
ii) Normal PT,
0z)
.
b) ITP
.
:,. dl Glanzrr.rana's thrornb-osthenia
Yon-Willebrand disease
r Factor VIII has two comPonents :
\) Factor VIIIc (procoagulant protein) synthesized in liver (main source) and kidney
ii) Von-Willebrand factor (VWF) synthesized in vascular endothelium (main source)Gte8) ar,d megakaryocytes.
r VWF factor helps in stabilization of factor VIII and also facilitates plateiet adhesion. Thus deficiency of VWF results
in:-
1) Clinical features of factor Vlll deficiency
r Bleeding into weight bearing joints; post traumatic ecchymosislhematoma; prolonged bleeding after surgery or
laceration; and prolonged PTT with normal PTaIls).
ii) Clinical features of platelet dysfunctlsn(etnasrzl
r Bleeding from small vessels of skin and mucous membrane (e.g. epistaxis); menorrhagia; GI bleeding; and
prolonged bleeding time(al os).
o Von-Willebrand disease is an autosomal disorder with autosomal dominant inheritance in more than goo/oLrMs aa)
and autosomal recessive inheritance in remaining. It is divided into :-
i) Type- I (most comm on t 70o/o) : Autosomal dominant; there is reduced quantity (partial deficiency) of VWF.
ii) Tlpe-2 (25o/o) : Autosomal dominant, with qualitative defect in VWF.
iii) Type-3 : Autosomal recessive; there is complete deficiency of VWF. It is the most sever form.
o Laboratoryfindings include: -
i) Prolonged PTTo{ros
ii) Normal PT
iii) ProlongedBTailMs e7)
DISORDERS OF PLATELETS
DISORDERS OF PLATELETS
r T-cells are progressively depleted with progressive atrophy of T-celi regions in lymphnodes and spleen. B-cells
are notmal,
r Small sized platelets are characteristic(1IMs03).
o Destruction of platelets takes place in spleen, stili the spleen size remains normal(AilMS07'a4'ee), a characteristic finding.
r Autoantibodies are of IgG class(ar i3) and are targeted against platelet membrane glycoproteins IIb-IIIa or Ib-IX.
r Due to peripheral platelet destruction there is compensator y increase in megakaryoctyes in bone marrowAlrMs
04' ee)
.
Types
o ITP is dMded into acute and chronic forms :-
1) Acute ITP
r It is seen in age group 2-6 years@et
os' AIIMS s4)
with no sex predilections(Pcr 0s).
50% cases are preceded by viral
infection{eer os). It is self limiting(rcr ror with spontaneous remission is seen in 80% of cases(Pct
o<' Ar'IMs ee). 'Ihe
1) Bernard-souliersyndrome
r It is an autosomal recessive disorder with defect in platelet adhesion due to deficiency of Ib-IX glycoprotein.
2) Glanzmann's thrombostheniatt t3' pGI e6)
r It is an autosomal recessive disorder with defect in platelet aggregationar I3) due to deficiency of IIb-IiIa
glycoprotein.
3) Wiskot-Aldrich syndrome (WAS)
r It is an X-linked recessive disorder caused by mutation it WAS protein (WASP) gene on chromosome 11.
r There is immunodeficiency with T-cell deptetion(AtlMseT) and decreasedlgMallvlssT).IgG and IgA are narmalG"ns
tr). IgE is increasedGtrMs e7) .
r T-cells are progressively depleted with progressive atrophy of T-cell regions in lymphnodes and spleen. B-cells
afe normal,
r Small sized platelets are characteristic(lrrMs 03).
c Destructionofplateletstakesplaceinspleen,stillthespleensizeremainsnormalGlMS0T'04'ee),acharacteristicfinding.
o Autoantibodies are of IgG class(Ar
i3) and are targeted against platelet membrane glycoproteins llb-llltt or Ib-IX.
o Due to peripheral platelet destruction there is compensator y increase in megakaryactyes in bone marrowGttMs
04' ee)
.
Types
o ITP is divided into acute and chronic forms :-
1) Acute ITP
r It is seen in age group 2-6 yearc@Gl 0s' AIIMI e4)
with no sex predilections(Pcl 0s).
50% cases are preceded by viral
ArrMsee). Tte
infection@clor). It is self limiting(rcrror with spontaneous re'rflission is seen in 80o/o of cases@ctot'
duration of disease is 4-6 weeks.
2) Chronic ITP
10'AIrMS04) and seen in adulthood, i.e. adult women less than 40 years. There is
a Itis more common inf,emales@Gl
no antecedent respiratory infection and spontaneous remission is uncommon. Duration of disease is > 6 months
ro)'
to 1 Year(Pci
Cn-rpre,n
Treatment
a IV immunaglobulin is the treatment of choiceailM's
er)
for neonatal as well as childhood ITP. Glucocorticoids are often
a lntruuterine infections(Att[s
82' PGt^il with -> RLlbella, Syphilis, Toxoplasmosis, CMV, HSV
o Neonatal bacterial sePsis
MISCELLANEOUS
Kasabach-Merritt syndrome
* Kaposiform hemangioendothelioma in a neonate can cause thrombocytopenia due to platelet sequestration,
consumptive coagulopathy and microangiopathic hemolltic anemia.
o Heart failure may be caused by AV rnalformations'
radiation'
o The treatment used includes corticosteroids, IFN-cr, vinristine, Iaser photocoagulation, and
e Surgery is not indicated because of risk o;f bleeding'
Neonate polYcYthemia
(PCV) or erythrocyte volttme
o polycythemia is defined as central uenous heruatocrit [also ca)led packed cell volume
fraction (EVF)I level of greatet than 650/o'
trisomy 13, 18
c Important causes of neonatal polycl,themia are twin-twin transfusionGrsr), maternal-fetal transfusion,
h1'poxia, and infant of a diebetic mother"
or 21; adrenogenital syndrome, neonatal Grave's disease, chronic intrauterine
a In asyrnptomatic neonates with pcv > 75o/o anil in symptomatic neonates, treatment
of choice is partia! excharuge
transfusion@PE'r) '
o Asymptomatic neonates with PCV 65-75Vo are treated conservatively with closed monitoring.
€onstitutional PancYtoPenia
major hematopoietic lineages on an
e Constitutional pancltopenia is defined as decreased marrow production of the 3
c
q
s On Hb electrophoresis: HbS moves slower than HbA towards positive eleetrode.
!'
t ln sickle cell anemia true is I Autosplenectomy due to thrombosis and infarction.
!,
t X-rayin sicklecell anemia: Crew haircut appearance of skull and fish mouth vertebrae.
a
& Gamma Gandy bodies are seen ln : Sickel cell anemia, CML, Cinhosis.
*l
t Mutation in thalassemia: Mainly point mutation (missense mutation) causing aberrant splicing.
,*,
*
. Osm.oticfygility inthalassemia : De5rease!.
,*,':,.ltbftd{re-aiefu.,iiue,tsrThr,eealpfiagenes"defeitiirn': r:::r::' :", ,
*:
s Earliest hemoglobin to appeor tGower-1, Gower-2, Portland (embryonic hemoglobins).
t fetaln*trtrxi,,coiiwed,toeduit:tr8€]r: Alkafi.aenaturatioaresirtAnl;ldsi &r5ip,Pg,les.s iron,
q Biiite cells seenin: G-6PD deficiency.
:
t
* Most severe form.of G6PD deficiency:Type-3.,.
.
* .lran istabsorbedfrorn;Duodenurnr,'.""',. :' ",r'.:,,..
:"1
,
& Anemia in iron deficiency: Microcytic hypochronic.
a Earliest response to therapy in iron deficiency Diminution of fatigue anO i11t9t1!!!V a1d
,o|r*!o.., lncre3yrnplil":_,.... ..,.....
s
a Laboratory finding in Von-Willebrands disease: Prolonged aPTT and BT with notr.f pf.
*
o Hemophilia A is due to deficiency of : FactorVlll.
; ehiistnias dlsetiSe {Hemap:6i1;ia ,8} ii due,ta defitiincU'ol': Eactor- lX .. ' ':.. :: :;:.:,
.:.,,11.:,, ,
a
a Bleeding from umbilicol stump in newborn: Factor Xltl deficiency.
'i.:!l:::::ii'.';3:'--'..:,]i]l:....::::::'':...il]t.1,]:]:]j::j]:]]].:1i,l...:]':];::]::'ii].|..'.
a Ng;€l!,$t9!.b{e6$n F$Xll;lFJMwkln6geni-prekaltikiein:.:=jj:;:
a Hemorrhagic disease of new born is dueto:Vitamin K deficiency.
a
a Hemorrhagic disease of newborn can be prevented by: Parenteral vitamin K at birth.
a
a Not seen rn /IP: Splenomegaly.
:
a ,$fJ,d?i$|&.i?:l$r$elrjfe uction,by,autoa*tibodies.
a Class of autoantibody in ITP:lgG.
a erdtti,ifP: i,r'Ndi3eil
a Chranic ITP: More common in females, spontaneous remission is uncommon.
r:::.j#:;,::t:i:,r,j.,:r .a :.:1;r:rittl:t: r' . :
a il?ledfi**Bt,qftha&€J
a Treatment of symptomotic neanatal polycythemra : Partial exchange transfusion.
a
C Blood volume in a preterm neonate ;90-11 0 ml/kg (average 1 00 mllkg).
t t,tt
3 ,t. 'tti.Slpii6€.i:ea.$.nlia,txotdlxiavbora.,:,'l87oto5.:.8%.
t Pediatric potycythemia is caused by: Cerebellar hemangioma.
*::,a:
I Constitutiona! pqncytopenia is seen in: Fanconi's anemia, dyskeratosis congenita, Shwachman diamond syndrome (but not in Dia-
mond-Blackfan syndrome).
c Epsilon aminocaproic acid and tranexamic acid are indicated in hemophilia when there is; Oral bleeding or epistaxis.
III
d
QUESTIONS
a) Alkali denaturation resistant a) Thalassemia (AIIMS lune 97, PGI lune 97)
f
:-rttr : 1 ti: a ._ r.
Cxg.lyTF.t1,1,1Ii
a) Codominant
28. l{}eieh erlzy \ae defi cieney causes leemolytic anemia-
(All India Dec.14 Pattern)
b) Autosomal recessive
c) Autosomal dominant
a) G-6-PD b) Aldolase
d) X linked recessive
c) Isomerase d) Enolase
Pancytopenia
a) Usually occurs in cow-milk fed babies (At 06) c) Tlpe I RTA
b) Onset occurs at 4-72 week ofage d) All are true
c) Intracranial hemorrhage can occur. 51. Bloodvolume in preterm neonate is - (CET Aug. 13
d) Intramuscuiar r,'itamin K prophylaxis at birth has a Pattern)
protective role
a) 90 m1/kg b) 80 ml/kg
c) 70 ml/kg d) 60 ml/kg
III
ANSWERS
HEMATOPOIESIS
) Ans. is'H i.e., Liver lRef: Robbin's Vh/e p. 620; Nelson lgth/e p. 19971
o During 2"d trimester, the major organ for hematopoiesis is liver.
3. Ans. is'd'i.e., Hb Gowers {Ref: Nelsan trB,h/e p. 20011
o During human development from early embryo to infancy different hemoglobins appear in the following
order -
J
Adrtlt hemoglobin
ANEMIA
7. Ans. is t' i.e., Copper deficiency fRef: O.P. Ghai ?th/e p. 333 6 Vh/e p. 302; De - Grouchy's S,h/e p. 11]
r Miscellaneous causes of megaloblastic anemia
t Thiamine deficiency s Hereditary orotic aciduria r Congenital dyserythropetic anemia
r Pyridoxine deficiency : Di-Gueglielrno syndrome : Hypothyroidism
THALASSEMIA
8. Ans. is ? i.e., Haemoglobin{Ref : O.P. Ghai S*/e p. 341 b Vh/e p. 307; Robbins Ze/e p. 632)
9- Ans. is 'b' i.e., Decrease in beta chain, increase in alpha chain {Ref : O.P. Ghai Btu/e p. 341 dl 7 /e p. 307; Robbin s
7h/e p. 632; Nelson 18tu/e p. 2033, 20j4)
p-globin chains,
oTheabnormalitycommontoallB.thalassemiasisdiminished synthesis of structurally normal
coupled with unimpaired synthesis of o-chain'
10. Ans. is 'd' i.e., > 3.5 lRef : Nelson 18th/e p. 20j5, 20i61
4].r;i:l:1i|
.: --.j:::i...:r::...i.a.::.:a:,.!:jrj!::::::ri:ili;::i.aj:..l::iiiiiltt:,i:il:l::l::ii!:i!ri::'.,i::a:1,1t::1-:i):::.;::1,,.1.
HbF 30-907o
=d?a=j,s"
.
Nestrof test
o This test is being widely used in India and other developing countries in thalassemia
screening Programmes'
to HbA2 estimation for confirmation of thalassemia trait'
o The cases which are positive, subjected
i 1. Ans. is
,c,
i.e. HbA, lRef: o.P. Ghai 8'h/e p. j41 d, 7h/e p. 308; Nelson ISth/e p. 2035, 20361
Hemoglobin A2
p of the normal adult hemoglobin
o In hemoglobin A, the polypepties consists of two o and two 6 chains i.e. the chain
is replaced bY the 6 chain.
e In normal adults hemoglobin A, is present in trace amounts. It accounts for l.5o/o
lo 3.5o/o of the normal adult
hemoglobin.
Clinical imPlication of HbA2
r HbA2 ievels have special application in the diagnosis of B thalassemia trait'
r Elevation of UbA, is present in these cases even through the peripheral blood smear is normal' but
r Microcytosi, uri oth., morphological characteristic;f P-thalassemia trait are also seen in iron deficiency
unlike B thalassemia trait HbA, level is decreased'
t2. Ans.is'c'i.e.,HbelectrophoresislRef:NelsonlSth/ep'2035'2036)
'The diagnosis of thalassemia syndromes is best established by Hb electrophoresis"
a
o Conversely, cells that are hypochronic and Jlatter have a greater capacity
to expand in hypotonic solutions,
lyse at lower concentration, are said to haue ilecreased osmotic fragility.
cells with increased surface/volume ratio are osmotically resistant and
are seen in iron deficiencY,
. fh.r.
thalassemia, liver disease and reticulocytosis'
t4. Ans. is 'd i.e., Thalassemi Hemoglobinopathies by Anupam Sachdeva lth /e p' 100)
t fRef:
o NESTROFT ( Naked Eye Single Tube Red Cell Osmotic Fragility Test)
is a screening test for detection of beta
thalassemia trait.
p. & 6h/e p, 310; Chapman 3'd/e p' 392J
15. Ans. is d i.e., Thalassemia &'d'i.e., Sickle cell anemia [Rel O,P, Ghai }tu/e i43
Bone Changes in Thalassemia
1. Bones become thin and pathological fracture rnay occ.or'
2. Massive expansion of ttre marrow of face and skull
produce s characteristics facies.
3. Severe maxillary hlperplasia and malocclusion'
4. prominant wldening oi diploi. spaces with
"hair on end appearance" caused by vertical trabeculae'
cortical bone
Crew-cut appearance-+
5. striking expansion of hematopoieiically active marrow that erodes existing
and induces new bone formation giving rise to crew cut appearance.
.,Hair on end appearance" -+ Sickle cell anemia, Hereditary spherocltosis, G-6-PD deficiency
Causes of
15. Ans. is'H i.e,, No cr-chain {Ref. Robbiub ftle p. 635)
I People who do not produce enough alpha globin chain have alpha - thalassemia.
N7. Am" i$ '€ i,e., ffb Bart's cannot release oxygen to fetal tissues {R$: Robbins p/e p. 636)
'In the foetus excess gamma globin chains form tetramers (Hb Barts) with such high afrnity oxygen that they
for
deliver almost no oxygen to tissues' - Robbins
18, An$, is T Le.,afuha-thalassemia lRef: N*sn t*/e p. 2037; O.p. Ghai */e p. 3a2 d, #/e p. 311, 3127
r Out of the given 4 tlpes of hemolytic anemias only alpha thalassemia is able to give rise to such severe presentation
birth. In all other conditions the newborn is either normal or has mild jaundice.
at
"Salmonella spp. and S. aureus are the major causes of long bone osteomyelitis complicating sickle cell anemia".
Harrison
)'7
--
Ans. is 'c' i.e.,Myco tuberculosis {Ref Nelson lg,u/e Chap,ter 462.1)
r There maybe infections due to capsulated organisms (Str. pneumoniae, H. influenzae) because of autosplenectomy.
G.6-PD DEFICIENCY
28. Ans. is 'a' i.e., G-6-PD lRef: O.P. Ghai B,h/e p. 339 b Vh/e p. 306; Nelson lyth/e p. 2041)_
r G6PD deficiency causes episodic intravascular and extravascular hemolysis.
19. Ans. is 'd i.e., Type 3 fRef: ltelsan l#hfe p. 2{}4t}
e It is of 3 types :
: Type I is the mildest form.
r Type II is a moderately severe form.
r Type III patients suffer from a non-spherocltic hemolltic anemia even without exposure to drugs.
30. Ans" is 'a' i"e., Iron deficiency anemia lRef: Reed tex below\
MCH pglcell
28-33 pglcell 19.4 pglcell
Antunia
o Microcltic hlpochromic anemia with normoblast and target cells suggests the diagnosis of Iron deficiency anemia.
r Though target cells are uncommon, they may be seen some times.
o Normoblasts : The bone marrow reveals a mild to moderate increase in erlthropoetic activity
manifested by increased number of normoblasts. - Robbins
31. Ans is'{ i"e., Decrcased irritability f&ef Wi*trobekhematotaglt l*fc p. 8291
"When specific iron therapy is given, patients often show rapid subjective improvment, with disappearance or marked
diminution of fatigue, lassitude, and other nonspecificc symptoms (e.g. irritability). This response may occur before any
improvement in anemia observed" Wintrobe's
o The eariiest hematological evidence of response of treatment is an increase in the percentage of reticulocltes and
their hemoglobin content.
a So,
T Overall earliest indicator of improvement --> decreased fatigue, lassitude and other nonspecific symptoms
I Earliest hematological evidence of improvement -+ Increased reticulocl.te count.
32. Ans. is'* i-e.,Increased Reticulocyte eount lRef : 0.P, Ghai #kle p,- 334 & Thfe p. j;all:
Reticulocyte count is the first to rise. This is followed by elevation of haemoglobin levels. Body iron stores are
restored alter correction of haemoglobin levels.
'Rise in Reticulocyte count occurs by the second or third day. This is followed by elevation of haemoglobin levels.
Body iron stores are repleted after correction ofhaemoglobin levels. ' - Ghai
OISORDERS OF COAGULATION
HEMOPHILIA
JJ. Ans" is'C i,e., Endothelial cells fRt' Rohbir;s 7h/ep. 6551
r Von-Willibrand factor is synthesized in vascular endothelium (major source) and megakaryoq,tes.
34. Ans. is t' i.e., t pf tnrf a.P. Ghai re/e p. 351 & 7/e p. 321]
c Hemophilia A is inherited as an X-linked rccessive trait.
o Laboratory findings ,f pff , Normal PT, Normal BT, and Normal platelet counts
35. Ans. is t' i.e., Autosomal dominant lRef Rabbids Tele p. 6551
r Most common pattern of inheritance is Autosomal dominant (> 90o/o)
36. Ans' is 'a'i'e', Isolated prolonged PTT with a normal PT
p. 207j1
IRel o.p, Ghai gtt/e p. jsl 6 6th/e p. 323; Nelson tYth/e
38' Ans' is 'd i'e', Factor XrrI deficiency [Ref : l.B. Henry clinical diagnosis and management by laboratory
20th/e p, 650l
methods
e Bleeding from umbilical stump suggests Factor XIII deficiency.
39' Ans' is t' i'e' Factor XIII tRel !,8, Henry, clinical Diagnasis and Management by Laboratory Methads 20th/e p,
6so1
o Individuals with a positive bleeding history, particularly with features
such as delayed bleeding, umbilical stump
bleeding or miscarriages and in whom the initial panel of screening
test is negative , should be tested for Factor
XIII deficiency.
41" Ans. is 'a' i.e., Prolonged prothrombine time lRef : Nelson lSthle p. 2029, zz31
o In hemorrhagic disease of the newborn there is delay in achieving
the normal vitamin K level.
t There is increased prothrombin time and increased partial thromboplastin time.
42. Ans. is'a'i.e., usually occurs in cow-milk fed babies
[Ref : Nelson rrth/e p. 773)
"Haemorrhagic disease of new born is more common in breastfed
infants because breast milk is a poor source of
vitamin K"
------ Nerson
PLATELET DYSFUNCTION
43. Ans. is ua' i.e., Platelet aggregation lRef : Robbin\ Vh/e p. 653)
Glanzmann's thrombasthenia
c Defect in platelet aggregation due to inherited deficiency ofglycoprote
in IIb-IIIa.
44. Ans. is'a'i.e., congenital defect of platelets lRef Rabbins vh/e p. 65i)
ITP
45" Ans. is t' i.e., Palpable splenomegaly tR# a.p. Ghai Bth/c p, 3sr 6 vh/e p. 3201
MISCELLANEOUS
Ans. is 'd i.e., Fhysiological anernia ffl'ef: A:newin irz inf*ncy, pedistric itc review *neric*n academy of pediatrics
2012)
r Physiologic Anemia of Infancy
1) Hemoglobin drops to low point at age 6 to 8 weeks
2) Erythropoietin nadir drops Hemaglobin
a) Term Infants: Hemoglobin drops to 9-11 g/dl
b) Preterm Infants: Hemoglobin drops to 7-9 g/dl
oc'i"e., RTA
Ans. is Type-I Nelson 78't'/e ch. 52.,4681
tflel
o There is type II RTA in Fanconi anemia (not type I RTA). Other options are correct.
Ans. is'd i.e,n 90 mllkg fkef: Maternal,fetal andneanatal physiologyby Susan Tucker Blarklsumt 4'h/e p. 235; Advsnces
iw pediatrics by Dutta p. 1541
53. Ans is 'b' i.e., Partial Exchange Transfusion fRef Nelson 18th/c p. 77jl
r PCV 72o/o in a neonate suggests the diagnosis of neonatal polycl'themia.
c Polycythemia is defined as central venous hematocrit [also calleil packed cell volume (PCV) or erythrocyte volume
fraction (EVF)I level of greater than 650/o.
o The neonate in question is also having intolerance to feed and abdominal distension.
r So, this neonate is having symptomatic neonatal polycythemia.
Treatment of neonatal polycythemla
o Therapy in newborns with polycy,themia is based on both the measured centrai venous hematocrit level and the
presence or absence of symptoms.
(1) Symptomatic polycythemia
o Partial exchange transfusion is the treatment of choice.
(2) Asymptomatic polycythemia
r In asymptomatic polycyhthemia, treatment depend upon hematocrit level (PCV).
(i) PCV 65-750/o
r Perform cardiorespiratory monitoring and monitoring of hematocrit and glucose levels every 6- l2 hours
and observe the patients for symptoms
r If hematocrit (PCV) becomes more than 757o, consider partial exchange transfusion (pET).
(ii) PCV > 75o/o
r Partial exchange transfusion (pET) is the treatment of choice.
55. Ans. is 'H i.e., 80-f 00 lRef: A,P. Ghai Bthle p. 332 & */e p. 298, Nelson IBn/e p. 2}r.f]
r Mean MCV at the age of 1 months is i04 fL.
,.Birth
bloodf
(c-or! 16.s 5j 108 18.1
1-3 days 18.5 56 10g t B.9
, d.rr... s s! 107
.)l .. .. 12.2
'
6months 11.5. 91 j1.g
: of.reticulocytes
Reticulocyte count Ym9er x 100
Total number oIRBCs
o The reticulocyte count serves as an important tool to indicate shortened RBC survival and the subsequent appropriate
response by the bone marrow to increase RBC production.
o Reticulocl'tes are young RBCs that have just left the marrow but still contain residual RNA.
o Normally, they remain for only 1 to 1.5 days in the blood.
o Normal reticulocytes count in an adult is 0.5% to 2%.
o In normal newborn range is 1.8o/o tg 5.8%.
i -. Ans. is t' i.e., Tibia [Rel lournal of Pediatric 1953; Pediatric (r child health 20081
Sternum: ->
o Hematopoietically active
o Site in cooperative patient like adult
Ilium: -+
o Apprehensive patient
o Useful in older children & adult
Tibia: -+
o Useful in newborn & infant and children below 2 year of age.
60. Ans. is 'c' i.e.,4 x wt (kg) x Hb deficit (gm/dl) fRef: O.P. Ghai 8th/e p. 335 dl Vh/e p. 301)
o Blood volume ml/kg. Each gram of hemoglobin contains 3.4 mg of iron. 50% of more iron should be
averages 75 to 80
given to replenish iron stores. Therefore iron requirements are determined from the equation.
Iron (mg) = r,r,t (kg) x Hb deficit (g/dl) x 80/100 x 3.4 x 1.5
= m (kg) x Hb deficit (g/dl)'x a
61. Ans. is'd i.e., Antibody mediated lRef: Gooilman & Gilman 10th/e p. 10891
62. Ans. is'a'i.e., Constitutional anemia [Ref: O.P. Ghai dt Th/e p. 313; Nelson 18'hle p. 20471
Constitutional pancytoPenia
r Constitutional pancltopenia is defined as decreased marrow production of the 3 major hematopoietic lineages on
an inherited basis, resulting in anemia, neutropenia and thrombocltopenia.
o Important causes are : -
s Fanconi anemia r Amegakaryocytic thrombocltopenia
r Shwachman-Diamond syndrome r Down syndrome
r Dyskeratosis congenita r Noonan syndrome
TII
KX\$MffiEKXETffiLffiGY
GROWTH HORMONE
. Pattern of growth Slowfrom infancy Slowfrom Slow from a few Slow frorn birth
bwlh after birth months
r5l
r End organ resistance to GH (GH receptor resistance) causes 'Laron syndrome' or 'Laron dwarlislnr(DNB
Hyperpituitarism
o MostcommoncauseofhyperpituitarismishormonesecretingpituitaryadenomaarlMs0l).
r The GH excess in children produces gigantism (in adults it causes acromegaly). There is accelerated growth with
enlarged body size (giant). Fatigue and weakness are earliest symptoms due to miid proximal weakness with muscle
atropy, i.e. giant child with weakness (weak giant(ArtMs04)). There may be features of compression due to tumor, e.g.
headach and visual field defects. Macroglossia, broad nose, raised ICI carpal tunnel syndrome and kyphosis may be
seen.
o Oral glucose challange test confirms the diagnosis (there is no decrease in GH leveis after glucose administration. In
normal person, glucose decreases GH secretion).
AMB!GUOUS GENITALIA
r Ambiguous genitalia refers to discrepancy between external genitals and internal gonads. These can be divided
into :-
A) Femalepseudohermaphroditism
, : Genotype is XX@rrs). Internal gonad is ovaryarrs) but external genitalia are virilizedar ls) (male differentiation).
t Congenital adrenal hyperplasia (CAH) due to 2l-hydroxylase deficiency is the commonest causeat NEEI, 13, 02,
pcr 07)
,
r Other causes are maternal virilizing tumor (arrhenoblastoma),maternal androgen administration, CAH due to
1l-beta hydroxylase deficiency, fetal placental aromatase deficiency{at tt), and WNT-4 gene mutationqt tt).
B) Male pseudohermaphroditism
: Genot-7pe is XY(ArIs). Internal genitalia are testis but external genitalia are of femalearrs).
r Important causes :-
l) Defect in testicular dffirentiation: Deletion of short arm of Y chromos ome,XY pure gonadal dysgenesis@Gl
pcl
oo
, Mixei gonadal dysgenesisal 13, 08)
.
2) Drtctintesticularhormonesynthesis:Leydigcellaplasia, 17-ahydroxylasedeficiencyqr13,PGros),3-BHSD
deficiency, 17-20lyase deficiency, 20-22 desmolase deficiency, l7-ketosteroid reductase deficiency.
3 ) Defect in androgen action : S-ct reductase deficiencyQct 0t)
, testicular feminization syndromea'ut) , Reifenstein
syndrome.
4) Defect in mullerian inhibiting hormone.
C) True hermaphroditism
r Both ovarian and testicular tissues are present either in the same (ovotestis) or opposite gonads.
o CAH, also called adrenogenital syndrome@NB rz), is an autosomal recessiye disorder caused by deficiency of e nzqes
involved in synthesis of steroid hormones in adrenal cortex.
r The deflcient enzyme maybe 2r-hydrorylase (most common(err3,DNBr2,NEED),l1-beta hydroxylase, 17 cr-hyd.roxylase,
3B- HSD, and cholesterol desmolase.
Pathophysiology
e All steroid hormones are symthesized from precursor pregnenolone which inturn is derived from<holesterol.
ACTH (adrenal);
LIIIT'SH (gonadal)
Cholesterol I
DHEA.S
I Cholesterol side chain cleavage enzyme (CyP 1t A)
+
Pregnenolone lTc[OH t IToH pregnenolon. J?9-lYu,Se'
I 178 HSD
------a------)
DHEA
J ,or',
Androsrenediol
Progesterone lTaoH
J,ors, lrBru
l7F nto
I
tI3BHSD
, t7 oH Progest..or. JZ?9-lY,ut1 Androstlnediorr" , Testosterone
I
t|
| 2l hydroxylase 2t hyd.o*ytu." I Aro-utur. Aro*utu."
t +
I
+
Deoxycorticosterone Deoxycortisol 178 HSD
I
,I Estradiol
iI
I I I hydroxylase llBhydroxylase
i
Corticosterone Cortisol
I
I I8 hydroxylase
t
18 OH CorJicosterone
tI
I
18 HSD -+ Renin
Aldosterone
2) 1l-B hydroxylasedeficiency
I Cycle will go upto deorycorticosterone and deoxycortisoleurrMsll,Aroe,DNB13) which are raised. So, there will be
i) Excess deoxycorticosterone -) It has mineralocorticoid activity which results in hypertension and salt
1, 0e).
f etentio nqIIMs 1
,, ii) Excess androgen -+Yirllization of female (female pseudohermaphroditism).Inmales, there will precocious
puberty due to excess ofandrogens.
3) 21 hydrorylase deficiency
r Cycle will go upto progesterone. So, there will be :-
i) Deficiency of mineralocorticoid -+ Saltlosing - hypotension,hyponatremia,low chloride, hyperkalemiq,(NBr
AilMS 03)
.
ii) Deficiency of cortisol (glucocorticoid): HypoglycemiaallMs 03' PGI00),
hyperpigmentation (due to excess ACTH)
iil) Excessandrogens-+Yirtlizationoffemale(femalepsueohermaphroditism).Inmales,therewillbeprecocious
puberty due to excess of androgens@EEr).
r ln all these enzymes deficiency, there will be loss of feed back inhibiton on ACTH because of deficient
cortisol. This results in excessive ACTH secretion and hyperplasia of adrenal --+ Congental adrenal
hyperplasia.
r ln all types of CAH, t here is hypoglycemia9claildueto deficiency of glucocorticoids.
ln all these enzymes deficiency, there will be loss of feed back inhibiton on ACTH because of deficient
cortisol. This results in excessive ACTH secretion and hyperplasia of adrenal + Conoental adrenal
hyperplasia.
ln all types of CAH, there is hypoglycemio(Pctoo)due to deficiency of glucocorticoids.
111) Cortisol defciency: Hypoglycemia(Al 11'08' 0'), Hlperpgimention of areolar and scortal areas in males and
genital creases in females (due to 'l eCfU secretion).
iv) Excess Androgen
t Males: Phenotypically normal for some years, precocious puberty.
t Females: Virilization (female pseudohermophrodite) .
C) Non-clasJic(aquired/late) from
r Patients with non-classical form or late onset form produce normal amount of cortisol and/or aldosterone, but
at the expense ofproducing excess androgens.
o These usually present in childhood or early adulthood with premature pubarche & symptoms/signs of PCOD.
o Hirsuitism, Acne and Oligomenorrhea are the most common presentingfeatures.
a) Cushing syndrome
b) 2l-hydroxylase deficiency
c) I 7-o hydroxylase deficiency
d) None
GO.lrApAL prsoRpERS
o Gonadogenesis refers formation of gonads, i.e. testes in rnales and ovaries in females. Genital ridge (urogenital
ridge) is the site where gonads develop. 'Primordial germ cells' are developed in the 4th week by proliferation of
ee)).
endodermal cells(NnEril07) of the dorsal wall of hindgut (part of yolk sacai0s''{P The primordium germ cells
migrate into genital ridge, where proliferation of both germinal and nongerminal cells leads to formation of gcnads.
a WT-1 and SF-l geaes stimulate genital ridge to'form primitive (bipotential) gonad which then differentiate either into
ovary or testis. DAX-I , WNT-4 and RSPaI genes(xt:t:t) are involved in developmett of female gonads (ovary); and
SRY gensdrn; is involved in development o{ male gonds (testes)(NEE?) from primitive (bipotential gonads).
e In male embryo at 6-7 weeks sertoli cells secrete anti-mullerianhormone (AMH), also called mullerian inhibiting
substance which causes regression of mulierian (pararnesonephric duct), the major ducts in fernales for external
genitals. Then the leydig cells start secreting testosterone under the influence of placental lTCG(^rEEr) il 8-12 weeks.
Testosterone causes development of Wolffjan duct (mesonephric duct), the main genital duct in males for external
genitals.
e In female embryo, AMH is not secreted by c;vary, and mulierian duct development occurs.
tz, Endocrinology
Precocions puberty
o Puberty before the age of 8 years in girls
or 9 years in boys is considered precocious
age of l0 years in giils is also considered as precocious. Ttuberty. Menarche before th,
f-.;'i#;F:Ei?e:li
A. Central precocious puberty
1. ldiopathic : Sporadic or familial.
2. Central nervous system abnormalities
i) congenital anomalles of c NS: Hypothalamic hamortomaailMsss,s3),hydrocephalus,
porencephaly, arachnoid
" cysts.
ii) Acquired lesions of CNS : lnflammation, granuloma,
trauma, surgery, radiation@ctos),chemotherapy.
iii) Tumors of cNS : pinear tumors, optic arioma, ependymoma, carniopharyngioma.
iv) Hypothyroidism
B. Peripheral precocious puberty : lsosexual
Boys
1. Testis: Leydig cell tumor, adrenal rest tumor,
testotoxicosis.
2,Adrenal:CAH{21orlt.fihydroxytasedefitiengy)tNgs6atMses,s3),yirilizingtumors{o|/',5].
3' hcc secreting tumors : Hepatomb, hepatobtastoma,
choriocarcinoma, chorionepithelioma, teratoma,
dysgerminoma.
4. Exogenoustestosterone
C. Heterosexualprecocity
1'Girls: virilization in girls due to virilizing CAH,
ovarian or adrenal neoplasia, polycystic
ovarian disease.
2'Eoys: Feminization due to estogen producing adrenal
tumors, exogenous estrogen, marijuana
smoking.
Note: Hypothvroidism usually causes delayed puberty,
but juvenite hypothyroidism ,";".;;.;;;
puberty. .r;;" pr"i'o.,o*
,lg-l
l.rl
Me@
r Central precocious puberty secondary to hlpothalamic
hamartoma.
Delayed pubertY
of 14 years in
signs of sexual development by the age
c Delayed puberty is ilefineil as failure of development of
budding by 13 years or absence of menarche by 16
boy. krgirls, delayed puberty is defined as failure of breast
17 years'
year(Alls) or lack of secondary sexual characters by
Cryptorchidism
of sexual differentiation in boys' At birth approxi-
r An undescended testis (cr-ptorchid) is the most common disorder
mately 4-5o/o of boys have an undescended testis'
first 3 months of life, and by 6 month
the
o The majority of undescended testes descend spontaneously during the
incidence decreases to 0'8%'
o If the testis has not descended at 4 months' it will remain undescended'
o Cryptorchidism is bilateral in 20o/o of cases'
o Consequences of cryptorchidism are :-
i) InfertilitYeqot)
ii) Testicular maligancy -+ Most common seminoma@Glo')
iii) Psychological effects of empty scrotum'
iv) Torsion
v) Associated hernia
done between 6-12 months (6 months is most
o Surgical orchidopexy is the treatment of choice and should be
06' At 04' ee)
aPProPirate)L|IMs '
THYROID DISORDERS
HYPOTHYROIDISM
hormone or a defect in thyroid hormone receptor activity'
o Hypothyroidism results from deficient production of thyroid
Congenital hYPothyroidism
(most common cause);abnormalities in development
o congenital hypothyroidism may be causedby iodine deficiency
l::il::::;i:|j4:;,::i.:.1:: :l::,i:t::::, :::,:.:).:,:,:
;i.:;:t!r;tla::::,a.::l:r.:,,..::f.:::
. ):,/t:..; :.. .
, ...a. -
z Eidouinology l
of thyroid (thyroid dysgenesisarrr)) or thyroxine synthesis; and presence of maternal anti thyrotropin antibod.ies.
o Mutation in Pendrin gene (SL26A4) located in chromosome T leads to pendered syndrome(Pcr04) which is characterized
by bilateral sensorineural hearing loss@Gl
04),
iliffuse colloidal {oitys@et o<; which later becomes nodular@c, or),
Clinical features
r Neonate is normal at birth due to presence of maternal thyroid hormones.
o First clinical sign is prolongation of physiological jaundice due to delayed maturation of glucuronide conjugation.
r Other features are :-
r Open posterior fontanel 6rts)ur4 *14" sutures r Umbilical hernia(Pclo
t Large tongusqtas) -+ Can cause respiratory dfficulties r Edematous, characteristic facies
r Rough dry skin(Dvr rs) which is cool & mottled : Constipation
r Hlpotonia, large abdomen, flaccid muscles r Pallor, hypothermia
r Sleepy, little cry, poor feed & chocking spells during feeding. r DelaYed PubertY(Pct 06' AnMs e!)
r Short neck with thick supraclavicular pad of fat may be present. r Refractory anaemia common
: Marked physical & mental retardation(DNB rs, ArMs oi),delayed social r Siow pulse, cardiomegaly & Heart murmur.
smile. r Delayed dentition.
r Short stature(oc'06), normal head size with short extremities. r Open mouth with protuberant tongue
t Short stature is disproportionate (upper segment > lower t Delayedbone growth (Bone age <
e4),
segment)(AIIMS chronolo gic al age)Gaus eo.
r Delayed relaxation ofdeep tendon reflexes.
o Note : ln congenital hypothyroidism there is hypotonia. Rarely the muscle may appear hypertrophied
(pseudohypertrophy) with and athletic appearance --+ Kocher-Debre-semeloignl synaromi'gives infont
hercules appearance.
iv) Centralhypothyroidism
r It is due to defective TRH secretion by hlpothalamus.
r There is no goitre and TSII is also reduced along with To6t tt).
X-ray findings
o Delayed appearance of ePiPhYsis
o Multiple foci of ossifcation -+ Epiphyseal dysgenesis
o Epiphyseal breakinglAttMs01) of 12th thorasic and l't or 2d lumber vertebrae'
r Skull -s (i) Large fontanelle, (11) Wide sutures, (Iir) Wormian bonesqttMs 01)
Enlarged 6 rounded sella turcica
e Delayed dentition
Treatment
o Levothroxine is the durg choice to treat hypothyroidism in children(Mo"ipd0e) '
Cretinism
o Cretinism is nothing else but the most severe form of hypothyroidism.
o Cretinism is a condition of severely stuntedphysical and mental growth dlue to untreated congenital hlpothyroidism
or from prolonged nutritional deficiency of iodine (acquired hlpothyroidism).
r When cretinism is due to nutritional deficiency of ioidne@Gl0i) it is referred to as endemic cretinism and when due
to congenital hypotlryroidism it is called sporadic cretinism.
c Thus clinical features of cretinism includes b oth features of congenital hypothyroiilism (in sporadic cretinism) and
acquired hypothyroidism (in endemic cretinism).
a) Hypopituitarism
b) Cushing syndrome
c) Addison's disease
d) Hypothyroidism
HYPERTHYROIDISM
Hypocalcernia
r Normal serum calcium level is between 8.9 - L0.2 mgldl. Symptoms of hlpocalcemia develop when calcium level falls
below 7.5 mgldl.
o Hypocalcemia presents with symptoms of tetany i.e., twitching, numbness, muscle cramp, carpopedal spasm and
laryngospasm.
r The characteristic signs are Chvostek sign (facial muscle spasm after tapping of face) and Trousseau's sign (flexion
of wrist and hlperextension of fingers after.inflation of sphygmomanometer cough).
o Treatment of choice for acute symptomatic hypocalcemia (tetany) is intrayenous calcium gluconateuuMs 00, uP 07) or
calcium chloride.
Hypercalcemia
o Hypercalcemia is defined as serum calcium > 11 mg/dl.
I Presenting features are hypertension, pol1uria, constipation, anorexia, depression, hlperreflexia, short QT interval,
band keratopathy, pancreatitls and peptic ulcer. Treatment of symptomatic hlpercalcemia includes furosamide,
glucocorticoids, calcitonin and bisphosphonates.
o Three important hlpercalcemic states are hlperparathyroidism, idiopathic hypercalcemia of infancy and familial
hypocalciuric hypercalcemia.
A) Hyperparathyroidism
r Most common cause in children is benigr parathyroid adenoma.
I There is increased serum calciumat 04), decreased serum phosphateal 04)
, increased alkaline phosphatase\, on)
,
increased serum parathormone, normal serum bicarbonate, and increased urinary calcium.
B) Idiopathic hypercalcem ia of infancy (I{illiams syndrome(Ar e3))
r It is due to abnormal metabolism of vitamin D.
r It is charact erizedby mental retardqtion, *upravalvular aortic stenosisQcl 8e),
etfin facies and motor deficit.
: Vitamin D and calcium intake should be restricted.
t It resalves spontaneously by age of 4 years,
C) Familial (hereditary) hypercalcemic hypocalciuria
r It is an autosomal dominant disorder due to mutati on ir calcium sensing receptorsAilMs oil in renal tubule and
parathyroid gland.
t There ishypercalcemia, hypophosphatemia, increased PTH, decreased urinary calcium (hypocalciuria)(etus
os)
snfl normal alkaline phosphatase.
r There is nephrocalcinosisqllMs 0s).
Hypoparathyroidism
r It can be caused by aplasia of parathyroid gland (Digeorge syndrome), HDR syndrome (hlpothyroidism, deafness,
renomegaly), autoimmune destruction or accidental surgical removal.
r Serum calcium is low with elevated phosphate.
o Musculoskeletal pain and cramps are the eailiest symptoms and progress to numbness, stiffness and tingling of the
hands and ferl(MAaE os).
ldiopathic hYPercalciuria
iru presence of normal blood calcium'
e It is an autosomal dominant disorder charucterizedby hypercalciuria
hematuria, dysuria and abdominal pain'3
r There is nephrolithiasis (renal stones)(Nmsos),recurrent
Diabetes Mellitus
r DM can be classified into :-
1) Insulin dePend.ent DM (IDDM) of of pancreas'
r It is the most common type of DM in children.It is caused by autoimmune destruction B-cells
like Addison's ilisease'
r There is strong assoicat rarrwlthilLA DR3 ardDR4, and with other autoimmune disorder
Hashimoto's thyroidis and celiac disease'
2) Non-insulin dependent DM (NIDDM)
the prevalence of NIDDM
r It is usually seen in older age; however during last 2 decades there has been a rise in
in children due to increasing obesiry
r It is a polygenic disorder which is caused by multiple factors, genetic and environmental'
3) Maturity oruset DM ofyoung (MODY)
25 years'
r It is an autosamsl dominant disorder seen in at least 3 generations before age of
r It is due to defective insulin secretion'
r It is caused by mutation in glukokinase gene'
are increased fasting blood sugar > 126 mgldl,random blood sugar > 200 mgldi and blood
I criteria for diagnosis of DM
> mgtdl2 hours after glucose toaa of 1'75 g/kgiPctlil to a maximum of 75 gm?Gt0T) ift glucase tolerance
glucose 200
test.
Treatment
r IDDM is treated with insulin whereas NIDDM is treated by diet modification' exercise and oral hlpoglycemic'
Nesidioblastosis
(PHHr) or congenitalhyperinsulinism
r Nesidioblastosis, also call edpersistenthyperinsuliruemichypoglycemiaofinfancy
(CI),isthemostcommoncauseofhyperinsulinemichlpoglycemiainneonates(Arl,)'
r It is due to$ - cellshYPertroPhY'
tt)'
o It usually affects infants and childrenbt
t Adults are affected less commonlyul') ' lt)
r There recurrentlrypoglycemic atta*s6t '
are
1r),
octeride and nifedipine'
o Treatment includes iv glucose, glucagon, diazoxideql
@
&
(B
&
&
&
&
&
&
&
QUESTIONS
c) XY ll, A f0dayoldmalepseudohermaphroditechildwith
di Female sexual characteristic with both testes & 46K{.karyotype presentswith BP of f 10/80 mmfu,
ovary Most likely e nzyme deficiency is - (AI::
Male pseurlohermaphrodism - (All India Dec15 Pauern) a) 21 hydroxylase
a) XX genorype, male external genitalia b) 17 hydroxylase
b) XY genotype, female external genitalia c) ll hydrorylase
c) Testis and ovaryboth present d) 3- beta hydroxylase
d) Male external genetalia and ovary present t2. A fiveyear old boy preeents with precocious pubertr
Cauees *f fernale pseudoherrnaphrodisrr - and a blood pre$sur€ of 130/80 mmHg. Estimation
(All lndia Dec.13 Pattern) of which of the following will help in diagnoois -
a) i7-alpha hydroxylase deficiency @r n,
b) 21-alpha hydroxylase deficiency il t tz hydroxy-progesterone
c) Mlxed gonadal dysgenesis b) t Cortisol
d) All of the above c) t Aldosterone
The most common cause of ambiguous genitalia in a d) t fi deoxycortisol
newborn is - (Ar 02) 13. A S-yr old boy presents with pubic hair develop-
a) 21 hydroxylase deficinece ment. He ie tall and has increased pigmentation
b) 11 p - hydroxylase deficiency of his genitalia atd phallic enlargement. Blood
c) 17 a - hydroxyalse deficiency pressure is 130/90 mm Hg. Measurement of which
d) 3 p - hydroxysteroid deficiency of the following hormones would be mosi likely to
5. Fseudohermaphrodifism in a fernale child io rnost be diagnostic? (AIIMS May t-
cornrnomiy due to - (NEET Dec.12 Pattern) a) Increase L7 beta hydroxyl progesterone
a) 2l-hydroxylase deficiency b) Increase cortisol
b) I 7-hydroxylase deficiency c) Increasealdosterone
c) I l-hydroxylasedeficiency d) Incrbase 11 deoxycortisol
d) 3-hydroxylase deficiency 14. Congenital adrenal hyperplasia is associated with-
.&drenogenifal syndrorne is most eommonly caused a) Hypoglycemia (PGI Dec 2ii
41. A child with decreased levels of LH, FSH and Testos- 49. The features ofneonatal hyperthyroidism include all
terone presents with delayed puberty. Which of the except - (CET Nolr. 11 Pattern)
following is the most likely diagnosis - (Ati2) a) Triangular facies with craniosynostosis
a) Klinfelter'ssyndrome b) Congestive cardiac failure
b) Kallmant syndrome c) Advanced osseous maturation
c) Androgen Insensitive syndrome d) Goiter is rare
d) Testicularlnfection
HYPOPITUITARISM & HYPERPITUITARISM
HYPOTHYROI DI SM & HYPERTHYROIDISM
50. A 9 year old boy presents with growth retardation
42. NOT a feature of hypothyroidism is (CET lune 14 and propensity to hlpoglycemia. Physical examina-
Pattern)
tion reveals short stature, micropenis, increased fat
and high-pitched voice. The skeletal survey reveals MISCELLANEOUS
bone age of 5 years. Which of the following is most
appropriate diagnosis - 6ltMS Nov 01) 60. A l0-month old baby previously norrnal, suddenly
becomes distressed in his crib' The external appear-
a) MalabsorPtion
ance of genitalia was normal, except hyperpigrnenta-
b) Growth hormone deficiencY
c) Adrenal tumour tion. Blood glucose showed a level of 30 mgTo' What
is the most Probable diagnosis?
d) Thyroxin def,ciencY
a) 21 hydfoxylase deficiency (At 11, AttMS May 11' 10' 09)
51. Characteristic features of growth hormone deficien- b) Hyperinsulinism
cy include all of the following except -
c) Familial glucocorticoid deficiency
ai Short stature since birth (AlllndiaDec'l4Pattern)
d) Cushingt sYndrome
b) SymPtomatic hlPoglYcemia
c) Delayed tooth eruPtion 61. Which one of the following is the earliest manifesta-
d) Sexual infantilism
tion of Cushing's sYndrome-
(AltMS MaY 0s)
- @llMS Malt
a) Loss ofdiurnalvariation
'Weak giants'are produced by
01)
52, b) Increased ACTH
a) Thyroid adenomas c) Increased Plasma cortisol
b) Thyroid carcinomas d) Increased urinary metabolites of cortisol
c) ParathYroidadenomas
d) PituitarY adenomas 62. ACTH secretion is highest during -
a) Noon (A.ll lrulia Dec.14 Pattern)
t3. Laron dwarfism is caused bY -
b) Evening
a) deficiency of GH (cET Nov 15 Pattern)
c) Morning
b) GH recePtor defect
d) Night
c) deficiencYofthYroxin
d) ThYroxin recePtor defect 63. A old boy has a fracture of fernur" Biochem-
10 year
ical evaluation revealed Hb f 1'5 gmldl and ESR 18
54. Which is false in Congenital Hlpopituitarism?
a) Growth hormone level < 7 ng/ml mm Ist hr. Serum calcium l2'8rngidl, serurn phos-
phorus 2.3 mgldl,alkaline phosphatase 28 K'd units
b) HlPoglYcemia
c) BabY small at birth andblood utea32mg/dl.' Which of the following is
the most probable diagnosis in his case- ,A104)
d) DelaYed PubertY
a) Nutritional rickets
55. Short stature, secondary to growth hormone defi-
b) Renal rickets
ciency is associated with - @ILMS Dec 95)
c) HlPerParathroidism
a) Normal bodY ProPortion d) Skeletal dYsPlasia
b) Low birth weight
c) Normal ePiPhYseal develoPment 54. A baby presents with tetany' First thing to be done is
d) Height age equal to skeletal age administration of - (AltMS lune 2000)
ltt
ANSWERS
AMBIGUOUS GENITALIA
ts"rt*. i^s "W &.*., b6*1* s*wxa| eh*raeter;st* with *v*ry { It e f: N*ts*w t *tk l e p- 2 3 6*}
o Genotype is XX. Internal gonad is ovary but external genitalia are virilized (male differentiation).
&xe. i& '-m* i.e., W g*ztts€yp*.,{*rxx*,X* eNterwal genit*lia
c Genotype is XY. Internal genitalia are testis but external genitalia are of female.
to. Ans is'l i,e.,Fetalplacental steroid sulfatase deficiency lRef williams 2vd/e p. BII
t Placental steroid sufatase deficiency is an X-linked disorder (affects only males) that does not lead to ambiguous
genitalia in afemale child.
c 'Placental steroid suJlatase deficiency is a rare X-linked disorder and all
affectedfetuses are males' -William\ 22,d/gl
o Congenital adrenal hlperplasia is the most common cause of ambiguous genitalia in female child.
r Fetal placental aromatase deficiency and WNT-4 gene mutation cause ambiguous genitalia in female child.
tl. Ans. is 'V i.e,,17 ahydroxylase lRef, Nelson t&h/e p. 2j66|
r This neonate has : -
i)Hypertension (normal BP in a neonate = 7Sl5O)
ii)
Male pseudohermaphroditism.
o This is seen in 17-alpha hydroxylase deficiency.
13. Ans is ld' i.e., Increase 1l deoxycortisol [Rel Nelson 18th/e p. 2362)
c Presence of Precocious puberty in a male child and lrypertension (BP of 130/80 in a 5 year old child is considered
hypertension) suggests a iliagnosis of congenital adrenal Hyperplasia due to 11-$ Hydroxylase deficiency.
r levels and excretion of 11 deoxycortisol is increased.
t4- Ans. is'a'i.e., Hlpoglycemia,'b" i.e., Hyponatremia, t'i.e., Hypokalamia, t'i.e., Hyperkalemb[Ref. Nelson
18'h/e p. 2j621
r Also see previous explanations : -
r Depending into type of deficiency, congenital adrenal hlperplasia (CAH) may be divided into : -
1. Salt retaining (17 -a hydrorylase or 11-B hydroxylase deficiency)
r Due to excessive mineralocorticoids there is -+ 1) Hypernatremia r11) In cr e as e d chlor i de
15. Ans. is 'a' i.e., Congenital adrenal hyperplasia {Ref: Nelson 18th/e p. 2j621
r Clinicalprofileofbabygiveninquestionmatchonlywithcongenitaladrealhlperplasia(mostprobably2lhydroxylase
deficiency).
Clinical manifestations of 2lhydroxylase deficiency : Sign and symptoms of cortisol and aldosterone deficiency are
produced.
c Progressive weight loss o Dehydration o Hypoglycemia
r Anorexia r Weakness r Hlponatremia
r Vomiting r Hypotension r Hyperkalemia
Lab findings : Tlpical laboratory finding associated with cortisol and aldosterone deficiency including hlponatremia,
hlperkalemia, acidosis and hlpoglycemia.
-+ Point to the remember is that the other form of CAH like iTcr hydrorylase and 1-B hydroxylase produce hypertension.
1S. Asas" is'"n* i.e., ?1 u- hydroxylase > t'i.e., 3- treta hydrorysteroitl dehydrogenase lftef Nelson 18d'/€ ch. 577;
{}kr! 7"/e p. 4921
r Hlponatremia, hlperkalemia and hlpoglycemia is seen in 21 o-hydroxylase and 3 p-hydroxysteroid dehydrogenase
(3 B-HSD) -+ Both have similar manifestations.
r But best answer is 2l-hldroxylase deficiency, as it is the most common cause of CAH.
21. Ans is
.a, i.e., congenital Adrenal Hyperplasia (cAH) fRef: Nelson 18th/e p. 23621
hypoglycemia and shock in this eight year old
o presence of wmiting, lethargy, dehydration, hyponatremia, hype*alemia,
male infant suggest a diagnosis of neonatal adrenal insuficiency/crisis'
t congenitalAd.renalHyperplasiaisthemostprevalen{rourriTodr"nalinsufi.ciencyinneonates(typicallyT-14days
joriaaiu"ryl and thi ilngle best answer amongst the options provided.
22. Ans. is
.b- adrenal hyperplasia fRef: Harrison 18th/e p'i053, i054; william's
i.e., simple virilizing congenital
p'240' 2411
Endocrinology, Essenlials ofPaediatrics 4th (Elsevier)
o Among the given options only 2lhydroxylase is the common cause of ambiguous genitalia' hypotension'
r Now the confusion'urir.s, be.au.e it-nyaroxytase deficiency tlpically presents with salt wasting and
whereas the child in question is having normal BP'
loss'
r Actually, some forms (simple virilizing form) of 2l-hydroxylase deficiency have normal BP and no salt
23. Ans. is'd i.e., 17 hydroxyprogesterone lRef : Harrison lVh/e p' 2345-23461
2L - hydroxylase deficiency'
o This is a case of congenital adrenal hlperplasia due to deficie rlcy of
which is then shunted into
o Because of the enzyme block ,there is increasedformation of iz hyilroxyprogesterone,
-
the production of testosterone.
o Levels ofcortisol and aldosterone are reduced'
{r 7h/e p, a59|
24. Ano, is 'W 1,e.,2|-u*lydraxyluile d*fisi*n*y t\e!: {},P, Gh*i 8,h/* p. 526-527
deficiency, causing hyponatremia and hyperkalemia'
r Na* is lZ2 (hlponatremia). That means, there is salt losing enzyme
hyperkaiemia. 17cr-hydroxylase and 1 1-B hydroxylase deficiency
o 21 hydroxylase deflciency causes hyponatremia and
i.e., Congenital Adrenal Hyperplasia (CAH) fRef: Nelson 18th/e p' 23621
Ans is'a'
hypoglycemia and shock in this eight year old
o Presence of vomiting, lethargy, dehydration, hyponatremia, hype*ale1nia'
maleinfantsuggestadiagnosisofneonataladrenalinsuficiency/crisis.
o congenitalAd.renalHyperplasiaisthemostpreuol"rirourriTailrenalinsuficiencyinneonates(typicallyT-14days
poridrliurryl ana *i in[te best q.nswer amongst the options provided.
Harrison 18th/e p'3053, i054; william's
Ans. is
.b- i.e., simple virilizing congenital adrenal hyperplasia fRef:
p'240' 2411
Endocrinology, Esseniials ofPaediatrics 4th (Elsevier)
o Among the given options only 2lhydroxylase is the common cause of ambiguous genitalia'
tlpicalty presents with salt wasting and hlpotension'
o Now the confusion arises, becaus. it-hydro*ylase deficiency
whereas the child in question is having normal BP'
deficiency have normal BP and no salt loss'
o Actually, some forms (simple virilizing form) of 2l-hydroxylase
27. Ans. is .d i-e", As snon as pregnancy is diagnooed {Ref Netso* l#/e p. %Gal
. Recommendations for pregnancies ar risk of CAH consists of administration of dexamethasone (20 mg/kg). It started
by 6 weeks of gestation, this ameliorates the virilization of the external genitilia in affected females chrionic villus
sampling is then performed to determine the sex and genotype of the fetus; therapy is continued only if the fetus is
an all'ected female.
r As ;rregnancy is diagnosed (by urine test) at around 6-8 weeks, so it should be the answer.
28- Ans. is 1a'i.e., > 6O0 (best probable answer) {Rel Medilineptus)
r Normal value of l7-hydroxlprogesterone in an infant/children > 1 months old is less than 100 ng/dl.
r In infant with cAH, 17-hydroxyprogesterone levels range from 2000-40000 ng/dl.
33" Ans. is'a'i.e., Tirrnor nf hypothalamus [ReJ: Nelsan 1*/e ch. 56j]
r Peripheral or pseud-precocious puberty is caused by increased secretion of sex steroids from adrenal or gonads
(testis or ovary).
r Central lesions (hlpothalamic) cause central or true-precocious puberty.
36" Ans, is ?' i-e., Congenital 2f-hydroxylase lRef: O.P. Ghai */e p" 532 tabl& (17.32) & 7/e p. 49* Nelson l*te p"
2j621
r Congenital 2 t hydroxylase deficiency causes precocious puberty in male due to excess of androgens.
r In female, it results in virilization
37- Ans" is t" i.a, [acrease F$Il increasc LH
o Hypergonadotropic hypogonadism is characterized by high FSH and LH.
e It is also called as primary hypogonadism or peripheral hypogonadism.
r The defect is at gonads level, so that sex hormones are not secreted and there is no feetl_back control on FSH ancl
t,H
-+ Increased secretion of FSH anil LH.
3S. Ans. is'H i,e, Mcn*rch e > 16 yexrr lR$; Gkai Z* le p- Wtl
o In girls, delayed puberty is defined as failure ofbreast budding by 13 years or absence ofmenarche by l1year ar
lack ofsecondary sexual characters by 17 years.
39. furs" i.c ti i.e-, C nstitution*llRf; *"P. Gh*i *fcp 535 tabtc (IZ.w) & Ple p. So3; AsWs &fc p. zg&j|
. Most common cause of delayed puberty is constitutional.
&. Ans, is'H i.e., Wwrln syndronre
r Turner syndrome, Klinefelter slmdrome and Swyert syndrome cause hypergonadotropic hypogonadism.
&'" Ans- is ud i-e,fuwrtwreft*earparllwhaw&s1wef: A,P. Gkai */e p StGsIf & frlep. 482-48.j; Nelsar I*/e p 2jZ2\
Hypothyroidisrn causes -
i) Delayedbone growth (Bone age markedly delayed)
ii) Delayedpuberty &
iii) Alteration in upper and lower segment ratio (upper segment > lower segment)
43- Ans" is 'H i.e., Hypothyroidism [Ref a.P. Ghoi */e p. 51s & 7/e p. 481; Nekon I*le p" 2322, z3zs]
e Multiple epiphyseal breaks, wormian bones with lethargy, growth retardation and mental retardation
suggest the
diagnosis of hypothyroidism.
44" &"ns- isY i.c.,@[email protected];i*w
a Hypothyroidism causes mental reterdetion along with skin dryness and olher features.
45. Ans. is'd i.e., Short limbs conpared to trunk; t'i.e", Short timbs and short stafirre
lR$ Netson l*/e p.
23i11
"The child's growth is stunted and the extremeties are short. The hands are broad and the fingers
are short,,.
"The child appears short and stocky'l
Congenital Hypothyroidism
About option d
o TSH resistance can also produce same picture i.e. raised TSH and low T4 with pituitary swelling.
o There is thyroid insensitivity to TSH which results in hypothyroidism (JT+ and T3). Because of reduced thyroid
hormone feedback, TSH is markedly elevated.
o However, Amongst the given options best option is primary hlpothyrodism because TSH resistance is a very rare
condition and further T4 levels are normal in Mild and moderate (Partial) TSH resistance.
Complete
.111...'' flofoyld hvn-9nl3sia .....
R"-::oiu"
. . r*:
:lr:,:+t ,t,':,.;, .l l!0Jmi!,,,:, hypoplasia
Mild Recessive Two
Partial (Mild) t Normal Normal Dominant One
48. Ans. is 'a' i.e., Cord blood at time of birth fRef: Neonatal Thyroid Sceening by Anju Virmani : Guidelines; Indian
fi
Academy of p ediatrics : http: / / w ww. iapin dia. org/ guidelines/ index. cfnl
o Neonatal hypothyroidism screening is done either in cord blood at the time of birth or blood obtained from heal prick
after 2 days of birth. Cord blood analysis at birth is preferreil approach as many patients do not turn up after 2 days.
49. Ans. is'd' i.e., Goiter is rare [Ref: Nelson 18"/e p. 2j30)
o Goiter is almost always present in congenitally hyperthyroid infants" -- Nelson
HYPOPITUITARISM & HYPERPITUITARISM
50. Ans. is 'b' i.e., Growth hormone deficiency lRe! O,P. Ghai 9th/e p, 511 6 Vhle p" 474; Nelson lSthle p. 22961
o Growth retardation along with hypoglycemia, micropenis, increased subcutaneous fat and high pitched voice is
characteristic ofGH deficiency. There is delayed puberity and skeletal age is less than chronological age.
51. Ans. is'a' i.e., Short stature since birth [ftel.' Nelson 18th/e p. 2296]
o The child with h)?opituitarism is usually of normal size and weight at birth.
52. Ans. is 'd' i.e., Pituitary adenoma lRef: Hanison 16h/e p. 2090; Nelsan l8.thle p. 2303, Xa4l
I Hlperpituitarism causes giants which have weak muscles and the most common cause of hyperpituitarism is
pituitary adenoma.
)-r- Ans. is'tr' i.e., GH receptor defect lRef: Nelson lVh/" ch' 5581
r Laron dwarfism is due to end organ resistance to GH (growth hormone recePtor resistance).
54. Ans. is t'i.e., birth [Rel O.P. Ghai 9e/e p. 511 6lh/e p, 474; Nslsan 18*/e p. 2296)
Baby small at
55. Ans. is 'd i.e., Normal body proportion [Rel O.P, Ghai 8n/e p. 511 6 Vhle p. 474; Nelson 18th/e p. 22961
56. Ans. is'a' i.e., Hydrocortisone
o Hydrocortisone, followed by GH are vital to be given in a child with lost pituitary function.
UNDESCENDED TESTIS
57. Ans. is'b" i.e., Infertility; t' Risk of malignancy lRel Nelson 18e/e p. 22601
Consequences of cryptorchidism
o Infertility o Torsion
r Testicular maligancy -+ Most common seminoma r Associated hernia
o Psychological effects of empty scrotum,
58. Ans. is'b' i.e., 6 months of age lRef: Nelson 18th/e p. 22611
"The congenital undescended testis should be treated surgically no later than 9-15 months. Surgical correction at
6 months is approPriate". - Nelson
lmportance of age at orchidoPexY
N Why after 4 months
testes descent spontaneously during first 3 months.
c The majority of the undescended
o So, orchidopexy should be done at 6 months, because spontaneous descend of the testis will not occur after 4
months of age.
59. Ans. is 'b' i.e., l-2 years fRef: Nelson 18th/e p. 22611
"Congental undescended testis should be treated surgically no later than 9-15 months. Surgical correction at 6
months is appropriate". - Nelson
MISCELLANEOUS
50. Ans. is t' i.e., Familial glucocorticoid deficiency lRef : Nelsan 18th/e p. 2j561
CNinital features
r Patients with familial glucocorticoid deficiency generally presents with signs and symptoms of adrenal
insufficiency with the important distinction thal mineralocorticoid production is ilroyt nor*ol.
o'Ihe most common initial presenting sign is deep hyperpigmentation of the skin, mucous membrane
or b<lth as a result of the action of adrenocorticotrophic hormone (ACTH) on cutaneous melanocyte stimulating
hormone (MSH) receptors.
r The syrnptoms are compatible with glucocorticoid deficiency. Many patients presents with recurrent
lrypoglycemia ar severe infections.
I In the neonatal period, frequent presenting signs include - feeding problems,
failure to thrive, regurgitation
and hypoglycemia manifesting as seizures.
61- Ans" is 1f Le", Loss of diurnal variation [R*J Nelsar 1*/e p. 2369; O.p. Ghai */e p. 524 & ?/e p. a90)
Nelsem writes -
"Laboratory
findings (for Cushing Syndrome)
s Cortisol levels in blood are normally elevated at 8 AM and decrease to less than 50o/o by midnight except in
infants and vttung children in whom a diurnal rhythm is not always established. In patients ,itt ,rihing
syndrome this circadium rhythm is lost, and cortisol levels at midnight and I AM aie usually comparable.
Abtuining diurnal blood samples present logistical dfficulties as part of an outpatient evaluation, bui cortisol
can be' measured in saliva samples, which can be obtained at home at the appripriate times of day. Night time
salivary cortisol levels are elevated and may be a screening test in obese chilitien.
64" Ans. is t'i.e., Calcium gluconate JRef O.p. Ghai */e p. 5ZZ & fr/e p" 4BZ; Nelson 18tu/e p. 23401
r The baby presenting with tetany is hypocalcemic, so must be treated immediately with calcium gluconate I.V
65' Ans" is'b'i.e., IV calcium gluconate with cardiac monitory {Ref see abovel
66. Ans. is 'b'i.e., Receptor insensitivity in kidney tubules lRef: O.P. Ghai 8th/e p. 514 6 Th/e p. 4771
r In nephrogenic diabetes insipidus, level of the ADH is normal.
t The defects lies in the distal tubule where the cells fail to respond to ADH.
$7. Ans is 'H i.e., r.75 gm/kg glucose; b' i.e., 25 gm as an adult [Rc-f, Nelsor t8e/e p. 2946)
Oral glucose toleranre test
r Doses are
i) Adult -) 75 mg
ii) Chilil -) 1.75 gm/kg of ideal weight, up to a maximum of 75 gm.
Cneprpn
6&. Ans. is ?' i.e., -A"fter 5 yearc lR$: AFI Text b*ok *f Medicixe *fe p. l li6j
o In IDDM, initial retinal examination should be done 5 yrs after the onset of disease as the sight tlireateniirg t'tIil,lopatili
usually does not appear in the 6rst 5 ps & thereafter', these should be screetted annualy by rel,ita cxLre ris.
o For NIDDM, initial examination should be done right lionr the tirne of diagnosis, i:recause upio 21qi. paxit:tlts lr.t'ic
retinopathy at the time of diagnosis & the reafter annualil'.
r Diabetic women rvho become pregnant, shoulcl have dilated e1'e exanrination irt the tti'st li:iurt'str't- r* t:l*sr:1nllo",';,.'
throughout the pregnancy.
,4"*s, is
nb'i,*,, 25-3{ }itis*t', JS'ri i-ll:,:tll:'.::1ll
$*" ,qat-!l.t'.!:
r Several factors influence the initial daiiy insr.rlin close per kilograrn olbocl,v i,r'eigirt.
c The dose is usually higher in pubertal children.
r It is higher in those who have to restore greater deficits of bodir glycogen, protr:'in, arr,l lll siol.r:s alld u,ho, titt:it'ir': '
:.Blilusinsrilin: ,':r::: : r
Age Target glucose Totaf daily insulin Basal insulin, o/o of Units added per Units added per 15
(yr] ' {Mg/dl} l ' tulkgtdl total daily dose lOO mgldt above . rgatmaal
target
0-5 1 00*200 0.6*0.7 25-30 0.50 0.50
e Newlydiagnosedchildreninthe"honeymoon"mayonlyneed60.T}oioofatuilreplacernentciose.'lbtaidailydoscper
kg increases with puberty.
'71 ,A"ns. is '-o- i.e., &trutatio* of ealciuxn sensing receptor {Ref : Nelsan 17h/e p. 215; Harris*w 16'hle p. 225*}
Histopathology
o Microscopically, pheochromocytomas are composed of polygonal to spindle-shaped chromaffin cells and their
supporting cells, compartmentalized into small nests or "Zellballeni'by a rich vascular network.
o The cltoplasm of the neoplastic cells often has a finely granular appearance, highlighted by a variety of silver
stains, because of the presence of granules containing catecholamines. Electron microscopy reveals variable
numbers of membrane-bound, electron-dense granules, representing catecholamines and sometimes other peptides.
The nuclei of the neoplastic cells are often quite pleomorphic.
Presentation
o Most patients with PHHI present shortly after birth with symptoms of hypoglycemia (e.g. hunger, jitteriness,
Iethargy, apnea, seizures). Older children, in addition to above symptoms, may also show diaphoresis, confusion,
or unusual mood or behaviour changes.
o The symptoms may be exacerbated by fasting and may improve after eating.
Treatment
e.
o Immediate treatment of hlpoglycemia is essential. Patients may require continuous IV glucose infusion. Glucagon
through
may also be administered.
is though r Other drugs used are diazoxide, octeride and nifedipine.
o Surgical treatment is indicated if medical therapy does not maintain normoglycemia.
nd starts
nount of
ANSWERS OF VARIOUS OTHER EXAMINATIONS
)ecreased 78. Ans. is 'd i.e., T4 TSH assary [Ref Has been explained)
r It is typical presentation of hlpothiroidism
79. Ans. is'a'i.e., Premature closure of posterior fontanelle {Ref: Nelson 18th/e p. 2322)
r There is delayed closure ofposterior fontanelle.
80. Ans. is'c'i.e., Levothyroxine fRef: O.P. Ghai 8'h/e p. 5186 Vh/e p. 483)
::rans from
81. Ans. is t'i.e., Graves disease [Ref : O. P. Ghai 8'h/e p. 520 6 7h/e p. 485)
eptide and 82. Ans. is 'b'i.e., Tingling of extremities [Rel Nelson 18th/e p. 2i43, 2j44; CPDT 18th/e p. 955)
o Musculoskeletal pain and cramps are the earliest symptoms and progress to numbness, stiffness and tingling of the
:.nr- authors hands and feet.
o These are symptoms of tetany due to hlpocalcemia.
dence. 83. Ans. is'd i.e., McCune - Albright's syndrome fRef: O.P. Ghai |th/e p. 5i2 d2 7h/e p. 499)
McCune - Albright syndrome is characterized by -
i) Cafe - au - lait spots iii) Precocious puberty
-s and their ii) Polycystic fibrous dysplasia ofskeleton iv) Endocrinopathy + Hlpothyroidism
:r',- of silver
:1s r-ariable I:I
C TI P T
E{USCUtffiSKM,IMY&L
MX$ffiKMKKS
01).
Most of the diseases of muscle fi.bres are associated wllh elevation of creatinine kinase (MM isoenzyme)(AllMs The
diseases of muscle fibres are called myopathies (which also include muscular dystrophies).
MYOPATHY
r Myopathy refers to any skeletalmuscle disease that causes structurai changes or functional impairment of muscle'
Important causes of mYoPathY are :-
l) Congenital myopathies: Central core disease, nemaline myopathy, myotubular (centronuclear) myopathy.
Z) Endocrine and metabollc : Hypothyroidism, hyperthyroidism, hypoparathyroidism, hyperparathyroidsm,
cushing,s slndrome(AllMsor), acromegaly, DM, Vitamin-D deficiency (rickets, osteomalasia@nMs07))' oncogenic
(Myopatfu is not seen in X-linkedhypophosphatemic rickets(ArrMs07)),
osteomalacia(AlrMs07).
3) Channelopathles : Hypokalemic periodic paralysis, hyperkalemic periodic paralysis, normokalemic periodic
paralysis.
4) Inflammatory myopathies: Dermatorpyositis, polymyositisA"'so'), inclusion body myositis.
5) Toxic myopathT: Ethanol, chloroquine, corticosteroids, hypolipidemic drugs.
6) Inborn error of metabolism :Lipidmyopathy, mitochondrial myopathy.
o:), Becker's dystrophy, myotonic dystrophy'
7) Muscular dystrophies : Duchenne muscular dystroqthy{Attus
Limb girdle dystrophy, fascio-scapulo-humeral dystrophy, Oculopharyngeal dystrophy, spinomuscular
02)
atroPhYqIIMs '
o Asageneralrule,myopathieshaveproximalmuscleweakness,exceptformyotonicdystrophywhichmainlyinvolves
distal musclesallMso2) (Neuropathies usually have distal muscle weakness),
o A muscular dystrophy is a type of myopathy in which there is abnormal growth of muscle. It is characterized by :-
i) lt k a primary myopathy
ii) It has genetic basis
iii) Course is progressive
iv) Degeneration 6 Death of muscle fibers occur at some stage of the disease
This is called pseudohypertrophy because it is not true hlpertrophy of muscles, instead the muscle is replaced by fat
and connective tissue.
o Deep tendon reflexes remains normal initially which may later on decrease6r's).
o Extraocular muscles are spared. Other features are scoliosis, epilepsy and mild mental retardation
r Patient die in the second decade of life because ofrespiratory failure and cardiomyopathy.
MUSCULAR DYSTROPHY
o A muscular dystrophy is a type of myopathy in which there is abnormal growth of muscle. It is characterized by :-
l) It is a primary myopatLry
ii) It has genetic basis
lll) Course is progressive
iv) Degeneration 6 Death of muscle fibers occur at some stage of the disease
r There is hypertrophy of deltoid and infraspinatus with wasting of posterior axillary fuld muscles.
A child is suffering from some neuro-mu$cular disorder.
His calf picture is as follows. The diagnosis is -
a) Myasthenia qravis
b) DMD
c) Peripheralneuropathy
d) Myotonic dystrophy
ph):
Ans. is'b'i.e., DMD
r Pseudohypertrophy of calf muscles (as shown in figure) is characteristic of DMD (Duchenne muscular
dystrophy).
:len
r Fascioscapulohumeral dystrophy showing facial weakness (inability to close eyes) and asymmetric scapular
winging.
r lzlyotonic dystrophy t)?ically starts in distal muscles('4r.Ilrs 02) (in contrast to other muscular dystrophies whici:
involve proximal muscles) . The classical form presents with myotonia, facial weakness (gives V-shaped upper lip , .
cataract, frontal baldness, endocrinopathies (hypothyroidism > hlpethyroidism; adrenal insufficiency; DM), cardiac
arrhythmia, GI motility disturbance and mild mental retardation.
o CPK levels are usually normal.
o Important motor neuron (anterior horn ceil) disorders in children are spinal muscular atrophy and poliomyelitis.
r Generalized hypotonia with frog-like posture and tongue fasciculations in SMA:I (Werdnig-Hoffrnan disease).
Myasthenia gravis
r Myasthenia gravis (MG) is an autoimmune disorder, characterized by autoantibodies against acetylcholinereceptors
at myoneural junction.
o Girls are affected more commonly than boys.
o There may be association of thymoma (but less common than adult myasthenia gravis).
r Clir-rical f"eatures of MG in children are :-
1) Neonatal MG
r It is by caused by transpiacer.rtal transfer of maternal anti - Ach antibodies to the fetus.
2) Congenital MG
I It is caused by genetic defect in Ach recepto rs (there are na anti - Ach antibodies) .In both neonatal and congenital
MG, baby is hypotonic, i.e. 'floopy infant'. Reflexes are preserved.
M
iilt
,l;
rl:
3) |uvenile MG
r It is caused by production of anti - Ach antibodies in children. It is associated with other
autoimmune clisorcler
like Hashimoto thyroiditis, SLE and |RA.
r It presents with fatigue of muscles of masticaticln, swallowing and respiration. But in children
specific features
are ptosis and diplopia with normal pupillary respones.
r Usually distal muscles are involved, but in some cases proximal muscles may also be involved.
r Thereistlpical diurnalvariationinweakness(moreintheevening(Ar1s))and.fluctuatingpatternofweakness
(patient suddeniy becomes asymptomatic). The weakness inteases with activity.
Diagnosis
r Following tests are used :
i) Ocular ice pack fesf (appiication of ice pack to eye relieves ptosis)
ii) cholinergic tests (edrophonium/tensilone test and neostigmine test).
Treatrnent
o Anticholinesterases (physostigmine) are the drug of choice. Other treatment options are
corticosteroids, mycophe,olate
mofetil, azathioprine and plasmapheresis. Thymectomy is useful for juvenile MC but not in congenital/infantile
MG.
a) Myotonic dystrophy
b) Mysthenia gravis
c) DMD
d) Becker's dystrophy
r fuvenile idiopathic arthritis is broad term that describes a clinically heterogenous group ofarthritides ofunknown
cause, which begin before 16 years of age.
o This term encompasses several disease categories :-
1) Iuvenile rheumatoid arthritis
2) luenile psoriatic arthritis
3) Iuvenile enthesitis related arthritis.
B) Polyarticular |RA
r It is characterized by involvement of 5 or more joints.
r There are two subtypes :-
i) Polyarticular RA positive
.ItischaracterizedbysymmetricaljointinvolvementalongwithUyeitis(^IIM'lt'At,e),andrheumatoidnodules(
AilMS 11, AI 09).
\
o RA factor and ANA are positive.
ii) Polyarticular RA negative
o RA factor and rheumatoid nodules are not seen.
o Arthritis in children is diagnosed if there is :
rltischaracterizedbyeyeinvolvmentwithiridocyclitis,glaucoma,cataract'
o It is associated with HLA - DRs and DRWS' I
B) PolYarticular )RA
r It is characterized by involvement of 5 or mote ioints'
r There are two subtYPes :-
i) PolYarticular RA Positive
r Itischaracterize dbysymmetricaljointinvolvementalongwithlJveitis(Alr*sll'Al0s)'andrheumatoidnodules(
A[,"II1S 11' At09),
\
o RAfactor and ANA are Positive'
ii) PolYarticular RA negatite
o RA factor and rheumatoid nodules are not seen'
C) Systemic |RA
a It is characterized by systemic features hke fever with rash(NEEr'AIIMS oI), lymphadenopathy, and
tuus ot ),
hepatosplenotnegaly(Nnnr'
r There is neutrophilic leukocltosis with raised ESR.
r ANA may e p ositiv e, but RA factor is negative@EEr).
b
o Initial drug of choice for fRA is one of the NSAIDs. NSAIDs commonly used in children are Naptoxen, lbuprofen,
8e).
Aspirin@ es) and Indomethacinql
M'5EELLAT{ EOt,'5
o NotafeatureofJRA:Raynaudt phenomenon.
s Absence of long bones: Phacomalia.
a Drug causing Phacomalia:Thalidomide.
a lnfantile coxa yero: Blount's disease.
* Multiple recurrent fractures with norma! heolrng : Osteogenesis imperfecta.
* Multiple fractures with various stages of heoling : Battered baby syndrome.
* Most common cause of acute osteomyelitis in children: Staphylococus aureus.
e Most common cause of septic arthritis in childern : Staphylococcus aureus.
& Acute osteomyelitis differentioted from soft tissue infe'cton by : MRl.
* Septic arthritis of hip joint in infancy :Tom smith arthritis.
* Most common fracture in children:Forearm.
* 2nd bone most common fracture in children: Clavicle.
III
QUESTIONS
l. l0 years old Ramu has increasing muscle weakness c) May be normal initially lateron increase
and raised CPK levels. The most likely defect is in d) May be normal initially lateron decrease
plasma membrane of - (AIIMS Nov 01)
10. An infant presents with hypotonia and hyporeflexia.
a) Nerves During his intrauterine period there was polyhy-
b) Muscle fibres dramnios and decreased fetal movements. Most
c) Basement membrane probable diagnosis is - (AIIMS May 02)
d) All body cells a) Spinal muscular atrophy
2, Drooping eyelids in evening in boy -(CET luly 15 pattern) b) Congenital myasthenia
a) Myasthenia gravis c) Congenital myotonia
b) Oculomotor nerve palsy d) Muscular dystrophy
c) Botulism toxin l l. Give the most probable diagnosis of a I yr. old child
d) All of above of normal intelligence with features of hypotonia.
On examination there are tongue fasciculations and
MYOPATHIES he keeps his body in a frog like position -
a) Guillian Barre Syndrome (AIItulS Nov 2000)
3. Myopathy is seen in all except - (AIIMS May 07) b) Limb girdle atrophy
a) X-linked hypophosphatemic rickets c) Downs syndrome
b) Oncogenicosteomalacia d) Spinal muscular atrophy
c) Nutritionalosteomalacia L2, In a 6 months old baby, floppy infant syndrome is
d) Cushing syndrome seen commonly due to infection with -
+. All of the following are a$sociated with proximal a) Clostridium welchii (AIIMS lune 2K)
muscle weakness fxcfpt - (All India Dec.14 Pattern) b) Clostridium tetani
a) Spinomuscularatrophy c) Clostridium Botulinum
b) Duchenis muscular dystrophy d) Clostridium septicum
c) Polymyositis
d) Myotonic dystrophy
ARTHRITIS
5. Duchenne Muscular Dystrophy is a disease of -
a) Neuromuscularjunction (A104) 13. Most cornmon chronie arthritis seerr in ehildren -
b) Sarcolemmalproteins a) IRA (CET lune 14 pattern)
c) Muscle contractile proteins b) Reactive arthritis
d) Disuse atrophy due to muscle weakness c) Rheumatic fever
6. Duchenne muscular dystrophy true - d) Sepsis
a) autosomal dominant (CET Nov 15 Pdttern) 14, A ten-year old girl presents with swelling of one
b) onset at second decade oflife knee joint. All of the following conditions can be
c) universal increase in creatine kinase considered in the differential diagnosis except -
d) normal cardiac muscle fibre. a) Tuberculosis (Ar 0i)
A 6 year old boy presents with progressive w€akness b) |uvenile rheumatoid arthritis
in muscles, and difficulty in walklng upstairs. He has c) Haemophilia
dtfficulty in walking on his toes and has a waddling d) Villonodularsynovitis
gait. Hypertro,phy of calf muscles in noted. His CPK
levels are 10,000 IU. Which of thc following is the JRA
most appropriate diagnosis - (AI 10)
a) Duchenne muscular dystrophy. 15. Age criteria for iI{A (All India Dec.1j Pattern)
b) Polymyositis a) < 10 yrs.
c) Congenitai myopathy b) < 12 yrs.
d) Myotonia congenita c) < 14 yrs.
8. Duclrnne's rnuscular dystrophy - (NEET Dec.12 Pattern) d) < 16 yrs.
a) X-linked dominant 16, All of the following are f€aturcs of systemic |uvenlle
b) X-linkedrecessive Rheumatoid Arthritis cxecpt - (AIIMS May 01)
c) Autosomal dominant a) Uveitis
d) Autosomal recessive b) Rash
9. Irr duchenne the knee jerk - (All India Dec15 Pauern) c) Fever
a) Exaggerrated d) Hepatosplenomegaly
b) Decrease
l. l0 years old Ramu has increasing muscle wealuress c) May be normal initially lateron increase
and raised CPK levels. The most likely defect is in d) May be normal initially lateron decrease
plasma membrane of - (AIIMS Nov 01) 10.
An infant presents wlth hypotonia and hlporeflexla.
a) Nerves During his intrauterine period thcre was polyhy-
b) Muscle fibres dramnios and decreased fetal movements. Most
c) Basement membrane probable diagnosis is - (AllMS May 02)
d) All body cells a) Spinal muscular atrophy
2. Dronping eyelids in evening in troy -(crT fuly 15 Pattern) b) Congenital myasthenia
a) Myasthenia gravis c) Congenital myotonia
b) Oculomotor nerve palsy d) Muscular dystrophy
c) Botulism toxin ll. Give the most probable diagnosls of a 1yr. old child
d) All of above of normal intelligence with features of hlryotonia.
On examination there are tongue fasciculations and
MYOPATHIES he keeps his body in a frog like position -
a) Guillian Barre Syndrome (AIIMS Nov 2000)
3. Myopathy is seen in all except - (AllMS May 07) b) Limb girdle atrophy
a) X-linked hlpophosphatemic rickets c) Downt syndrome
b) Oncogenic osteomalacia d) Spinal muscular atrophy
c) Nutritional osteomalacia 12, In a 6 months old baby, floppy infant syndrome is
d) Cushing syndrome seen commonly due to infection with -
n All of the following are associated with proximal a) Clostridium welchii (AIIMS lune 2K)
muscle weakness except - (All India Dec.14 Pattern) b) Clostridium tetani
a) Spinomuscularatrophy c) Clostridium Botulinum
b) Duchenis muscular dystrophy d) Clostridiumsepticum
c) Polymyositis
d) Myotonic dystrophy ARTHRITIS
5. Duchenne Muscular Dystrophy is a disease of -
a) Neuromuscularjunctior (Alo4) 13. Most eommon chronic arthritis seen in children -
b) Sarcolemmalproteins a) IRA (CET June 14 Pattern)
c) Muscle contractile proteins b) Reactive arthritis
d) Disuse atrophy due to muscle weakness c) Rheumatic fever
6. Duchenne muscular dystrophy true - d) Sepsis
a) autosomal dominant (CET Nov 15 Pattern) 14, A ten-year old girl present$ with swelling of one
b) onset at second decade oflife knee joint. All of the following conditions can be
c) universal increase in creatine kinase consldered in the differential diagnosls except -
d) normal cardiac muscle fibre. a) Tuberculosis (Ar 03)
a) Duchenne muscular dystrophy 15. Age eriteria for JRA * (All India Dec.13 Pattern)
b) Polymyositis a) < 10 yrs.
c) Congenital myopathy b) < 12 yrs.
d) Myotonia congenita c) < 14 yrs.
Duchnne's muscular dystrophy - (NEET Dec.12 Pattern) d) < 16yrs.
a) XJinked dominant 16. All of thc followlng are features of syetemic |uvenlle
b) X-linkedrecessive Rheumatoid Arthritie cxecpt - (AIIMS May 01)
c) Autosomal dominant a) Uveitis
d) Autosomal recessive b) Rash
In duchenne the knee jerk - (AllIndiaDecl5Pattern) c) Fever
a) Exaggerrated- d) Hepatosplenomegaly
b) Decrease
17. All of the fbllowing are seen in Systernic ]uvenile a) Hemophilousinfluenzae (AllMS May 94)
Arthritis, except - (NEET Dec.12 Pattern) b) Staphylococcus aureus
a) Rheumatoid Factor + ve c) Gonococi
b) Hepatosplenomegaly d) Pneumococci
c) High fever with rash 22. Acute osteomyelitis can best be distinguished from
d) Elevated E.S.R. soft tissue infection by - (AMC 2K)
18. Which of the following is not a feature of Juvenile a) Clinicalexamination
Idiopathic Arthritis - (AttMS May 11, Al 09) b) X-Ray
a) Rheumatoid nodule c) CT scan
b) Spikes ofhigh fever d) MRI
c) Uveitis 23. Gower sign is classical of one of the following condi-
d) Raynaud'sphenomenon tion- (Karn 04)
a) Congenital myopathy
MISCELLANEOUS b) Werdig-Hoffman disease
c) Duchenne muscular dystrophy
19. Fhocomelia is - (NEET Dec.12 Pattern) d) Guillain-Barre syndrome
a) Absence oflongbones 24. Duchenne's muscular dystrophy is a disease of -
b.) Absence of brain a) Neuromuscularjunction (Manipallg)
c) Reduplication ofbones b) Sarcolemmalproteins
d) Absence ofheart c) Muscle contractile proteins
20. A one year old child presented with multiple frac- d) Disuse atrophy due to muscle weakness
tures seen in various stages of healing. The most 25. Drug of choice initially in |uvenile chronic arthritis is
probable diagnosis in this case is - (AIIMS Nov 05)
a) Scurry a) Salicylates (At 8e)
b) Rickets b) Indomethacin
c) Battered baby syndrome c) Prednisone
d) Sickle cell disease d) Phenylbutazone
!II
l
CuAprsnirr3
A[\JSWERS
1. Ans. is 'b' i.e., Muscle fibres [Rel Chandrasawta Taylor 3thle p. 9531
o Increase in CPK level with muscle weakness suggests muscle cell damage.
n Ans. is'a' i.c", h4y*stlaeraia gravis $re! Gkl;*i 7"le 7t. 5731
c Ptosis/drooping of eyelids with diurnal variation (more in the evening) is seen in |uvenile myasthenia gravis.
MYOPAT'H!ES
3. Ans. is'a: X-linked hypophosphatemic rickets fRef: Nelson 18th/e p. 2551; Ilarrison 17h/e p. 26941
o Myopathy is not seen in X-linked hlpophosphatemic rickets. Other three options are causes of myopathy.
*d'
4. Ans" is i.e., J!{yertonic dystrophy lR(: A.P. Ghai 6tt'le p. 551 d- 7t'le p. 557-57A; &ktrsom 18'hle p. 25,}4}
e DMD is an X-linked recessive disorder with usual age of onset at 3-5 years. CPK levels are elevated.
e Histoiogy of cardiac muscle shows absent of dystrophin on sarcolemma.
1 Ans" is 'a'i"e., Duchenne rnuscular dystrophy p.
lReJ: Nelsan LE'h/e 2541, 25421
o Progressive weakness, dilirculty in walking upstair, hlpertrophy of calf muscle with raised CPK suggest the diagnosis
of DMD.
nb'
8" .{ns" is i.e., X-linkecl rece$$ive tRef 0.p. {ileoi Sthle p. 595 6 7h/e p. 5661
t0" Ans. is oa' i.e., Spinal muscular atrophy [Ref Nelson l9thle p. 2557; CI.P. Ghai 9nh/e p. 569, 591, 594 6 Vh/e p. 574, 573,
r aol
e Out of the given options only spinal muscular atrophy is able to cause hlpotonia and hyporeflexia during infancy.
Rest of them either present late in childhood or do not give the symptoms.
11. Ans. is'd' i.e., i"e., Spinal rnuscular atrophy fRef: CPDT 15'h/e p. 694; A.F. Ghai 8'h/e p. 559, 591, 594 & 7h/e p. 559,
574, 573, 613; Nelsaru 17hle p. 2A75, 2A761
e Features of hypotonia andfrog like position suggest the diagnosis of Floppy infant syndrome.
o There are many causes of floppy infant syndrome.
e Out of the four option given in the question three of these can cause FIS -
s Downs syndrome
v G.B. syndrome
e Spinal muscular atrophy
o Spinal muscular atrophy
x Features of normal intelligence and tongue fasciculations strongly suggest spinai muscular atrophy.
a Down's syndrome
x Can be easily ruled o:ut as intelligence is impaired in Down's syndrome.
o G.B. syndrome
x Cap be ruled out as it presents as an acute case with a past history offever or viral infections.
x Majority of patients recover within few days to 2 weeks.
' . :::' ..:.,.. .:., .:.:.:. ....... . :
t2. Ans. is'c' i.e., Clostridium Botulinum lRel Nelsan 18tt'/e p. 1225)
r Botulism causes acute flaccid paralysis -+ floppy infant.
ARTHRITIS
Ams. is 'a' i.e., |Rd [?{ef; {}.F. Gkai B,},la p.624 $ Zhle 1>. 595 tabte (20.1}}
r
Amongst the given option only )RA causes chronic arthritis in children.
t4. Ans" is t' i"e., Haemophilia lRef Maheshwari 3d/e p.185; O.p. Ghai Bele p. 624, 625 {z p/e p. 5991
o Althoughallconditionsmentionedintheoptionsmayproduceswellingofonekneejoint,theclueliesinthefactthat
haemophilia is an X Linked recessive disease and is not manifested in giils who act only as carciers.
JRA
t5. ,Ans. is kf i"e", < 16,vrs" [ii{r. 0.p. Ghai Thle p" 6{}A}
r General criteria for diagnosis of |RA includes : -
l) Arthritis of one or more joints
ii) Onset below the age of 16 years
iii) Persistingfor at least 6 weelcs
iv) Exclusion ofother causes ofarthritis
t6. Ans. is'd i.e., Uveitis [RefO.P. Ghai 8th/e p. 626 b Th/e p. 6001
e The eye manifestation are seen in Pauciarticular and Polyarticular lF.Abut not in systemic
IRA.
r@ can be divided in 3 major clinical tlpes
JRA
JA
. 4 or lessjoints involved joints affected . Rash
. 2 subtypes . 2 subtypes . Lymphadenopathy
. Splenomegaly
. ANA can be (+ve)
1.7. A*s" is na' i.c., Kke&naatoisl Fae tarr +ve [I{(r: {}.{1 Gh*i 8,hl* p.626 $ Thle p. 6AA}
Rernember
1. Eye manifestation (Irdocyclitis) can occur in both pauciarticular and polyarticular
|RA and absent
in systemic fRA
2. ANA-can be present in all forms of IRA
3' R.heumatoid factor & Rheumatoid Nodule are (+ve) only in some cases of polyarticular
form.
4. Rashes Splenomegaly and lymphadenopathy are present in system lRA.
Cn.csrER,t,3
MISCELLANEOUS
tg. &x*. i*'*l i'*", A t**xn kwy,\z*rt'*t' l ll'':i: l}' {ikrti'''' ir: ;;'i't'St'
{ ;'
20.Ans'ie'Ci.e.,BatteredbabysyndromelRef:?arikhdh/ep'18fl
baby syndrome'
. Multiple fractures at different sites and of different ages suggest the diagnosis of Battered injury is at variance with the
whom d.gr.. and tlpe of
r Battered baby syndrome - should be considered in any child in
historY given.
rWheninjuriesofdifferentagesandindifferentstagesofhealingarefound.
serious injuries'
o when there is a purposeful delay in seeking medical attention despite
of ury"bo.r., subdural hematoma, failure to thrive, soft tissue swelling or skin
r who exhibits evidence of fracture
bruising.
2l.Ans.is'b-i.e,,Staphylococcu$aureuslfuef:NelsonlTh/ep'2297J
o Bacteria are the most common pathogens in acute skeletal infections'
staphylococcus aureus infection is most comlnon'
o The microbial spectrum is deverse in suppurative arthritis, but
r Salmonella is the most common cause of osteomyelitis in children with sickle cell anemia'
22. Ans. is 't i.e.,MB.ll&e! Nelson 18th/e p' 28431
and for differentiation between bone
r MRI radiographic imaging technique lbr the identification of abscess
is the best
and soft tissue infection'
p' 595 6 Vh/e yth/e p' 568)
23. Ans. is 'C l.e.,Duchenne muscular dystrophy lRef : O'P' Ghai
24, Ans. is 'c' i.e.,Muscle contractile proteins [Ref : CMDT p' fi251
25. Ans. is ,a>v i.e., salicylatee > Indometh*cin{Ref: Nelson 18th/e p. 10051
o Initial drug of choice is one of the NSAIDS'
r NSAIDs commony used in children are Naptoxen, lbuprofen' Aspirin and indomethacin'
IAP 705
-
o For one option go ahead with salicylates -
IAP 745
.In USA, the pil, has approved aspirin, tolmetin, Naproxen and lbuprofen for usage in children" ' -
rlr
FL&JXM &
KX,ECTKffi&YYK
birth, Thereafer it delines progessively to 600/o by the end of one year. After that it remains constant.
o Distribution of water in diferent compartment of body is :-
Total bodyWater
t 600/o ol body weight (Pct07,04)
e Most oUuiaont ion (cation) in ECF is Na*, and normal serum sodium concentration is between 135-145 mEq/L,
Other predominant ions in ECF are Cl , HCO, and Ca*2.
o Most abundant ion (cation) in ICF is K* and normal serum concentration of K. is only 3.5-5.0 mEq/L. Other pre-
dominant ions in ICF are Mg2t, and organic anions.
tilater requirrnent in a norrnal child
r Water requirment of a child depends upon the weight of the child -
: Weight 3 10 kg : 100 ml/kg/day. For example a 10 kg chilil requires 1000 ml water per d.s,yliP""' tt; (100x10).
t Weight 10-20 kg: 100 ml/kg/day for Jirst 10 kg (i.e. 1000 ml) plus 50 ml/kg/day for every kg above 10 kg. For example
l5 kg child requires 1250 ml of water per day (1000 ml for first 10 kg and 250 for next 5 kg).
t Weight > 20kg: 100 ml/kg/day for lirst 10 kg (i.e. 1000 ml), plus 50 ml/kg/day for next 10 kg (i.e. 500 ml) plus 20
ml/kg/day for every kg above 20 kg. For example, a 30 kg child requires 1700 ml of water per day@re ott [1000 ml
for first 10 kg plus 500 ml for 10-20 kg plus 200 ml (20x10) for 20-30 kgl.
DITIYDBATIOil
r Dehydration is a conditon that occurs when the loss of body fluid, mostly water, exceeds the amount that is taken in.
o Most common cause of dehydration in children is diarrhea. Large amount of water and water soluble nutritive sub-
stances such as electrolytes, metabolites and vitamins are lost from the body during diarrhea episodes. Loss of water
from the body causes a reduction or shrinkage in the volume of ECF.
o Depending on the concentration of sodium, this ECF reduction can be classified into -
1) Isonatremicdehydration
r Sodium loss is parallel to water loss so that sodium concentration in ECF or plasma remains normal ( - i40
meq/L).
'. It occurs in about 50% of diarrheal cases ECF decreases and ICF is normal.
2) Hyponatremic dehydration
r Sodium loss is more than ECF loss It occurs rn 40-45o/o of diarrheal cases. Because of low osmolality (due to
reduced sodium) water moves from extracellular to intracellular compartment *) signs of dehydration (wrinkled
skin due to loss of elasticity).
t Thus ICF increases and ECF decreases(AllMs0o).
t This type of dehydration occurs when water intake is inad.equate1umsoo)
3) Hlryernatremicdehydration
r In about 5% of cases, especially in chiid who has been given fluids with more salts, serum level may be elevated
(> 150 mEq/Lteet o:t',,. Water moves from inside the cells to the extracellular compartment(Pct
03).
t Thus, ICF decreases and ECF remains normalQcros). This may mask the physicalfindings@ctos) of dehydration
and the patients may be undertaken as mild dehydration even in the presence of severe dehydration -+ com-
plications of severe dehydration may occur due to delay in management.
t So, hypernatremic dehydration is more dangerous(Perx).
Thirst Drinks normally, Thirsty, drinks eagerly Drinks poorly, or not able to
not thirsty drinkrA"5'
I ::i:ii:':::r"
Ski6.?inch "'i:,,:, :::':':
Girei'backtiiitkllel , Goatbatk5lol.ii$!,+*x*soot ir::
cgeslhag,.k,,.*€firtlow.$r!a?.mlt{et-,.
02 AllNE$ol . :.. .... | ..,.,.:
Decide The patient has lf the patient has two or more lf the patient has two or
No signs of signs, including at least one sign, more signs, including at least
Dehydratisnfiroz there is Some DehydrationII'02, one signl there is Severe
ailMs 00) ailM' 0o) 02' Att[s oo).
Dehydrationrfl
Ttiat ,:',:tr:t'i UieTreatment Pltn :
Weight the patient, Treatment Plan B(' Weigh the patient and use Treatment
g(iln4Aflil4s.tb): ,. 'i,, ., o2,Attfrisoo) plancwoz^ttfts@, Ufgently
Water requirrrent in a normal rhild
r Water requirment of a child depends upon the weight of the child -
t : 100 ml/kg/day. For example a 10 kg chilil requires 1000 ml water per day11ip"u tt) (lQ|x70).
Weight < 10 kg
:Weight10-20kg:100 ml/kg/dayforfirstl0kg(i.e.1000mI)plus50ml/kg/dayforeverykgabovel0kg.Forexample
15 kgchild requires 1250 ml of water per day (1000 ml for first 10 kg and 250 for next 5 kg).
: Weight > 20kg: 100 ml/kg/day for first 10 kg (i.e. 1000 m1), plus 50 ml/kg/day for next l0 kg (i.e. 500 ml) plus 20
ml/kg/day for every kg above 20 kg. For example, a 30 kg child requires 1700 ml of water per day(orc 0t1 [ 1000 ml
for first 10 kg plus 500 mi for 10-20 kg plus 200 ml (20x10) for 20-30 kgl.
DE}IYDRNTION
r Dehydration is a conditon that occurs when the loss of body fluid, mostly water, exceeds the amount that is taken in.
a Most common cause of dehydration in children is diarrhea. Large amount of water and water soluble nutritive sub-
stances such as electroly'tes, metabolites and vitamins are lost from the body during diarrhea episodes. Loss of water
frorn the body causes a reduction or shrinkage in the volume of ECF.
r Depending on the concentration of sodium, this ECF reduction can be classified into -
1) Isonatremicdehydration
r Sodium loss is parallel to water loss so that sodium concentration in ECF or plasma remains normal ( - 140
meq/L).
r It occurs in about 50% of diarrheal cases ECF decreases and ICF is normal.
2) Hlponatremic dehydration
r Sodium loss is more than ECF loss It occurs in 40-450/: of diarrheal cases. Because of low osmolality (due to
reduced sodium) water moves from extracellular to intracellular compartment -) signs of dehydration (wrinkled
skin due to loss ofelasticity).
t Thus ICF increases and ECF decreases@IlMs00).
t This type of dehydration occurs when water intake is inadequate(drrusoo:t
3) Hypernatremicdehydration
r In about 5% of cases, especially in chiid who has been given fluids with more salts, serum level may be elevated
(> 150 mEq/L{tct ost1.
Water moves from inside the cells to the extracellular compartmen{Pct 0s).
t Thus, ICF decreases and ECF remains normal(Pcr 08). This may mask the physical findings@er ot)
of dehydration
and the patients may be undertaken as mild dehydration even in the presence of severe dehydration -) com-
plicatlons of severe dehydration may occur due to delay in management.
t So, hypernatremic dehydration is more dangerousqclet).
Thirst Drinks normally, Thirsty, drinks eagerly Drinks poorly, or not able to
not thirsty drinkrA,15,
SkinPinch' :',: :' Goej bac*'qljikly4 Goeshi'ktlittflfylete:-;rosoot :: ; r::::' '' caa; lia+,viry
'r: 5to-,wlyrl11?r{,3i@,,.- r
Declde The patient has lf the patient has two or more lf the patient has two or
No signs of signs, including at least one sign, more signs, including at least
Dehydrationrfloz there is Some DehydrationrA'oz one signs, there is Severe
AilMS 00) AilMS 00) 02' attMs oo).
DehydrationrAt
Treat: ..:..'rr''':): ::. Use lreatm.ent P.lan' Weight the patient, Treatment Plan BGt Weigh the patient and use Treatment
hw3zAttMsoa)
: ,,. 02, AUMS$o) plan C(At
oz AnMs&)
U rgently
Note: Skln pinch is less useful in infonts or children with marasmus (severe wosting),
Kwashiorker (severe malnutrion with edema) and obesity'Ato2,Nano6)
to use increased Correction of existing water and electrolyte defecit Best IV fluid sotution is Ringer tactatekrahsl)
amounts of home
75 ml/kg ORS in first 4 hrluwe7) Normol saline can be usedtatt$sot)
available fl uids(/'P'"'
9s) Maintenance Therapy: Dextrose is not effective
ORS Packslsrannerest Replacement of ongoing losses due to continuing lOO ml/kglPcts3t is to be given as shown below:
r Inseveredehydration,ifintravenouslineisnotpossibleorfailed,intraosseousaccessintheproximaltibiaispreferred
qlternative in children less than 6 years of age(AIIMS 03' 0r). In children > 6 years, percutaneous femoral line should be
attempted.
2.6(PGl02,uPsc
1o) Sodium 75iAr
15, pcl es,8e)
.'.;6eu..*;
.i.::li3.5inlla,6tiiiti ::,ii.
;i#iffi ., .
c Oral fluid therapy is based on the observation that glucose given orally enhances the intestinal obsorption of salt
and water, and is capable of correctingthe electrolyte and water deficit.
Glucose 125
l
-:.Srditi*r.' 45IAl{.6Jr
Potassium 40
Chloride,.' :r:,70.:..::::
Citrate 7
I a'
0.3
l..6:66.,.2
300arI3)
HYPOVOLEMIC SHOCK
ELECTROLYTE IMBALANCE
r Dietary requirment of sodium in children is 2-3 mEq/kg body weight per day and dietary requirment of potassium
13),
is 1-2 mEq/kg.body weight per dayal
Hyponatremia
o Hyponatremia is defined as serum concentrationofNa + < 130 meq/L Hlponatremia causes a decrease in the osmolality
ofECF.
r Because the intracellular space then has a higher osmolality, water Inevitably moves from the extraceilular to intracellular
space.
r Increase in intracellular water causes cell to swell. i
!
o Although cell swelling is not problematic in most tissues, it is potentially dangerous in the brain because it is contained l
in the fixed shell the skull. As brain cells swell, there is an increase in ICT. So brain cells swelling is responsibe for
most of the symptoms of hyponatremia.
t Anorexia, nausea 6 vomiting t Coma
1 C onv ulsiont(Kerata
e7' PGI 8e) s Drowsiness
: Headache t Circulatory failure and hypotension(Pcl 8e)
Hyponatremia can also cause muscle cramp and weukness6"'d"e7PGI8e),
PGI I
c Central pontine myelinosis is classically associated with overlay rapid correction of hyponatremia.
r Treatment of hlponatremia is :-
1) In low ECF volume & asymptomatic-give ORS/Normal saline.
2) In complicated like seizure-give 3-5 ml/kg of 3% hypertonic saline to raise Na by 5 meq/Lit(DNB
cases I5).
3) Never do rapid correction (> 12 meq/Lit in 24 hour) can cause Central pontine myelinolysis (CPM).
Hypernatremia
I Hypernatremia is defined as Na+ Concentration > 150 meq/L Most children with hypernatremia are dehydrated and
show tlpical clinical signs and symptoms.
o Children with hypernatremic dehydration tend to have better preservation of intravascular volume because of the
shift of water from the intracellular to extracellular space. This maintain blood pressure and urine output(KerataeT),
and allows hypernatremic infant to be less symptomatic initially and potentially to become more dehydrated before
medical attention is sought.
r Probably because of intraceilular water loss, the pinched abdominal skin of a hypernatremic dehydrated infant has a
"doughy" feel(uPsc 8e),
o Hyperntremia causes CNS symptoms due to neuronal shrinkage (water shifts out of the cell) : -
I Lethargy(r"'"totz) t Restlessness
: High pitched cry and hyperpnea ; Fever
: lrtitabilitY(uPsc e8' Keruta e7)
T Weakness
a Nausea
o Hlpernatremia is associated with hypoglycemia and mild hypocalcemia.
o Brain hemoruhage is the most devastating consequence of hl.pernatremia -+ may be subarachnoid, subdural or
meningeal.
o There is strong correlation between cerebral plasy and history of neonatal hypernatremia.
o Seizures and coma may occur, seizures are more common during correction of hypernatremia.
o Although central pontine myelinosis is classically associated with rapid correction of hyponatremia, it can occur in
children w ith hy p er natr emi a.
Hypokalemia
r Hypokalemia is defined as serum potassium values of less than 3.5 meq/L,Important causes are :-
1) Excessive Loss in GIT or kidney : Diarrheaqlel),laxative :use, RTA (distal or proximal), Gitelman syndrome, Bartter
syndrome, cushing syndrome@IlMse3) (due to adrenal adenoma or hyperplasiaale4)), hypomagnesemia
2) Drugs : Diuretics (thiazide(Ale4)/furosamide), cisplatin, aminoglycosides, amphotericin, p-agonists, theophylline
3) Others: Alkalosis, spurious hypokalemia in leukemia, anorexia nervosa.
o Symptoms are non-specific and are related to muscle (muscle weakness) and cardiac function (cardiac arrhphrnias).
o ECGclranges areprominentUwave(eailiest),JlatteningandinversionofTwave,prolongedPRinterval,wideQRs
complex, QT prolongation and depressed ST segment.
Hyperkalemia
r Hyperkalemia is defined serum K* concentration > 5.5 meq/L.Important causes of hyperkalemia are :-
as
1) Decreased renal exceretion : Renal failureal e4' AIIMS e3), Addison disease, CAH (2l-hydroxylase and 3 B-I-{SD
deficiency), ACE inhibitors/AT II antagonists, NSAIDs, potassium sparing diuretics, heparin, trimethoprim,
pentamidine, cyclosporine.
2) ' Trasnscellular shifi: AcidosisqllMse3), rhabdomyolysis, tumor lysis syndrome, insulin deficiency{AttMs,{ digltals,
'succinylcholine, malignant hyperthermia, exercise.
3) Others: Blood transfusion, spurious high value (hemolysis, thrombocytosis, leukocytosis).
o Patients may present with nausea, vomiting, paresthesia, muscle weakness, fatigue and ileus. ECG changes show tall
tented (peaked and natow) T-wave, prolonged PR interval, wide QRS complex, flat/absent P waye and ST-segment
depression.
Fluld &Ele*rolyte
a A child with diarrhea and vomiting with inadequate water intoke: Extracellular hyponatremic dehydration.
, Earliest and most seirsitive indicator for decrease:in intravascular,volume;lincreased heart:rate. : :
'l}
t Daily recommended dietary intake of potassium in a child:1-2 meq/kg.
t Acute hyponaffemio does nafeause,lDianhea',:.':'r.
, Convulsion in a child with delrydration is due to..Hyponatremia.
* Signs,ofhypernatremicdehydrailoniinitabiJity, lethaigy,,highpitchedcry,restles5ness.Doughf.J*in.,r,,,
* Hypokalemia is not seenin : Acute renal failure.
i' Hyperkalemia is not seenin : Cushingt syndrome.
o Treatment of vomiting with metabolic alkalosis in a child : lV normal saline with potassium.
* LatemEtabaticacidasis'isseenln:.Pretermbabyoncow,milk. ' . ., .',:,,,,:,.1, ._,,
III
SUESTIOHS
) Ans. is'b' i.e., 1000m1/day {Ref: O.P. Ghai */e p. 72 $ th/e p. 51)
o Up to 10 kg, the requirement is 100 ml/kg/day.
r So, Maintenance fluid for a 10 kg child is 1000 ml/kg/day.
DEHYDRATION
6" Ans. is 'b" i,e., Ilyperna*ernic {Rqf: A.P. Ghai 8e/e p. 7 j-76 (r 7e/e p. 261)
t Hypernatremic dehydration is more dangerous.
Ans. is t'i.e., Extracellular dehydration with hyponatremia fRef O.P. Ghai 9th/e p. 73-76 d2 7h/e p. 261; Nelson
17h/e, p 199-201, 1200, 18567
o Extracellular fluid consists of
t Interstitial (intercellular fluid)
t Circulating blood
t IntestinalJluids and secretions
r lntracellular fluid consists of fluid present within the cells.
o Loss of fluid in diarrhoea and vomiting comes from extracellular fluid. Therefore there is shrinkage or reduction in
the volume of extracellular fluid.
o Diarrhoea and vomiting both cause loss of Na* rich Jluid therefore there is decline in the serum sodium level
(hyponatremia).
r This causes fall in osmolality of ECF leading to shifting of Jluid from ECF to lCF causing further decrease in ECF
volume.
8. Ans" is 1d'i.e., Skin Pinch can't be evaluated in this child tnf O.p. Ghai Bth/e p. 7j 6 Th/e p. 2641
Frist step in assessing the skin pinch requires status of malnutrition of child as skin pinch is less useful in infants or
children with + Marasmus (severe wasting). Kwashiorker (Severe malnutrition with edema). Obese children
Child in the given question is 2 yrs old with the expected weight being 10 kg. But patient weight 6.7Kg. and so he is
certainlymalnourished. Skin pinch in such a malnourished child will not be able to evaluate the status of the dehvdration
correctly.
9- A*s; is ? i.e-,- $ev'ere dehydration
o Information in question are : (i) drowsy child, (i1) snuken eye, and (i11) skin pinch take time to revert back. These are
signs of severe dehydration. Treatment plan is C.
1&- Ane. is. s* i-e., Fleid of ehoicc-O,RS lRff Gbai 7e/e ch. 244!
11. Ane. i$ 'lf ie", oral rr&ydration therapy IR"f oP" Gh*i *fc p" zi & ple B" 264-26s1
The chilil in question is irritable but drinking fluids, He thus falls in the category of 'Some dehydration' and needs
to be managed in accordance with PLAN B.
Treatment plan B is oral Rehyilration therapy and hence the answer here.
12" 3 i.e., *Iothers rnilk and household ftrids, 'd'i .e", A{o[&ers mit& ard OB$ tQ.ef: O"E GEwi *le
Ans" is p. VS
e Pfep 26al
fremnent flan to prwent detrydreliofi - ?bn &
The mother should be educated to use increased amount of culturally appropriate home available fluids.
In addition, they should be given ORS packets for use at home.
Breast feeding should not be discontinued.
13, Axe" is'b' i.e., iXK ml t&"f A.p. Qlsoi *le p" ZJ & Ple B" 265|
Grddtrines {or rreating patfents witt} so{ne dclqdration {&trt not scverc defrfdratiom} Ueaeme*G plan E
c Basic is to give 7 5 ml/kg of ORS in the first 4 hours.
<5kg 200-400 ml
5-8 kg 400-600 ml
8-11 kE 600-800 rnl
1 1-16 kg 800 - 1200 ml
16-30 kg 1200-2200 ml
>30k9 > 2200 ml
14" An$" is 3 i.e,, 2$-41 mUkg lW A"p" Qtrwi *le p zZ & Pte p. 265|
Nntravenous fiuid 6erapy for severe de@rdt$on - &eaGment plam C
o Give i00 ml/kg of the chosen fluid as follows
t5" An*. is'a'i-e., SX! mI tR* A.p" 6kai */e p" zL-r3 & *fe p" 26sl
c Initially 100 ml/kg of fluid is given.
c So, fluid required = 100 x 4 = 400 ml.
16. Ans. is t'i.e.,I.V fluid
r Child in question is not able to drink (not taking orally) -+ Plan'C'treatment (immediate IV fluids).
11 Ans" is t' i.e., Normal saline {Ref: O. P. Ghai Sthle p. 73 (r */e p" 265)
18.
19" Ans. is'b' i"e., Potassium chloride-I.5 g1n; {Rsf O"P Ghai 6th/e p" 272 & Vhle p" 263; Park 2*/e p" 19vj
2.6 Sodium
...,29,rt,,.,'
'1.5
65
:,:. Zg :i.'[Or:,:.
75
22. Ans" io 'b' i.e., 300 [Sd A.P. Glrai 6tble p. 109]
o Osmolarity of Re So Mal is 300.
Ans. is t'i.e.,45 rnmoUllRef O. P. Ghai*/ep. 109)
The sodium content of ReSoMal is 45 mmol/l --- Ghai 6'h/109
24. ,Ans.is'a' i.e., Increase Na+ absorption by co transport [Ref: O. P. Ghai 6'h/e p. 109)
e Orai fluid therapy is based on the observation that glucose given orally enhances the intestinal obsorption of salt
and water, and is capable of correcting the electrollte and water deficit'
26. Ans is t' i.e., 2"9 gm lRef: A.F. Ghai Vh/e p. 263)
27. Ans. is 'd i.e., Skin turger lRel O.P" Ghai */e p. 26a)
28. Ans. is t' i.e., Any dehydration [Ref O. P. Ghai */e p. 272-27j 6 7*/e p. 263]
29. Ans" is 'a' i.e., 1-2 Meq/kg fRef: Nelson 18'h/e p, 2791
31. Ans. is'a' i.e., Decreased serum sodium lRef; See abave explanation]
33. Ans. is tn' i.e., 3Yo NaCtr fRef: Nelsan n8d'/e ch. 52, 53; Gbai 7'/e p. 5)l
o In complicated hlponatremia like seizure-give 3-5 ml/kg of 3% hypertonic saline to raise Na by 5 meq/Lit.
34. Ans. is nH i.e., Acute Renal failure fRef: Nelsan l8"le p. 2821
c In acute renal failure, there is hyperkalemia. Adrenal tumor (causing Cushing's syndrome), diarrhea and thiazide cause
hlpokalemia.
MISCEI.LANEOUS
36. Ans. is 'H i.e., Bolus of Ringers lactate lRef: Harrkon 1&/e p. 265, 266; Nelso* l&h/e p. jAfi
It is a case of metabolic acidosis (lactic acidosis) due to peripheral circulatory fall:ure (It is a common knowledge that
in cases of peripheral circulatory failure metabolic acidosis occurs due to production of lactic acid).
In moderate or mild cases of metabolic acidosis i.e., when the pH is > 7 .2 metabolic acidosis needs no speciJic t/t.
T/T of the underlying cause is suficient.(it will correct the acidosis)
Once the underlying cause (here tissue perfusion) is corrected the pH will return to normal
But when the pH is < 7 .2 specific bicarbonate therapy is warranted because this degree of acidosis may depress cardrac
contractility.
According to Harrison
"In general severe acidosis (pH < 7,20) warrant the intravenous administration of 50-100 meq of NaHCO, over
30-45 minutes during the initial , 1 to 2 hours of therapy".
So here, besides fluid administration to correct tissue perfusion, HCO, transfusion is also required because pH is 7.
The question is which complication should be first attended to, peripheral circulatory failure or severe metabolic
acidosis.
Harrison states:
"The undeilying condition that disrupts lactate metabolism must first be corrected, tissue perfusion must be
restored when it is inadequate".
J/. Ans. is'b'i.e., I.V. Normal saline and potassiamlkef: Nelson 18th/e p. 3051
Definifion
'An acidosis occuring after second day of life, in which base excess values are lower than -Smeq/L on two
consecutive estimations done at least 24 hours qpart".
Efmdog!
o Prematurity is the most important single predisposingfactor in the development of LMA.
o The incidence varies considerably depending upon the gestational maturity and protein content of feeding formula.
. In preterm neonates fed on a modified cow's milk the risk of developing LMA is very hrgh.
9. Ans. i0 'U Le.,$crum protein {Ref Nelsor, tflle p. 205-2101
r Normal calcium level is 8.9-10.1 mg/dl (total calcium).
o Slightlyless than half of the total serum calcium exists in free or ionized form. Remainder is bound to protein (mostly
albumin). Ionized calcium is relevant for cell fuction.
"There are few clinical situations in which the total calcium is not an adequate surrogate
for the ionized Ca++
concentration. The most common and severe problem is the presence of hypoalbuminemia".
o Each 1 gm/dl of albumin in the serum binds about 0.8 mg/dl of calcium.
r A low total calcium concentration may be normal in a patient with significant hlpoalbuminemia.
r Now it is clear from above that a low level of serum protein lowers the total plasma calcium but not the ionized
calcium, So, before treating hypocalcemia, measure the serum protein level.
/10. Aas. iE'C ic.o Intra Osceuo I.y" fluids lRef: Love e Bailey 2*/e p. 290; 23d/e p. 2761
"If LV. route is unsuccessful, introasseus access in the proximal tibia of an uninjured leg is the preferred alternative
for children younger than 6 yrs. In children older than 6 yrs a percutaneous femoral venous line should be
attempted.
41. Ans" isu ie., < 6yre of age{Ref: Abo see above expianatian)
{2, Ans" is 'd i.c., f,xcessive intake of sodium ffuef: Ghoi @/e p" 97; Nelson 17/e p. 197-199)
o The child is having hlpernatremia. Serum sodium >170 mEqll- (Normal level is 1i5-145 mEq/L).
o Urine sodium is also very high, >70mEq lL (Normal urine sodium level in <20 mEq/L)
s This combination can be seen with excessive intake of sodium.
o With excessive intake of sodium there will be increase in serum sodium and excessive excretion of sod.ium in urine
(Kidney tries to compensate for increase in serum sodium by excreting large amount of sodium).
o Diabetes Insipidus --) Serum sodium conc. will be high but urine sodium conc. will be very low (Lack of
ADH leads to defect in concentration of urine).
o Acute necrosis
r Severe dehydration
--+ Urine sodium conc. will be high but serum sodium conc. will be low.
Urine sodium concentration will be low.
--)
43. Ans is'd" i.e", 80 mI 10% dextrose in 20 ml NS [Ref O.P. Ghai 7/e p. 288]
o The most commonly used IV Jluid preparation in neonates is N/5, 10o/o dextrose.
o So, in ideal preparation:
(i) NS should make 1/5th part (20o/o) of solution (i.e. N/5)
(ii) Preparation should have 10 gm ofdextrose in 100 ml (i.e. 10% dextrose).
10% dextrose in 20 ml of NS as it will provide 8 gm of
glucose at
. Amongst the given options, closest one is 80 ml of
normal saline concentration of N/5'
c) N/5 saline
III
GK}WKYXCS
& GK&TMY'XE
MXSffiKMKKS
GENETIC DISORDERS
o Beside genetic disorders one other group of disorders, which is unrelated to genes or choromosomes, is called
Teratogenic events(Ar06) (Sometimes called congenital malformation). These are due to exposure to teratogenic
agents during Pregnancy.
Pedigree analysis
o pedigree analysis is the analysis of human gene transmission(A/rs). Pedigree chart is a diagrammatic method of
illustrating the inheritance of genes within a family'
r The starting point is often the identification of an affected individual, called the'propositus'or'proband', i.e. propositus
or ltrobanil is the individual which is studied in a pedigree, such as the individual with
a certain ilisease or other
inherited interest.
r After identification of propositus/proband, there is construction of a genetichistory or pedigree of the individual's
are used to denote sex,
family. By convention, each generation is displayed on a different level, and standard symbols
zygosity and other information about each family member'
Disotders
II
III
I
Affected Affected
il
witd Wild type
male female male l'emale
aa aa aa aa
(affected) (Normal) (affected) (Normal)
: If both the parents are affected than the chance of having unaffected baby is 2so/our 05. AIIMI 04)
Aa
: Note t Ehlers - Danlos syndrome (EDS) has all three mendelian pattern of inheritance(At 07)
.
l. One parent is carrier and the other is nornral - > 50oh of child will be carrier.
Aa
2. Both the parents are caruier --> 25% children will be afficted, 50% will be carrier and 25ok will be
normA/'"''"'.
AA Aa Aa
3, One parent is affected and other is carrier -+ 50% of child will be affected, 50% wilt be carrier"""o''.
AA Aa
AA Aa Aa
AA
AA AA AA
AA Aa
n*
Cn-artx.*'1,15,
r Note : Ehlers - Danlos syndrome (EDS) has all three mendelian pattern of inheritance@10') .
l. One parent is carrier and the other is normal - > 5Oo/o of child lvill be carrier.
Aa
2. Both the parents are csrrier --> 25% children will be afficted, 50% will he carrier and 25'% will be
normaln"''o).
AA Aa Aa
3. One parent is uffected and other is carrier + 50% of child wilt be affected, 50% will be carrier'''""'
AA Aa
AA Aa Aa
AA
AA AA AA
5. One parent is ulfected and one is normal -+All will be carrier @"'0"
AA Aa
Note - | have given the percentage of genotypically affected children. Affection of phenotype will be different be-
cause all carrier will be phenotypically normal (as autosomal recessive disease is manifested only in Homozy-
gous state). So in 1st situation all child (100o/o) will be phenotypically normal, in 2nd situation 750lo child will
be phenotypically normal and in 3rd situation 500/o will be normal in 4th situation no child will be normal and
in 5th situation all will benormal. But you remember the precentage of affected children for which there is no
confusion.
* Glycogen storage
3)
disorderst'^t 1
[Iniparental disomy
o Autosomal recessive diseases manifest in homozygous state. But there is one exception to this rule, i.e. Uniparental
disomyro'o't. Uniparental disomy occurs when a person receives two copies of a chromosome, from one parent and
no copies from other. In this condition if the child receives two copies of the affected chromosome from the carrier
parent, he/she will manifest the disease.
X-linked disorders
X-linked re(essive
o Except for a few conditions, all X-linked disorders are X-linked recessive.
o AsmalehasonlyaneX-chromosome,themalewithaffectedgeneonX-chromosewillalwaysmanifestthedisease4l
10).
o On the other hand, female has 2 X-chromosomes, heterozyogous female will be carrier@Egr) because of expression
of normal allei on the other X-chromosome.
o Note - Female with Tirrner syndrome (only one 'X'chromosome) can manifest X-linked recessive disorders.
o 50o/o boys of the carrier mother will be affectedAt 13' NEET) .
o All daughters of affected father will become carrier, i.e. affected father will transmit the defective X-chromosome to
all the daughters.
o Father will not transmitt the disease to son as boys do not inherit X-chromosome from fathe/NEEr) .
r Three important sceneria may be there.
i) Father is afected mother is normal: All female children will be carrier and male childen will be normal
x"x xux
ii) Father is normal mother is carrier:50o/o of male children (son) willbe affected@113'NEar), and 50olo of female
children will be carrier.
rll) Fgher carrier: 50% of male children will be afected, 50% of female children will be
is affected and mother is
affected and 50% of female children will be carrier
x"x xuv
X-linked dominant
r In this, both males and females are affected. All the sons of affected father are normal and all daughters are affected.
The affected mother transmitt the disease to half (50%) sons and half daughters.
xo
xox
Mastubskeietal, "", ,Hema{alqsiaql. , , l It:l t:r':tg, :.: .'.. .,,,.. :.,' .M€lobalic,', ..: .,, - ',. :,.,11r';. N.erVous,,,,,',, ::,,, .,.,.' .
:poi;"1t'
LE.' ::... :. i.: ::::1 :.:
.6-6.PD deficiencyw
Fragile-X syndrome
o Fragile - X syndrome is the prototype of diseases in which the mutation is characterized by a long repeating
11' 0e)
sequence of three nucleotideseGr .
'&;fienetlcDisarders
r In fragile X syndrome,trinucleotide repeat mutation involve CGG on non coding region.
r Clinical features of fragile - X syndrome are :-
t Mental retardation r Mitralvalve prolapse
t Large testis@NB AMU (macro-orchidism)
13, 0s)
r Hlperexntesible joint
t Long face with large mandible@Mu 05) r High arched palate
: LAtge eVerted eArS@NB 13' AMU os)
o Fragile X syndrome is the second most common genetic cause of mental retardation,
after Downs syndrome,
b) Fragile-X svndrome
c) Turner syndrome
d) Hlpothyroidism
oo*
Ans. is i.e., Fragite-X
r Mental retardation in child with large elongated face and large everted'ears is
characteristic of FragilelX
syndrome.
Mitochonrial disorders
c Mitochondrial DNA is the only non-chromosomal DNA in human cells.
I Mitochondrial DNA is always maternally inherited. Thus diseases caused by mutation in mitochondrial DNA are
always inherited from mother to next generatiorx@Itus 12, AI07),
o All children from affected mother will inherit the tlisease. But no children will
inherit the disease from affected father.
o Both male andfemales are affected6llMslt'o"". Aff"rtrd son tloes not transmitt
the disease to next generation@cl t0),
e Important mitochondrial disorders are Pearson syndrome, Leigh syndro me, MELAS@I ts),
Kearns-Sayre Syndrome
(r{S5)r"o' "1 Leber hereditary optic neuropatfu (LHoN)rNmD, Chronic
progressive external ophthalmelagia@Grl,) and
NARPGrrus0e).
Genomic imprinting
r A person inherits two copies of their genes, one from mother and one from father.
Usually both allels of gene are active
in ceils' However, in some cases, one of the allel (either maternai or paternal) is silenced
and only the counterpart
remains active.
r when the aliel inherited from mother is silenced/inactivated (paternal aliel is active), it is
called maternal genomic
imprinting. When paternal allel is silenced (maternal allel is active) it is called paternal genomic
imprinting.
. Thus genomic imprinting leads to preferential expression of an allel depending on its parental originqr
oe' os)
r It is due to maternal genomic imprinting(AlI3'NEEI) in which there is deletion on maternal chromosome 15.
r They are characterizedby hypotonia, mental retardation, seizures, ataxia, and inappropriate laughter (Happy
puppets).
o Besides genomic imprinting, the above two slmdromes may aiso be caused by a phenomenon called Uniparental disomy
(UDp;rrr,r.t in which a person receives fwo copies of a chromosome from the same parent and no copy from other
parent. Prader Willi Syndrome may be due to inheritance of both copy of chromosome 15 from mother (Maternal
UDp(NEEIArMs
ro)) and Anglemann syndrome may be due to inharitance of both copy of chromosome 15 from father
(Paternal UDP(Arr3)).
r These disorders are due to chromosomal mutations which results in either abnormal number or structure of chromosome'
Triso mles (involvi n g auto so mes) Down syndrome (Trisomy 2'l ), Edward syndrome (trisomy 18),
Pata u synd rom e (trisomy 1 Sbttws
0& oG))
.
Down's syndrome
r Down's syndrome is the most common chromosomal disorder^'IMsnn) and most common congenital cause of mental
retardation (2d most common genetic cause of mental retardation is Fragile -X syndrome),
Cytogenetics
o Basic molecular defect in Downs syndrome is extragenetic material of chromosomeZl.It may be due to :-
1) TtisomY 27@ItMstt'PGI11)
r This is lhe most common cause (95o/o), There is an extra chromosome 21 (i.e. three 21 chromosomes) which
is due to meiotic nondisjunctional
10)
in ol'um. The extra chromosome is of maternal origin{Ar ro). The most
important risk factor is advanced maternal age (> 35 years).
2) Roberston translocation
r This account s for of cases. Extra material of 21 chromosome comes from Robertson tanslocation of iong arm
3o/o
of chromosome 21 to another acrocentric chromosome (22, or 14 or 15), i.e. t (22: 21), t (14:21), or t (15:21)
(NEE[,AilMs1l,PGI lr).
It has no relation with maternal age.
3) Mosaicism (Mosaic 276ILMS
lt PGI
'
11)
)
t In2o/oof patients there is mosaicism, i.e. occurance of two or more diflerent tlpes of cell population (46 XX I
Geiriefiit,Dlsordeis
Cliniral features
o Most striking feature in the neonate is hlpotonia@EnD and although the
diagnosis is usually evident at this time, it
may sometimes be missed if the baby is very or his facial features are concealed by ventilatory apparatus.
Premature
o Other clinical features include :,
1) General:- Mental retardation@EEr), short stature
2) Cranio-facial:- Brachycephaly(ua*os't, epicanthic fold, protruding tongue, small ears, upward sloping palpebral
fissures (Mongoloid slant eGI o0)) , strabismus, nystagmus, Brushfieil spots in
irisavEEr, Ar 06).
3) Limbs:- Fifthfinger clinodactyly\IlMse3), single palmar crease (simian crease@EEr,pcl,00,ArrMSe3)),wide
gap between
first and second toes (sandle gap eGI0s)) .
4) Congenital heart disease@G.,2) :- Common AV canal, ostium primum/endocardial
cushion defect type ASD (most
06, DNB t2)), ysD, pDA,
common1r fallot tetralogy.
5) GIT:- Anal atresia, Duodenal 4fyssiq@rss), Hirschsprung disease(Arnr), annul ar p
ancr e asal e 4),
6) Increased incidence of leukemia (1o/o). Leukemias common are ALL (most
common)@Gl 02), AML (M7-AML)
transient my'eloproliferative disorders(NnEr), and]uvenil CML.
7) Others : Early onset of Alzheimer\ disease?G'02), Decreased immunity wlth recunent
infections{pcrorl obesity,
DM, Hypotlryysiflisyn4t oe) .
a) Down syndrome'
b) Fr,agile.X syndrome
',
c) Turner syndrome
d) Hypothyroidism
, r These are typical facial features of Down syrrdrome, i.e. flat faciei, upward
slant of eye, and open
mouth with protruding tongue. ,!'
& pqlatewEEr'attvsos'06)
Ceft lip and cleft & Low birth weight
& Flexed-fingerswith polydoctyly'AttMsos'M) 6 Closed fists with index finger overlapping the 3'd
w Occular hypotelorism{NEEr) * digit and the 5th digit overlaping the 4'h.
& Visceral and genital anomalies & 15olo cases are lethal in 1't year
are there.
(cystichydromaal
r Clinical features in childr enare edema of dorsum of hands andfeet(Nanrt, sweiling of nape of neck
ea)),bilateralwebbingofneckal04),andcongenitalheartdiseases lmostcommonbicuspidaorticvalve@NB13)foliowed
os)), AS, MVP]'
by coarctation of aorta (2nd most commonqttMs
ts shott 0a' Ar ot),
webbed neck6' o')
low posterior hair lineqt
0a)
widely
o Clinical features in adolescen are stature@Gt
' '
cubitus
spacednipples(Ar03) with broad chest, hypertelorism, epicanthus, slanted palpebral fissure, ptosis, micrognathia,
hlpothyroidism, streak
valgus (increared carrying angle6l04)),sensorineural hearing loss, shortfourth metacarltal\ron),
ovariesa/ ri), and sexual infantilismecr
0a).
Tlrner syndrome is the mosf important cause of ptimary amenorrhea@t
ee)
may be glucose intolerance, obesity and insulin resistance. Mental retardation is not
,3). There seen4l '
carrying
Turner syndrome showing shield chest with widely spaced nipple, webbed short neck, and increased
angle.
I
\prER L 5 Genetics & Genetic Disorders
. Note: Noonan syndrome is not a chromosomal disordey'conedo6).lt is an autoso mal dominont (Mendelian
inheritonce) disorder. lt has been explained here because it has features similar to Turner syndrome.
Klinefelter syndrome
r Klinefeltersyndromeisthemostcommonchromosomaldisorderassociatedwirhmalehypogonadismandinfertility.
It is defined classically by a 47,XXY(PGr0') karyotype with variants demonstrating additional X and y chromosomes.
(Other variants can have 48 XXXX rarely 49 XXXXY or mosaics can be there with some cells containing normal
46' XY and others 47, XXY). Classically, it results from meiotic non-dysjunction of sex chromosomes (40% during
spermatogenesis and 60% during oogenesis). Mostly, non-dysjunction occur during 1,t meiotic division.
o The patient has male phenoQpe with feminizing features due to extra X-chromosome (note : presence of one y
chromosome is sufficient for male phenotlpe. Thus XY, XXY, XXXY all are males). Extra inactive chromosome appears
as Barr body.
o Important clinical features include microorchidism with normal external genitalia, mental retardation@Gl 0t),
gynecomastia, lack of secondary sexual characteristics with eunuchoidecl 01) body habits, disproportionately long
arms and legs, hypogonadism(Pcl01), increased incidence of tumors (breast carcinoma, germ cell tumors), increased
incidence of autoimmune disorders (e.g. SLE), and cardiac problems (most common is mitral valve prolapsea'o se)
,)
Testosterone levels are decreased, whereaslevels of gonadotropins (FSH/LH) are elevated@Gt01),
* PedlOree ala.lVsis chart is used for: lllustrating the inheritance of genes u tuily:
'a AhA$ ,4i!; ,,
in . . ..
dbobywhenb.othparinti'ielve'auiosonil:domini,ant,aiieasei25ge.'.1;,:.:.
* Chances of being affected if one parents has autosomal dominant disorder:50o/o.
* if one parent is having autosomal recessive disorder and other parent is c.arrier:5oo/o:.
e Chances o! hau!.ng diseases.if b3th parents are carrier of autosomal recessiue disease :25o/o.
*
I Only males are affected:X-linked recessive.
* Fpthe$'
t,
l:, rynimifr;l.iraa*i:use'rajm : iiJinkedi :,
Noonan syndrome
r Noonan syndrome is an autosomal dominant(Ar 03)
disorder which affects both females and males@NB r3). The most
phenotypic features resemble females of turner syndrome, but they have normal sex chromosome and normal karyotyps(oNs
li)(46 XX or 46 XY), i.e. male or
female with turner phenotype.It is due to mutation on chromosome 12.
o Important features arc short statureqle7'AIIMSe4), webbed neck, low set ears, cubitus valgus, ptosis, micrognathia,
hypertelorism, down-slanting palpebral fissure (antimongoloid slan{Al ee' AIIMS e4)), clinodactyly, cryptorchidism,
i.e. undescended small fssfisqt os' e7' AIIM9 e4), pectus carinatum or pectus excavatum, sensor ineural hearing Ioss(DNB
i3), congenitai heart diseases (supravalvular pulmonary
stenosis\I eT,AIIMS e4) : most common, ASD, hypertrophic
cardiomyopathy(Al03),anddefectinconduction/rhithm),anddelayedpuberty: Testosteronelevelsareoftenlow@N813).
Kfinefelter syndrome
o Klinefelter syndrome is the most common chromosomal disorder associated with m ale hypogonadism and infertility.
It is delined classically by a 47,XXY(PGI0'I) karyotype with variants demonstrating additional X and Y chromosomes.
(Other variants can have 48 XXXY, rarely 49 XXXXY or mosaics can be there with some cells containing normal
46, XY and others 47,XXY). Classically, it results from meiotic non-dysjunction of sex chromosomes (40%o during
spermatogenesis and 60% during oogenesis). Mostly, non-dysjunction occur during 1,t meiotic division.
r The patient has male phenotype with feminizing features due to extra X-chromosome (note : presence of one Y
chromosome is sufficient for male phenotlpe. Thus XY, XXY, XXXY all are males). Extra inactive chromosome appears
as Barr body.
r Important clinical features include microorchidism with normal external genitalia, mental retardation@Glo,),
gynecomastia, lack of secondary sexual characteristics with eunuchoid@Gl 01)
body habits, disproportionately long
arms and legs, hypogonadism(PGl01), increased incidence of tumors (breasi carcinoma, germ cell tumors), increased
incidence of autoimmune disorders (e.g. SLE), and cardiac problems (most common is mitral valve prolapseeqer.)
Testosterone levels are decreased, whereas levels of gonadotropins (FSH/LH) are elevated@cl0t).
c Pedigree onalysis chart is used for: lllustrating the inheritance of genes in a family.
t Chances of having unoffe:cied baby when both porents have autosomal dominant disease ..25o/o.
o Chances of being aiected if onte porents has autosomal dominornl disorder'. 5Oo/o.
i;,,,:,ehqnces af.haviig disea5e if one parent is havlng autg;amAi iiiessiive Aliarder,,and,it:bsrp.atent is,iarrii*: 50%.. :
* Chances of having diseases if both parents are carrier of autosomal recessive disease :25o/o.
3.,, ekaqeei.of htiviaeircaseifbott!..$fenfs,dre affiitid, eu.tasomilrc-cessil*ii,ssr.ll00%:',r,,r"',
t Chances of having disease if one parent is carrier for AR disease ind other is norlmol: 0olo (50olo will be carrier).
::$.: ' Natii n a ata* 6,nt eL do tiiin ait :gis o r.dcc Tab g dise.ir$
a Anly.malesare7ff11yd:X-liyked recesllve, .
:t;lb 1
Fatiers not transmitt the disease to son: X-linked.
a Mothers not transmitt the disease to daughters : X-linked recessive.
::*.:
* Only males are affected and females act as carrier: X-linked recessive'
x Differentio! expression of same gene depending on parent of orgin: Genomic imprinting
a Functional gene is inherited from one Parenf : Genomic imprinting'
c Paternal 15 deletion or Maternal 15 disomy'. Prader Willi syndrome'
w Maternal 15 deletion or Paternal 15 disomy: Angleman syndrome'
e Obesity with mental retardation:Prader will syndrome'
w Mother transmitting disease to all children : Mitochondrial disorders.
* Both males snd females ale affected but ma[es do not transmitt the disease : Mitochondrial disorders'
a Common ocular findin g in trisomy 13 (Patau syndrome):Bilaleral microphthalmos
'l
& Maltiple defects with cleft tip, cleft palate, microcepholy, microphthalmos and scalp defect;Trisomy 3.
:tr:1:::;;:,;:::':;;"IJ ji,,,,,,.mv23(D.wnsvndr.me,
e Not seen in Down's syndrome : Decreased nuchal thickness, hypertonicity, Pigmented birth mark.
,losaic 21.
w Downsyn:dromeisdueto..Trisomy2l (mostcommon); Robertsoniantranslocation13-15/21,22121;!
e Most common cause of trisomy 21 in down syndrome : Maternal nondisjunction in
meiosis 1 .
:';:,#l::, ;;;1';":,,:ili,
e Down syndrome:TrisomY 21.
* Klinefetter syndrome is diagnosed by: Karyotyping'
:i:;:i,'i;::;:,:::,::,i:::;,J::::,.*)me,+sxo,
w Male with present Barr body,, sv.ndrome (47XXY)'
1,'":t:,,:l
* Most cammon birth defect in North lndra : Neura[ tube defect (spina bifida).
s Most common birth defect in rest of lndia: Musculoskeletal defects.
c Skull in Down's syndrome: Brachiocephaly,
a Distinguishing feature of Edward syndrome (Trisomy 78) : Rocker bottom fect'
* Not seen in Turner syndrome : Mental retardation.
w Not a feature of Noonan syndrome: Chrolos.omal abnormality'
w Jeune syndrome {asphyxiating thoracic aplasia) is : Autosomal recessive disorder'
w pierre Robin syndrome consists: Micrognathia (mandibular hypoplasia), cleft palate, CHDs, respiratory obstruction, foreshortened
floor of mouth, normal size tongue.
* Mutation in a sinqle gene produces effect on mare than one choracteristic: Pleiotropy.
* Child resemembles grand-parents: Atavism.
&&x
QUESTIONS
Pedigree analysis chart- (All lndia Dec15 Pattern) is normal and the other is carrier and the child is
a) Used for growth monitoring also affected. What is the reason - (At 07)
b) To assess side effect during chemotherapy a) Germ line mosaicism
c) Used to see gentic transmission b) Genomic imprinting
d) To assess developmental delay in infant c) Penetrattion
2. A child with a small head, minor anomalies of d) Uniparental disomy
the face including a thin upper lip, growth delay, 9. An affected male infant born to normal parents
and developmental disability can have all of the could be an example of all of the following, except -
following, except - (At 06) (Ar 06)
a) A chromosomal syndrome a) An Autosomal dominant disorder
b) A teratogenic syndrome b) An Autosomal recessive disorder
c) A mendelian slmdrome c) A polygenic disorder
d) A polygenic syndrome d) A vertically transmitted disorder
J. All of the following conditions have autosomal dom- 10. True statement about inheritence of an X linked
inant inheritance except - (All India Dec.14 Pattern) recessive trait is - (Ar e7)
a) Fabry disease a) of boys of carrier mother are affected
50o/o
b) Marfan's syndrome b) 50% ofgirls ofdiseased father arecarrier
c) Osteogenesis imperfecta c) Father transmits disease to the son
d) Ehlers Danlos slmdrome d) Mother transmits the disease to the daughter
4. The chances ofhaving an unaffected baby, when 11. Kinky hair desease is disorder where an affected
both parents have achondroplasia, are - (Al 0s, AIIMS child has peculiar white stubby hair, does not grow;
May 04) brain degeneration is seen and dies by age oftwo
a) 0% years. Mrs A is hesitant about having children
b) 25Vo because her two sisters had sons who had died form
c) 50o/o kinky hair disease. Her mother's brother also died
d) 100% of the same condition. Which of the following is the
5. In family, the father has widely spaced eyes,
a possiblemodeofinheritenceinherfamily - @t04)
increased facial hair and deafness. One ofthe three a) X-linked recessive
children has deafness with similar facial features. b) X-linked dominant
The mother is normal. Which one of the following is c) Autosomal recessive
least likely pattern of inheritance in this case- (AI 06) d) Autosomal dominant
a) Autosomal dominant 12. Study the following carefully -
b) Autosomal recessive
c) X-linked dominant
d) X-linked recessive
AUTOSOMAL RECESSIVE
6. A parent is homozygous and a parent heterozygous for Read the pedigree. Inheritance pattern ofthe disease
an autosomal recessive gene. What will be the out- in the family is - (At os)
come - a) Autosomal recessive
a) 75o/o children affected (AIIMS May 9a) b) Autosomal dominant
b) No child affected, but all are carriers c) X-Linked dominant
c) 50o/o children affected, rest are carriers d) X-Linked recessive
d) 25Vo children affected, rest are carriers 13. Which of the following is the most likely inheritance
7. For a normal husband and wife the first child was pattern in the pedigree given below- (AttMS May 04)
diagnosed to have cystic fibrosis. What is the per-
centage ofchances for the second child be afiected -
a) 25 b) so (PGl Nov 14)
c) 0 d) 75
e) 100
8. In an Autosomal Recessive (en) disorder, one parent
a) Autosomal dominant lip, cleft palate, microcephaly, small eyes, scalp
b) Mitochondrial defect and polydactyly, seen in which syndrome-
(AIIMSNov
c) Autosomal recessive 06, MaY 08)
a) Edward Syndrome
GENOMIC IMPRINTING b) Patau Syndrome
c) Down Syndrome
15. Diflerential expression of same gene depending on d) Turner Syndrome
parent of origin is referred to as - (AI 0s,06)
25. Cat eye syndrome is- (All India Dec.14 Pattern)
a) Genomic imPrinting a) Partial trisomy 18
b) Mosaicism b) Partial trisomy 13
c) Anticipation c) Partial trisomy 21
d) Nonpenetrance d) Partial trisomy 22
16. The process underlying differences in expression of
a gene, according to which parent has transmitted, is
called (At06)
DowN sYNDR0ME
a) Anticipationb) Masaicism
c) Non-penetranced) Genomic imprinting
26. Increased nuchal fold thickness is a feature of -
t7. Maternal disomy of chromosome 15 is seen in - a) Paul-Bunnel syndrome @I 99)
a) Prader - Willi spdrome (AttMSNov 10) b) De-pan syndrome
b) Klinefelter's syndrome c) Downs syndrome
c) Angelman syndrome d) Cri-duchat syndrome
d) Ttrnert syndrome zz, Most common presentation of down syndrome is-
18. Which of the following hormones are raised in a) Cognitiveimpairment (All lndia Dec15 Pattern)
AUTOSOMAL DOMINANT
AUTOSOMAL RECESSIVE
6. Ans. is t' i.e., 50% children are affected, Rest are carriers {Ref: Robbin's 7h/e p. 1611
. One parent is affected and other is carrier -+ 50% of child will be affected, 50% will be carrier.
Aa Aa
c All should be phenotypically normal, because autosomal recessive disease manifests in Homozygous state.
o But there is exception to this rule, i.e. uniparental disomy.
Uniparental disomy
o Uniparental disomy occurs when a person receives two copies of a chromosome, from orie parent and no copies from
other.
* In this condition if the child receives ,two copies of the affected chromosome from the carrier parent, he/she will
manifest the disease.
9. .A.ns. is 'a' i"e., Autosomal dominant disorder {R"ef : Rabbinb Vh/e p. 160, 16l)
In Autosomal dominant disorders indiviiluals are affected in successive generations. The disease does not occur
in the offspring of unaffected individuals' -
e If both parents are normal, the disease cannot be autosomal dominant because it is manifested in Heterozygous
state, So, even a single gene affection amongst the allel will cause the disease to be manifested. To be normal, a
person should have normal copy of both allel. If both parents are normal, that means there is no abnormal gene.
o At least one of the parents should be affected to transmit the disease to child.
X-LIhNKED
10" Ans. is 'a'i.e., 50% of boys of carrier rnother are affected lRe! &obbins Vh/e p. 1521
o 50% boys of the carrier mother will be affected.
e All daughters of affected father will become carrier, i.e. affected father will transmit the defective X-chromosome to
all the daughters.
o Father will not transmitt the disease to son as boys do not inherit X-chromosome from father.
11. Ans. is 'a' i.e., Xlinked Recessive {Ilef: Rabbin's Tnle p. 152}
e The clues in this question are -
1) Only males are manifesting disease.
2) Females are acting as carriers -+ sisters sons had suffered from the disease.
r Both these are features ofX-linked recessive disorders.
About other options
e In X-linked dominant disorder the females will also manifest the disease.
o In autosomai dominant and autosomal recessive disorders, both males and females are affected.
tz. Ans is 'd' i"e., X Linked R.ecessive fRef: R.abbin's Vh/e p. l52l
o Similar to above question, only males are manifesting disease and females are acting as carrier.
c It will be easier to solve this question if I will change the represention of Pedigree -
XY xx d
XY xdy xx
().Jormal male) (Carrier female) Qrlormal male) (Affected male) Q.{orma1 female)
d
XY XY
d
XY XY xx
d
xx
o The Pedgree starts from normal male and carrier female.
r Carrier female transfer the mutated X-chromosome to half the male children and half of the female children.
r Second generation pedgree starts when one of the carrier female marries to normal male.
r Here also she transfer her mutated X-chromosome to half of the male children and to half of the female children.
t3. Ans. is 'd' i.e., X linked dominant lRef: Chandrasoma Taylor 3'd/e p. 232, 233]
o It is an X-linked dominant pattern of inheritance.
r The features which suggests the X-linked dominant pattern of inheritance are-
r A single abnormal X chromosome is sufficient to express the disease.
r A11 of the female offsprings of a diseased male XY will receive the abnormal X chromosome and express the
disease, whereas none of the male offspring to the diseased father will have the disease (as sons dont receive X
chromosome from their father).
: A diseased mother can transmit the abnormal X chromosome to both daughter and sons equally.
14. Ans. is t' i.e., Mitochondrial inheritance fRef: www. springerlink)
r This pediagree chart has following two characteristics : -
i) Disease is manifesting in both males and females.
ii) But, the diseaSe is transmitting to next generation only by females (mother).
r Both these are characteristics of mitochondrial diseases.
All children from affected mother will inherit the disease but it will not be transmitted from an affected father to his
children. --- Harrison's 16rh/e 374
GENOMIC IMPRINTING
15. Ans. is 'd i.e., Genomic imprinting [Rel O.P. Ghai 8*/e p. 6i7 6 7h/e p. 612; Rabbins Th/e p. 186)
The pthenomenon referred to as genomic imprinting leads to pereferential expression of an allele depending on
its parental origin. --- Harrisons
16. Ans. is t' i"e., Genomic imprinting [Refr O.P. Ghai Y'h/e p. 637 (t 7h/e p. 612; Robbin's Vh/e p. 186)
r There are functional differences between paternal and maternal genes. So the expression of gene will be different
depending on, whether it has transmitted by father or mother. This is called genomic imprinting.
\v. Ans. is'a' i.e., Prader-willi syndrome [Ref : Nelson 18th/e p. 498, 51j, 5161
t ln Prader- Willi syndrome, about 60% of cases have maternal uniparental disomy (maternal UPD- missing the paternal
chromosome l5).
18. Ans. is ?' i.e., Ghrelin [Ref NORD Gaid.e to Rase Disorders Lippincott Williams 2002 p. 2j7]
o Prader Willi Syndrome is associated with elevated circulatinglevels of Ghrelin.
TRISOMIES
21. Ans. is'a' i.e", Trisomy f 3 [Re/ Robbin's fl/e p' 176, 177; O.P. Ghai 8il'/e p' 6j9 6 7h/e p" 615]
t Clefi lip, cleft palate, scalp defects suggest Trisomy 13 or patau syndrome.
r The highest discriminatoryt values are for ectodermal scalp d*cts and harelip and cleft Palate in trisomy 13 and
elongated skull and simple arches on all digits for trisom)t 18.
Cneerra r5
tl. Ans. is
nMqlme'
{}l.e{: Nets*w t7h/e Chap 8t Tabk 81"2]
Patau Syndrorne
o Trisomy of 13th chromosome o CIeft lip often midline a Polydacity with flexed fingers
* Ocular hypotelorism o Bulbous nose o Low set ear
c Holoprosencephaly o Microphthalmia o Cardiac mallormation
a Scalp defect o Hlpoplastic or absent ribs a Rocker bottom feet
23. ,4.ns. is 'b' i.e., Bilateral mieropthalmos [Rel Robbiw's 7h/e p" 176, ]77; A.P. Gkai &'hle p. 639 & 7h/e p. 6] 5)
x Important ophthalmological abnormalities in Trisomy 13 (Patau syndrome) are microphthalmiaand cloboma of iris.
ub'
21. Aats" is $.e., Patauz Syrx&rrau,ae {ltet': !{elson 17h/e Ch*p. 8} 'lable 8x.2"1
c Trisomy 13 - Patau Syndrome a XO - Turner Syndrome
o Trisomy 18 - Edward Syndrome o XXY - Klinefelters syndrome
* Trisomy 21 - Down Syndrome
25" Axes. is '&' i,e",War$an T'risormy 22 Ule.f: Darlawd's 2&'1'le p. 152{j}
o The supernumerary cat eye syndrome (CES) chromosome is dicentric, containing two copies 22q11.
DOW{I{ SYrllPR0ft,l8
to. Ams. is 'c' i,e", Downk Syndrorne $lef: A.P. Gkai $th/e p. 645 {r Vhle p. 5}4}
Nuchal fold thickness is inteased in Down syndrome. This feature is used in suspecting the diagnosis of Down's
syndrome prenataly.
o* iNelsow }&tt'/eChap.8t}
27. Axns, is i;.*..,A*zgxzitzw*iaxpairwzcxtt{Ilef:
* Cognitive impairement with developmental delay and mental retardation is universal.
*d'
)q Ams" is i"e., Hypertonicity [Rrf 8"P" Gbsri 9th/e p" 638 et 7h/e p" 613: l,{elsow n$th/e y:. 5{}8}
e Most striking feature in the neonate rs hypotonia and although the diagnosis is usually evident at this time, it may
some time be missed if the baby is very premature or his facial features are concealed by ventilatory apparetus.
lo Ans" is 'l)' i"e", dJndescended testis lRef : A,P. Gkai 8'h/e p. 638 dr Vh/e p. 613; Nelsaw 18tk/e p. 5811
* IJndescended testis has not been described as an association with Down's syndrome.
30. Ans" is 'd' i.e,, Respiratory tract infection uncommon [Rel O"F. Ghai 9th/e p" 638 dr 7h/e p. 613; Nclsan 18th/e p.
s081
e Chronic rhinits, conjunctivitis and periodontal disease are common in Down's syndrome.
a Lower respiratory tract infections pose a threat to life.
e Pneumonias are common in patients with Down's syndrome.
3r" is 'h' i"e,, ExaeXoeardial cushioee t{efeet [Ri,ii ]{elscm tr&Lt'le ch.6231
"&ras"
o Most common CHD in Down syndrome is ostium primum tlpe of ASD which is the simplest form of atrioventricular
septal defect also called as endocardial cushion defect.
32" Aras, is'tr' i,e., Dowm syndrome lRc.f: Na{saw }.8't'/e {:14{ep. 42b.51
o Ostium primum ASD (an incomplete atriventricular septal defect) or endocardial cushion defect is common in Down
syndrome.
Ana. is'# i.e., Atriovemtricular Septal De&et $&ef: R.*bbi*'s Ett'/e Chapter 811
o Approximately4}o/oofthepatientshavecongenitalheartdisease,mostcommonlydefectsoftheendocardialcushion
or ostium primum type atrial septal defects, atrioventricular valve malformations, and ventricular septal defects.
o Cardiac problems are responsible for the majority of the deaths in infancy and early childhood.
o Several other congenital malformation, including atresias of the esophagus and small bowel, are also common.
o#
-).+ " Am,s" isi.e., VS}} Ule, &relson 1E'hle ch.?; GkwiTt'/ep.6t3]
a In down syndrome, most common CHD is endocardial cushion defect (septum primum type of ASD).
-13. Ans. is 'd i"e", Normea[ tt"e-f: Awwa trap paedi*tric 18tl'le p.210t)]
o Narchi H, studied the value of routine neonatal ECG in l't 48 hours of life to diagnose CHD in 37 neonates with Down
syndrome :-
a, 650/o (24 newborns) had no CHD and normal ECG.
, 35o/o (13 newborns) had clinical CHD with :-
i) Half (7 newborns) of them normal ECG'
ii) Half (6 newborns) with abnormal ECG'
36" Ans. is
.a'
i.e., Increased PAPPA {Ref. Dutta */e p 492496, CGOT */e p 11; O-P- Ghai */e p. $s & */e p' 51a\
38" Ans. is 'd i.e., All of above lRef: Ghai /'/e p' '614)
. See aext ofthe chaPter.
39. Ans. is
.b,
i.e., nntestinal atresia & t'i"e., Duodeaal atresia [Ref, 0"P" Ghai */e p- 638 & f le p' 613;
Ndsonl86/eP.5881
o Most common cause of Intestinal obstruction in Down's syndrome is duodenal atresia.
r Duodenal atresia is a tlpe of intestinal atresia'
4&. Ans. is "b, Le", Noadysjunction in materaal meiosi$ {&e$ See above explanationl
r In trisomy 21, the additional number 21 chromosome is derived from the mother
in 95o/o of cases'
I It is due to nondysiunction of 2 t st chromosome at the time of meiosis'
In nondysjunctiorL chromosomal pair fails to separate in first meiotic division during
gametogenesis'
r
4t- Ans. is i' ie." Trisomy 21. {Ref Rabbbfs *fe p. 175; o.P- Gtusi */e p- 637 & */e p' 6131
r Down syndrome (Trisomy) is the most common of the chromosomal disorder. It occurs in frequency of 1:800 to
l:1000 newborn.
42. .&ns. is t' i',e., t (X l:14) [Rei Nelson 17e/e Chap' 81)
: lo 95o/o of cases of Down Syndrome - trisomy of 21. Extra chromosome is of maternal in origin
o 10/o have mosaic with 46 chromosomes'
o 4o/o have robertsonian translocation'
t (.22 :21)
t (14 :21)
t (15 : 21)
o very rarely long arm of chromosome 21 is triplicate (Partial trisomy)
43- A.ns is 1d i.e." Deleted 2l {Ref, Ghoi *te p.637 & */e p.613, X4; Nelsan 1*/e p' 5091
4V. Aa* is
*S 1.7/e p. L925, I{wfisn 1*/e p" 2122; O.P. Ghai */e p' 6a0 & 7/e p' 6151
Le., Turoet's syadmme tR f: *)son
Webbing of neck, increased carrying
Noonan syndrome presents with most features similar to Turner's Syndrome.
Noonan's and Turner's Syndrome but short fourth metacatpal is
angle, low hair line are present in both
characteristic of Turner's syndrome only'
48. Ans. is 't i.e.,45X:O lRef: O.P, Ghai */e p. 540 dr tle p" 616|
49. Ans. is 'c' i.e., Turners Syndrorne lRef Ckai Vkle p. 616\
50. Ans. is'b'i.e., Bicuspid aortic valve lRef: Nelson 18h/e Chapter 58fi
o Turner's syndrome is commonly associated with congenitalheart diseases.
e The most comlnofl anomaly associated is bicuspid Aortic valves iru one third to one half of the patients 6A0/0).
r Other congential anomalies associated with Turner's syndrome -+ Aortic coarctation (30olo), Aortic stenosis, Mitral
valve prolapse, Anomalous pulmonary venous drainage
MISCELLAHEOUS
53. Ans. is 'U i.e., Pigmented nem l\ef; Harrkan' 18h/e Chapter 61; Disarder af development and Iearning, Val-( by
MarkWotraie p.2261
c Clinical features of fragile - X syndrome
: Mental retardation : Long face with large mandible r Hlperexntesible joint r Mitral valve prolapse
r Large everted ears t Large testis (macro-orchidism) r High archedpalate
54. Ans. is''b' i.e",45 X O genome
Barr body (Sex - chromatinl
e It is a densely staining inactivated condensed X chromosome that is present in each somatic cells af female.
o It is found inthe nucleus.
e It is used as a test ofgenetic femaleness -+ it is possible to determine the genetic sex of an individual accordlng
to whether there is a chromatin mass present on the inner su;r{ace of the nuclear membrane of cells with resting
as
or intermitent nuclei. Remember following fact and the question will seem yery eacy.
e Chramatid boily (Barr body or sex chramatin) is derived from one of the two X-chromosomes which becames
inactivated.
e The nurher of Barr bodies is thus one less than the number of X-chromosomes.
ilote-
o Barr body is found in female But -
r Kleinefelter syndrome is male with Barr body.
r Turner syndrome is female without Barr body.
55. Ans. ist'i.e.,Dcwn'ssyndromelRef:Nekontcxtbookafped,iatricsl&h/eChapter8l,587tablc&1-1&51-21
c In the given karyotype, there is trisomy of 21 chromosome, which is characleristickaryotype of Down syndrome (see
above explanation).
56" Ans. is?'i.e.,Turaer'ssyndromelRef:Netsantcxtbaqkafpc.diatrtesl*leChapter8l;Harrisanblshle
Chqpter 349; Rohbins Vhlc p. 179]
r In the $venkaryotype there is single X chromosomes and ail. other pairs are normal i.e., 45XA, which is diagnostic of
turner's svndrome.
Ans. is '* i.e., Karyotypingl&ef,Gkai Sth/e p. 64a d* Vh/e p. 6151
Ans. is 'b- i.e., l{eural tube defects (Spina bifida) {R"ef Textbaok af envirorumental & Genetic Faedia{rics}
o In North India, neural tube defect is most common.
o In rest of the India, musculoskeletal defects are more common.
59. Ans. is'd' i.e., Fragile X syndrorne lRef: Robbin's Vh/e p" 182)
60. Ans. is t' i.e., Brachicephalic [Rel; O,P. Gkai $tule p. 638 d? Vt'/e p. 61j]
dt. Ans. is'd'i"e., Rocker bottom feet [Rel Nelson lVhle p. 384; O.P. Ghai Sthle p. 539 d2 7h/e p. 614]
62. Ans. is'c'i.e., Chromosomal abnormality lilef Nelson 18th/e p. 5141
63" Ans" is'd i.e., AR [Rel Pediatric Urology l't/e p. 145]
a f eune syndrome, also called asphyxiating thoracic dysplasia, is a rare autosomol recessive condition character rzedby
skeletal abnormalities, along with renal, hepatic and pancreatic abnormalities.
rrt
XNFKCry'XMEJS
MXSKASK
VIRAL INFECTIONS
MUIIIPS
o Mumps is caused by a RNA Virusbelongingto famtly paramyxoviridae.
o Man is the only nafural host, and sources of infection are clinical or subclinical cases.
r Infection is acquired by air droplets through regtiratory route.
c Period of infectivity (communicability) is 4-6 days before the onset of symptam to a week thereafter {N oo.
r MumpsvaccineisaliveattenuatedvaccineqtEar),preparedfromlerylllynnstrain?Glo6).Oneclinicalattackofmeasles
also confers life long immunity.
cHlcr(Elr Pox
r Chicken pox is caused by Varicella-Zoster Virus (HSY-III).
r Infection is transmited by air droplets.
o Incubation period is 10-21 daysqerot).
o Infectious Tteriod is 2 ilays before to 5 days afier onset of rash.
o The crusts (scabs) from chicken pox are not infective, i.e. crushed lesions are non-infective?cl 06' 01).
r Chicken-pox usually affects children of age gronp 5-9 years. Clinical features of chicken pox has two stages :-
1) Pre-eruptive stage : Characterized by fever, back pain, malaise and shivering.
2) Eruptive stage: It is characterizedby a characteristic rash with following features (which must be differentiated
from rash of small pox) :-
i) Superficial@I ts) and unilocular(Ar 1' (rash of small pox is deep seated and multilocular).
i, Symmetrical, mostly onflexor surfaceqllMslo) (rash of small-pox usually affect extensor surface).
iii) Centripetal distributional (rash of smallpox has centrifugal distribution).
13)
iv) Affects axilla but spares palms and soles (rash of small-pox affects palms and soles but spares axilla).
v) Pleomorphic(Ar 13), with appearance of all stages of rash simultaneouslyuttus to) (rash is monomorphic in nature
in small-pox).
vl) Dew-drop on rose petal apperance6IIMSe3) (rash of small-pox has umblicated apperarance).
vii) Area of inJlammation around the rash (in small-pox there is no inflammation around the rash).
vll|)Evolution of rash is rapid, scabs begin to form 4-7days after rash (evolution is slow, scabs begin 10- 14 days
after rash).
r Though the disease affects children commonly, it is more severe in adults than in children,
',,...,.'..:, r;li,,:01ii*i#c$,!$1i,.- ii
Most common complication of varicella is secondary bacterial infection of skin, usually caused by streptococci or
staphylococci. The most common extracutoneous site of involvement in children is CNS. Varicella pneumonia is the
most serious complicationfollowing chicken - pox in adults.
r Important complications of chicken pox are:-
i) PulmonarT.' Pneumonia(Arrrs86 uPsc85)
ii) CNS : Cerebellar ataxia, encephalitisarMs86 uPsc8s), meningitis, GB syndrome, Transverse myelitis.
iii) Others : Myocarditis, Nephritis, arthritis, hepatitis, corneal lesions, thrombocytop€ni4(e[arssr, wscrs), bleeding
diasthesis.
o Latent infection is established in cranial nerve, sensory ganglia and spinai dorsal root ganglia. The virus may reactivate
in immuno-suppressive conditions, resulting in herpes zoter in about 10-30% of persons(Arusto).
e Perinatal transmission of varicella occurs when VZV crosses the placenta@t8e)afid infects the fetus. It is most
threatening if transmitted during 1't trimester and can cause fetal yaricella syndrome (cicatrising skin lesions(Ar 8e),
limb hypoplasia, chorioretinitis, microcephaly).
MEASLES TRUBEOLA}
r Measles is caused by a RNA virus(pcros) of paramyxvirus family@Gr0s). So far only one serot,,pe (antigenic type) of
measles virus is lulownaro8).
o The only source of infection is a case of measles, carrier are not known to occurAilMs os' e8)
.
o Infective period (period of communicability) is 4 days before and 5 days after the appearance of rash, infectivity is
maximun during prodromal stage@roa).
t Secondary attack rate is 80o/o@108) (less than rubellaqltMs0''n') which ftas SAR 90-95%),
o Age group most commonly involved is 6 months to 3 yearsal ro), with involvement of.male and female
os, e8).
equallyarMs
a Transmission is through respiratory tract by droplets (mainly) or sometimes through conjunctiva. Measles shows
cyclic trendares) with epidemic every 2-3 years(Pcroa).
a On attack of measles confer life long immunityutas),
a Maternal antibodies provide immunity upto 6 months of age(@ce
os)
.
Clinical features
r Clinical features are divided into following stages :-
1) Prodromal stage
r It begins 10 days after the infection and is characterized by fever, coryza with sneezing, lacrimation and
photophobia. A day or two before eruptive phase (appearance of rash), Koplik spot(Pci 04) (pathognomonic of
measles@"')) appears on buccal mucosa, opposite the l"t and 2"d lower molars(pcr05).
2) Eruptivephase
I It begins 14 days after infection. A maculopapular rash begins behind the eArseGI se) and spreads rapidly.
3) Post measle stage
r It is characterized by weight loss, growth retardation, diarrhea, cancrum oris, candidiasis, reactivation ofTB
,*
and malnutrition particularlyvitamin A deficiency (keratomalacia,ecl03,02,o0), xerophthalmia).
$
i r Complications of measles are :-
k
i)
i Respiratory: Otitis media (most common complication)rero'), pneumonia\I
pneumonia(Pcros)), bronchitis, laryngitis, croup.
07) (Giant cell or Hecht's
ii) CNS: These are most seriousoEEr) and include encephalitis, transverse myelitis and a rare complicationGr0T) SSPE
(Subacute sclerosing panencephalitis)@et oz).
iii) Gastrointestinal: Gastroentritis, hepatitis, appendicitis, diarrheaar0T), ileocolitis, mesenteric adenitis.
iv) Others : Myocarditis, glomerulonephritis, thrombocytopenia.
ERYTHE'VIA IN FECTIOS[JM {FIFTH DISEASE}
ost
o It is caused by human herpes virus-6 (HSV-61oet .
o Similar illness is caused by Parvovirus B-19 and Echovirus. Age group involved is 6 mt to 3 yr.
* Incubation period --> 5 to 15 daYs'
c Clinical manifestations include abrupt onset with high grade fevet mild pharyngitis and Coryza. The temprature
01' 00' Iipnet es)
comes down rapidly in 3 to 4 ilays when a macular or maculopapular rash appear@IlMs starting from
'
trunk and sometimes extending to the extremities and face?et . Rash lasts for 24 hours, and disappear in 1-2 days
os)
01' 00).
e There is occipital and post-auricular lymphadenopathyqrtMs
e Infectious mononucleosis is the most characteristic disease produced by Epstein Barr Virus.
* Most infections are asymptomatic.
o Headache,Abdominalpain,andchillsarealsoseeninfewcases.Thereisfeveralo2'AttMse3),malaise,sorethroat,(exudative
pharyngitis), loss of appetite and generalized lymphadenopathy : Posterior and anterior cervical LN are almost always
enlarged(Ar 02, AilM e3). Splenomegaly is found in 50-75o/o cases while hepatomegaly is found only in 3|o/oat 02) cases.
Laboratory findings :
a) Atypical Lymphocytosis$t 02' AItMs e3) ' Comprising over 10%o of total lymphocytes at sometime in the illness.
b) Paul Bunnel test is Positive
c) Monospot test is the screening test
HEPATITIS VIRUSES
{& vrrotogyl,: ,. RN,A ' . ,', ', DNA ',.1 : RhlA :., ,ir:-RNA..: :. .RNA'
ci,qpT]ER|rf,let:
T?ansimilsion'1.'.:...
ixPit-"[$,i 1'..'''.".l':...r
ii)'fecojoial.,.,:,"- :
rili)se,Ilta*i r:.:,ir :r:: :::
irij.P.6rinq1tJ,.. "
-.,' .;, i
a Chron_fc infection No
.
'':.: '::,,:':: :. .Y'eS:''t''. ''::aa,,' ri
t ':.Fu kn inent df ssase,. ,,: :1rR5ia, lll .':,'
who are
c Most important riskfactor that determines pterinatal transmission is HBe AglAr03). HBs Ag carrier mothers
where as catrier mothers
HBe Ag positive almost invariably (> 90o/o) transmit hepatitis B infection to their offspring,
with anti HBe rarely (10 to 15%) infect their offspring'
o Infants born to Hbs Ag positive mothers should receive both HBIG and HB vaccine@t,\ee'AIIMS('') intramuscularly
at seperate sites within 12 hours of birth, followed by 2nd and 3rd dose of vaccine
at I and 6 months respectively'
PO!.IOMYELITIS
I) Subclinical (inapparent) infections (g5o/o) : Most commonallMsT') and play predominant role in spread of infection'
ii) Minor (abortive) illness (4.8o/o): Present with fever, sore throat, headache and maiaise.
111) Asepticmeningitisat")/non-paralyticpolio(1o/o):Therearesignsandsymptomsofmeningitis'
paralysis
") with absent teflexes\I13). Respiratoty
ts' 1-rus
iv) paralytic polio (<1%)(Ar 13) : There is flaccid paralysisLt
is the most common cause of deathate2)'
* sternous physical exercise(AilMs
Riskof paralytic polio is itrcreasedby:Tonsillectomy, tooth extraction, adenoidec tomy,
or), fatigue, intramuscular injection\llMs oz), and cortisone administration.
Treatment of poliomyelitis
o There is no specific treatment.
. Management is primary s),mptomatic and supportive.
1) Bed rest -+ Because physical activity and trauma increase the risk of paralysis.
2) Relief of pain and muscle spasm -+ Hot moist packs applied to the muscles relieve pain and spasm (sisfer
kennY's tre atm ent )( etus os ).
o The primary route of infection of HIV in pediatric population is ve rtical transmissionfrom mother to child. probability
of transmission from mother to infant/fetus ranges between 20-30o/oGI 13, NEED(L5-25)/o in developed countries and
25 -35o/o in developing countries).
t Mostlyvirusistransmittedduringdelivery(perinatal)@Gle7,Ketutas7). Itmayalsobetransmitted.transplacentalduring
pregnancy (in utero)(k'"t"e') and postnatal by breast feedinglK*,r"tz) (leastcommon).
o The risk factors for vertical transmission include high maternal viremia (most important
factor), preterm delivery (<
34 weeks), first-born twin, Vitamin-A deficiency, prolonged (> a h$ rupture of membrane, LBW (> 2.5 kg), and low
maternal CD4 count.
o Cesarean section reduces the risk of transmission(Pcr 08' AilMS 03)
.
o Other routes of transmission in children is transfusion of blood and blood products. Sexual transmission is seen in
adolescent population.
BCG?GIB'1il.
ClinicalStage 1
r AsYmPtomatic rs)
r Persistent generalized Lymphadenopathya/
Clinical Stage 2
I HePatosPlenomegalY
r PaPular Pruritic eruPtions
r Seborrhoeic dermatitis
I Extensive human papilloma virus infection
r Extensive molluscum contagiosum
I Fungal nail infections
r Recurrent oral ulcerations
r Lineal gingival erl'thema (LGE)
I Angular cheilitis
r Parotid enlargement
r HerPes zoster
r Recurrent or chronic RTIs (otitis media' otorrhoea' sinusitis)
Clinical Stage 3
adequately responding to standard therapy
: Moderate unexplained malnutrition not
(14 days or more )
r Unexplained persistent diarrhoea
lUnexplainedpersistentfever(intermittentorconstant,forlongerthanonemonth)
r Oral candidiasis (outside neonatal period )
r Oral hairY leukoPlakia
r Acute necrotizing ulcerative gingivitis/periodontitis
r PulmonarY TB testing is necessary
con?rmatory diagnostic
r Severe recurrent presumed bacterial pneumonia conditions where
r Chronic HlV-associated lung disease including brochiectasis
r Lyrnphoid interstitial pneumonitis (LIP)
rUnexplainedanaemia(<8g/dl),andorneutropenia(<1000/mm3)andorthrombocltopenia(<50000/mm3)for
more than one month
Clinical Stage 4
r Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy
I Pneumocystis pneumonia
r Recurrent severe presumed bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis,
but excluding pneumonia).
r Chronic herpes simplex infection; (orolabial or cutaneous of more than one month's duration)
I Extrapulmonary TB
I Kaposi's sarcoma
T Oesophageal candidiasis
I CNS toxoplasmosis (outside the neonatal period)
r HIV encephalopathy
r Conditions where confirmatory diagnostic testing is necessary
r CMV infection (CMV retinitis or infection of organs other than liver, spleen or lymph nodes; onset at age one
month or more)
r Extrapulmonary cr)?tococcosis including meningitis
r Any disseminated endemic mycosis (e.g. extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis)
r Cryptosporidiosis
r Isosporiasis
r Disseminated non-tuberculous mycobacteria infection
r Candida oftrachea, bronchi or lungs
r Visceral herpes simplex infection
r Acquired HIV associated rectal fistula
r Cerebral or B cell non-Hodgkin lymphoma
r Progressive multifocal leukoencephalopathy (PML)
r HlV-associated cardiomyopathy or HlV-associated nephropathy
BACTERIAL INFECTIONS
o Pertussis,alsocalled'100daycough',iscausedbyBordetellapertussis(only5%casesarecausedbyB.parapertussis).
o There is no cross immunity[AflMse7) between B. pertussis and B. parapertussis.
o Source of infection is a case of pertussk@I 13' PGL'),Ihere is no subclinical case or chronic carrier t1^1"6lrMs e7' Ares).
r Period of infectivity (communicability) extends from a week after exposuse to about 3 weeks after the
onset of paroxysmal stage. Catarrhal stage is most infectiveares AIMSeT). Secondary attack rate is high, i.e.
es, PGI 12, AIMseT),
90o/o@I
. More cases occur during winter and spring months@Grl2) due to overcrowding.
e It is a disease of infantsar es) and young children (< 5 years). Infants are susceptible to infection from birth because
maternal antibody does not give them protection(ArrMs e5). Incidence and fatality are more among femalearmses) than
male children.
o Modeoftransmission-+Whoopingcoughisspreadmainlybydropletinfectionanddirectcontact.Eachtimethepatient
coughs, sneezes or talks, the bacilli are sprayed into the air. Most children contract infection from their playmates who
are in the early stages of the disease. The role of fomites in the spread of infection appears to be very small, unless
they are freshly contaminatedaliMs e5).
o Infective material -+ The bacilli occurs abundantly in the nasopharl'ngeal and bronchial secretions, which are infective.
Objects freshly contaminated by such discharges are also infective.
o Incubationperiodisl-2weeks(7-l4days)ecl12'AIIM'10).Thediseasetakesaprotractedcoursecomprisingthreestages,
each lasting for about two weeks :-
1) Catarrhal
ii) Paroxysmal
C.ulpia'n:...i5u,
i.rl) Convalescent
o Catarrhal stage is the stage of maximum infectivityremrseT,Ales) . Maximum complications occur in paroxysmal stage.
o Important complications of pertussis are atelectasis, emphysema, bronchiectasis(A[Ms e7), pneumothorax, otitis
media, encephalopathyarMseT), convulsions, ataxia (non-cerebellar\IlMssT)),hernia, rectal prolaps e, subconjunctival
Ms 7),
h em o r rh ageqrr
e
ifltr acranial hemorrhage and s evere malnutrition.
r For diagno sis, gold standard is isolation of organism in culture from nasopharyngeal secretionallMs 11' 0s, AI 11).
o Erythromycin is the drug of choice for treatment of cases(Ar") as well as for contacts. Isolation period is 4 weeks
or untii paroxysms cease.
DIPHTHERIA
Control of diphtheria
o Cotrol of diphtheria requiresr-
A) Control in cases and carrier
r It includes early diagnosis and treatment, along with isolation.
r Cases are treated by diphtheria antitoxin plus penicillin or erythromycinari3).
r Carriers are treated by only erlthromycin (no antitoxin(Al13)).
r Isolationperiodisforatleast14daysoruntilprovedfreeofinfection,i.e.2consecutivenoseandthroatswabs,
taken 24 hours apart, shouid be negative before terminating isoiation.
B) Control for contacts (prophylaxis for contacts)
r Non-immunized close contacts of diphtheria should be given penicillin/erythromycin(elruse2), diphtheria
antitoxin, qnd vaccination (by toxoid).
: In immunized contact nothing is required if the booster dose was taken within previous 2years,and ifbooster
dose was taken more than 2 years before, only a booster doses oftoxoid is required.
TUBERCULOS!S IN CHILDREN
TUBERCULOSIS IN CHILDREN
Diagnosis
o Following investigations are used for TB in children :-
i) Sputum smear AFB
I It is used in older children as young children do not expectorate out sputum. It is used only for presumptive
diagnosfuuttusotl '
r Most of pediatric pulmonary TB is sputum smear negative(DN8 r5r.
TT,BERCULOSIS I N CHILDREN
Diagnosis
o Following investigations are used for TB in children :,
i) sputum smear AFB
r It is used in older children as young children do not expectorate out sputum. It is used only
for presumptiye
ot)
diagnosisAums .
Drug Regimen
r Category 1 -> 2 (H3 R3 Z3 E3) + 4 (H3 R3)
r Category 2 -+ 2 (S3 H3 R3 Z3 E3) + 1 (H3 R3 23 E3) + 5 (H3 R3 E3)
r Category 3 -+ 2 (H3 R3 23) + 4 (H3 R3)
-:..:,;}$',,ij.;.,=r.'...'r,..;.;;:'..,f 1,..' .,
55
':t:.,1;,
3,Q.,'r.:r.:r;
15
Prevention of perinatal TB
r If mother has active disease, ATT should be started for mother.
o Neonate should be given INH prophylatcisqlqo) till mother is sputum negative or at least 6 months(DrvB '5).
r Routine BCG vaccinationatqq) should be given to mother.
o Separation of mother and neonate is not required ard breast feeding should be cantinuedqlo).
Congenital tuberculosis
r Although it is rare as mother having tuberculosis primarily present with infertility.
o f'uberculous bacilli sometimes pass throgh umblical vein and may develop focus in liver (hepatic complex).
r When neonate aspirate amniotic fluid containing bacilli then develop GI tuberculosis or iung infection.
r Neonate usually present as respiratory distress, hepatosplenomegaly lymphadenopathy.
r Overall liver is most commonly involved in congenital tuberculosisarr5).
Treatment
r If tetanus immunoglobulin is administered within time it neutralizes tetanus toxin and significantly lowers
mortality(AttMs . If a person is having serous wound and is uncertain about immunization status, combined active
ee)
o CMV is the most common cause of congenital infection(uPsc 10).Infections occur in fetuses born to mother who develop
primary infection during pregnancy.
c It leads to cytomegalic inclusion disease. Most infections are asymptomatic. Petechie,hepatosplenomegaly@Gte4) and
jaundice is the classicaltuiad of presentation. Other important features are microcephaly, intracerebral calcification(PGl
e'1),
IUGR, chorioretinitis, thrombocltopenia and inguinal hernia.
Diagnosis
o Virus isolation of CMV is the definitive diagnostic method. Specimens may be urine (urine culture@IlMso6'), saliva,
blood (buffy coat), bronchoalveolar washing, or amniotic fluid.
o Serology is not very helpful. IgM test lacks sensitivity and specificity. IgG tests are not diagnosticailMs 06)
as IgG
antibodies can cross the placenta (may be of maternal infection).
c PCRfor viral genome (DNA) may be usedaltMs06).
r In histopathologic examination, CMV infected cells contain large intranuclearaltMs06) and small intracl,toplasmic
inclusion bodies, which are pathognomic.
o It is commonly caused by HSV-2rrctoo) (70o/o cases are caused by HSV-2 and3Oo/o caused by HSV-1 ).
o Case fatality rate exceeds 600/o in untreated neonatai herpes. '
o The infection is acquired by passage through an infected genital tract at birth. The greatest risk i.e., 50% transmission
rate occurs with a primary infection in the mother at time of delivery (because the antibodies have not yet developed,
there is more virus present and no antibody transfer). With recurrent herpes at term, the transmission rate is only
8% or less.
o Neonatal infections present on the 6th day postpartum. There are three major categories:-
r Localized skin, eye and mouth infection
r CNS infection
r
Dissenminated infection
o The hallmark of neonatal HSV infection - the vesicular, ulcerative skin lesions occur in only 30-43o/o children. If left
untreated the virus dissenmination can occur to internal organs which is the most serious complication of neonatal
herpes.
Cnlri'r&,
CONGENITAL SYPI{ILIS
o Transmission of T. pallidum across the placenta may occur at a.ny stage of pregnancy, but the lesions of
congenital syphilis generally have their onset after the fourth month of gestation.
c Earlymaternalslphilishasmorechancesoftransmission(75-90o/o) thanlatematernalsyphilis.
o Adequate treatment of mother before 16'h week of pregnancy prevents fetal damage.
o Effects of maternal slphilis on pregnancy are :-
i) Still birth > abortion
ii) Prematurity
iii) Neonatal death
iv) Non fatal congenital syphilis.
Diagnosis
o It involves Dark ground Microscopy and VDKLGTTMS 11' AI07),
o As IgM does not cross placenta, its presence in neonatal serum confirms congenital syphilis and helps differentiating
it from seropositivity due to passively iranfered maternal antibodies. The tests to detect IgM are -
1) FTA-ABS (195IgM FTA-ABS1{Lott.
ii)S1philis Capita M test.
r Congenital infections develop only when the nonimmunized mother develops infection during pregnancy or less than
6 months before pregnancy.
r The incidence of transplacental infecti on is lowest in first trimester but the disease in neonates is most seyere. The
incidence of transplacental infection is highestin third trimester (after 6 monflrs) but the infant is not severely affected.
r Most of the infections are asymptomatic. The symptomatic baby presents with characteristic triad of chorioretinitis (most
ea),
commonqte3)),hydrocephalus and intracerebral calcificatian. Other feattres are microcephalyqilMs microphthalmia,
mental retardation, deafness, blindness, epilepsy, thrombocltopenia, anemia, nephrotic syndrome, and optic atrophy.
Diagnosis
r Diagnosis is mainly dependent on serological tests. These are :-
1) IgG
t Presence of lgG in infants's blood does not confirm the diagnosis of congenital toxoplasmosis because IgG can
easily cross the placenta. So, one cannot predict whether the IgG is of maternal origin or due to fetal infection.
Transplacental IgG antibody disappears by 6-L2 months of age.
r Serological tests to detect IgG : -
i) Sabin-Fieldman dye test (Most preferred lgG test and golil standardqttMs 10)).
2) IgM
t IgM does not cross the placenta; therefore, IgM is the test of choice for determining congenital infection(DNB 13).
r Serological tests for IgM are :-
i) IgM IFA (indirect fluorscent antibody test)
ii) Double sandwich enzyme linked immunosorbant assay : - More sensitive than IgM IFA.
rll) Immuno sorb ant agglutination as s ay (I SAGA)
3) IgA
t IgA may have greater sensitivity for neonate coffipared to IgM assay(DNB 13).
Prevention
o Spiramycin1ilMse4'%) is given during pregnancy to prevent vertical transmission of toxoplasma.
cYsrrcERcoSrs
r Cysticerci can be found any where in the body but are most commonly detected in - brain, skeletal muscles,
subcutaneous tissue or eye. Neurocysticerosis is the most common parastitic infection of the CNS.
r Seizures are the presenting finding in> 70o/o of cases(Pcr0'). Seizures are generalized in 80% cases but simple or
complex partial seizures@Gr") may occurs. Intraventicular neurocysticercosis is associated with hydrocephalous and
acute, subacute or intermittent signs of increased intracranial pressure. Meningeal neurocysticercosis is associated
with signs of meningeal irritation. A fulminant encephalitis@Gr03) Iike presentation also occurs most frequently in
children who have had a massive initial infection.
r Ocular neurocyticercosis presents with decreases visual acuity due to cystecerci floating in the vitreous, retinal de-
tachment or irrdocyclitis.
CONGENITAL INFECTIONS
r Congenital infections are those which are transmitted from mother to fetus or newborn child.
o Congenital infection may be :
i) Transplacental,
ii) Intrapartum (peripartum)
iii) Post partum (postnatal).
r Transplacental infections, also called vertically transmitted infections, are infections that are transmitted from
pregnant mother to fetus, through placental circulation. Important transplacental infections are : Rubellaal 11' rN e0),
CMVINe0), HPV B-19, HIV@ 11), HSVaI 11),VZV, HBVaI ir), HCV toxoplasma(N eo), treponema pallidum (syphilis),
listeria, plasmodium and TB.
r
ii
c,rprEnrr;;;#&
o Intrapartum infections are transmitted at the time of delivery. Important intrapartum infections are CMV HSV HBV
HIV E.coli, group-B Streptococci, gonococci, chlamydia and listeria.
e Post-natal infections are transmitted after birth. Important ones are CMV HBV VZV HTLV-1, HlV, HSV and
enterovirus.
o Symptomatic neonatal CNS infections are more common in : HSV (76-1 00o/o), rubella (26-60Vo).
t Asymplom'a$c,neonqtal(lVS infecfion are'mare eommon in: CMV, toxoplasma, syphitis.
a lmportant causes of posterior auricular or suboccipital cervical lymphadenopathy in children: Roseola infantum, rubella, scalp infec-
tion.
Mijs{:common causeof:posterior airicular ar suboccipital lymphadenopathy in children without obvious disease or secondary infection
l
: Pediculosis capitis (lice).
& A child presenting with sore throat, fever and acute cervical lymphadenopathy, first investigation : Hemorgram.
& Mosi comman manifestation af HPV infection in children: Multiple'papillomatosis.
{t Number of pustules to diagnose a severe bacterial infection in children: > 1 0 pustules.
d Ni.mber of pustules in local Qacterial infection: Less thanl Opustules.
* Drugs used to treat resistant falciparum malaria in children -
i) < B years age : Quinine + Clindamycin or atovaquone + proguanil.
I &
li) > 8 years age : Quinine + doxycycline/clindamycin or atovaquone + proguanil,
A:line of conjunctiial inflsrnmation on lower eye lid margin: Steinei! line in measles.
& Maximum chances of neonatal chicken pox: lf maternal infection occurs near delivery (5 days before to 48 hours after delivery).
& Most severely affected age group by rubella: Fetus (Unborn child).
xxx
QUESTIONS
l. Trans-placental spread is least associatedwith? 10. Child (girl) is suffering from varicella (fever rash).
a) HBV b) Rubella (Ar 11) And child's aunt is pregnant. IMhen is it earliest that
C) HSV d) HIV the child can meet her auat - (PGI Nov 14)
a) When the lesions have crusted
b) Immediately
CONGENITAL RUBELTA c) Anytime as the child is aunt's favourite
d) After the delivery of the baby
2. .All of the following statements are true about con-
genital rubella except- (AttMS May 11,Nov 08, At 05) ll. l{hich of the following intrauterine infections is
a) It is diagnosed when the infant has IgM antibodies associated nith limb reduction defects and scar-
ring of skin - (AIIMS May 11, AI 09)
at birth
b) It is diagnosed when Ig G antibodies persist for a) Varicella virus b) Herpes virus
more than 6 months c) Rubella d) Parvovirus
c) M.C. congenital defects are deafness, cardiac
malformation and cataract MEASLES
d) Infection after 16 weeks ofgestation results in
major congenital defects 12. Measles virus is - (NEET Dec.12 Pattern)
1. Trans-placental spread is least associatedn'ith? 10. Child (girl) is suffering from varicella (fever rash).
a) HBV b) Rubella (Ar 11) And child's aunt is pregnant. When is it earliest that
c) HSV d) HIV the child can meet her auat - (PGl Nov 14)
a) When the iesions have crusted
b) Immediately
CONGENITAL RUBETLA c) Anltime as the child is aunt's favourite
,' d) After the delivery of the baby
of the following statements are true about con-
.A.ll
genital rubella except- (AIIMS May 11, Nov 08, AI 05) ll. Which of the following intrauterine infections is
a) It is diagnosed when the infant has IgM antibodies associated with limb reduction defects and scar-
ring of skin - (AltMS May 11, At 09)
at birth
b) It is diagnosed when Ig G antibodies persist for a) Varicella virus b) Herpes virus
more than 6 months c) Rubella d) Parvovirus
c) M.C. congenital defects are deafness, cardiac
malformation and cataract MEAStES
d) Infection after 16 weeks ofgestation results in
major congenital defects 12. Nleasles virus is - (NEET Dec.12 Pattern)
5. All are true about congenital rubella syndrorne, 14. Measles is infectious during - (PGI Dec 98)
61. ln * 3 year ald child, mo$t eommon ccuse efhepati- b) Spread along the nerves onlY
tisBis- (PGl June 97) c) Requires oxygen
a) Pin prick d) I.P. is variable
b) Saliva exchange e) Causes deep wound invasion
c) Perinatal
d) Blood transfusion
P6t-to
62. AaS &ay - old infant developed ictertrs and two days
later symptorn$ alld *igns of acrte liver faiI:wre ap' 6&. Mostcofflmon a*tx*e o{ &eatloiwcascolt *cwf'*po,&w'
peared. Child was fotrnd to bc poritive for !trbs Ag. myetriti* ia - (AIIMS lune 97)
The mother was also HSs Ag carmer.lbe rn*ther's a) Intercostal muscles paralysis
hepatitis ts sererlogicaf profile is likely to be - b) Convulsion
a) (At 03)
HBs Ag positive only c) Cardiac arrest
b) HBs Ag and Hbe Ag PositivitY d) Respiratory failure
c) HBsAg and anti - HBe antibody positivity
69. Pnfio virus i*€e&iar] ean rcss]t in all cxeept -
d) Mother infected with mutant HBV a) Anterior horn cell damage (AIIMS Dec 91)
63. A neonatc born to ir#ected hepatitis- & mo€hcr, b) Autonomic involvement
slrould tre treated with - (AI 09.99)
c) respiratoryinvolvement
a) Isolation d) Paralysis in > 7\oto ofcases
b) Immunoglobulins 78. Kenny Paeks were $sed irc thc treatmert trf -
c) Hepatitis-B-Vaccine a) Poliomyelitis (AIIMS 03)
d) Immunoglobulins & hepatitis-B-vaccine b) Muscular dystrophy
64. A 30-year old Nady &elivered a hcalthybaby *t37 c) Polyneuropathies
week of gestation. $he was a known case of ctrronie d) Nerve injury
hepatitis E i*fe&ian $he was pasitive for H"SsAG bwt 1t A"ewtctlaeetdparalysi* is reported im a ehifd aged -
megativefar6BeAG. r#hich of the follenring is the a)- 0-3 years (AI 02)
mo$t apfrroprtatetreatmewt for the bab,y - b) 0-5 years
(AllMS Nov 05)
c) 0-15 years
a) Both active and passive immunization soon after
d) 0-25 years
birth
b) Passiveimmunization soon afte birth and active 72. ?rtre abeitrt 6roiio - @llMS Nov 07, Mav 08)
III
CriAptEe::li
ANSWERS
1. Ans. is None > c i.e., HSV lRef : Infections : Microbialogy {r w*nagetnent 3d/e p. 3461
o Sorry guys, all the four organisms given in options can cause transplacental spread.
o Common transpiacentallytransmitted infections
l.Viral -+ CMV (most common), HBV HCY HIV Rubella, HSV Parvovirus-B19, Variceliazoster, coxsackie
virus.
2. Bacterial -+ Slphilis, TB
3.Parasites -+ Plasmodium, toxoplasma,T-cruzi.
r However, we have to choose one options. Option t' (HSV) seems best to me :-
'Although HSV infection can couse transplacental (Pre-natal) infection; it is more appropriately considered
under perinatally acquired infections (during delivory)". Infectious neonatology
"lf herpes seroconversion occurs early in pregnancy the risk of transmissiort to the newborn is very low. In women
who acquire genital herpes shortly before delivery, the risk of transmission is high". Harrison
"Despite there inclusion in table, many viruses, including HSV and hepatitis viruses, are rarely acquired as
intrauterine infections. They are typically transmitted vertically (i.e. during the delivery process".
Pediatric hospital nredicine
Congenital rubella
2. Ans. is 1d' i.e., Infection after 16 weeks of gestation results in major congenital defects lRef lawetz 23dle p.
567, 568; Harcisan l&le p" 1153)
In general, the earlier in pregnancy infection occurs, the greater the damage to the fetus. Maximum damage to the
fetus occurs when infection is acquired in the first trimester of pregnancy.
o Maternal viremia associated with rubella infection during pregnancy may result in infection of the placenta and fetus.
o The most important factor in the pathogenicity of rubella virus for the fetus is gestational age at the time of
infection, The eailier in pregnancy infection occurs, the greater the damage to thefetus.
3. Ans. is t' i.e., Aortic Stenosis [Ref Nelson 18th/e p. t j40; Myung Snle p. 2Z]
. Nerve deafness is the single most common clinicalfinding amonginfant with congenital Rubella syndrome.
t PDA is the most common CHD in congenital rubella synilrome.
o Classical triad of congenital rubella consists of --> Cataract, Deafness, CHD
r Mentil retardation is also common.
4. Ans. is t' i.e., IgM antibody in fetat blood [nef Nelson t8,hle p. 13401
Laboratory diagnosis
r Isolation ofvirus in cell cultures ofthroat samples, urine or other secretions.
t Normally, maternal rubella antibodies in the form of IgG is transfened to infants and is gradually last over a
period of 6 months, Persistent beyond 7 year in an unvaccinated child suggests the diagnosis of congenital
rubella.
o Presence of Ig M antibodies is diagnostic.
r PCR for rubeila RNA.
5. Ans. is'b'i.e., Renal anomalies ["&t' Netrsom lStt'/e p. ]34A]
CHICKEN POX
8. Ans. is 'b' i.e., Sec. bacterial infection [Rel O.P Ghai 8th/e p. 214 & 7h/e p. 186; Harcisan 17/e 110j1
e The most common infectious complication of varicella is secondary bacterial superinfection of the skin,which is
usually caused by streptococcus pyogenes or Staphylococcus aureus.
cerebellar,
. The ffiost comrnon extracutaneous site of involvement in children is cNS --> Miningitis, Encephalitis,
at axia, Rey e's syndr om e
: Varicella pneumonia is the most serious complication Jollowing chickenpox in adults,
9. Ans. is t' i.e., Enteritis lRef: O.P- Ghai 8tu/e p. 214 & Vh/e p' 186]
10. Ans. is 'a' i.e., When the lesions have crusted IRel O. P. Ghai 8&/e p. 214 6 Ple p. 186)
on the first
r Varicella Zoster (chicken pox) is a highly contagious disease, a centripetal, pleomorphic rash appearing
day of the illness and a relatively short course of illness'
r The crusts from chicken pox lesions donot contain viable virus and are therefore not
infective. Period ofinfectivity
range from a day prior to the illness and up to 5 days after the onset.
ofthe rash.
children with chicken pox are removed from school or day care centres for 6 days after appearance
11. Ans. is 'a' i.e., Yarecella virus [Ref Nelsor 1*/e p' 1j68]
reduction defect (limb
r Congenital varicella syndrome is characteristically associated with scarring of skin anil limb
hypoplasia).
Scarring of skin is the commonest feature of congenital varicella syndrome and the characteristic
cutaneous
t
lesion is called "Cicatrix".
NilEASLES
14. Ans. is'b' i.e., 4 days before pand 5 days after rash [Ref O.P. Ghai 8*/e p- 213)
r period of communicability for measles is 4 days before and 5 days after appearance of rash.
15. Ans. is rtl' i.e., *Ieasles tRef OP Ghai 8/e p' aa)
16. Ans. is '-o- i,e., Measles f&ef : Harrison 17&/e p' 1215; 16*/e p' 1149)
measles and is seen in
t primary giant cell or Hecht's Ttreunonia is seen in case of measles. It is a complication of
immunocompromised and malnourished patients'
fi,luMPS
l*le p. 1#/e p. */e p" 217 6 */e p'
tT" Ans. is.d i.e., Orchitis and Oophritis [Re/: Ha'7'bott 1220; 1154; O-F. Ghai
1881
,,Orchitis is the most cotnmofl comltlication of mumps among posq,ubertal males , developing in about 20%o of
" Harrison
cases
,,
Mumps virus mostly causes a milit childhood d.isease , but in adult complications including meningiti-s and
orchitis arefairly commoru" Iawetz 23th/e - 560
t, i.e., Meningn€ncephaliti$ can precede parotitis [Ref Nelsoa 1*/e p. 1342; A.P. Ghai gele p. 217 &
lg. Ans" is
frleP.1Sv-188\
meningitis may develoqt before, during, after or in the absence of parotitis!'
,Aseprtic lVh/e-1220
19. Ans, is 'b' i.e., Fifth disease lReJ: A.P. Ghai }t,,/e p. 216 6 6t,/e p. 2t)B)
r Erythema infectiosum also known as fifth disease is caused by parvo virus (B-19).
20. Ans. is'b'i.e., Roseala infantum tRef O.p. Ghai }th/e p. 216 (r 6th/e p. 2A8l
t In roseola infantum the temprature comes down rapidly in 3 to 4 days when a macular or maculopaytular rash
appear' starting from trunk and sometimes extending to the extremities and face.
21. Ans. is t'i.e., Rubella [Rel Nelsoa tSth/e p. 1i39; O.P. G.h*i Stu/e p. Zt6 & dh/e p. 2Ag, 586l
a Roseola 10-14days Fever (3-4 days) Pink macular rash appear- o Usually occur in
lnfantum (6th ing at the end of illness. children between
disease) caused c Resolves within 2 days 2-6 yrs. of age
by HHV-6 t It spares the face
Rubella 14-21 days Usually None t, Mild maculo papular Rash, Postauricular & sub-
Rapidly spreads and occipital adenopathy
gone by day 4 & Polyarthralgia
Erythem 13-i8 days e Slapped cheek appearence t May cause Aplasfrc
infectiosum e Reticular rashthat waxes & crisis
(Fifth disease) wanes over 3 wks
caused t ln 50%o childrenrash re-
byParovirus mains -after 1O days
,,)
Ans. is'c'i.e., Roseola infanturn lRet A. P. Ghai }th/e p. Z16 6 d'/e p.208|
e The child is having roseola infantum. It is caused by Human herpes - 6 (HHV-6).
r The most prominent feature is abrupt onset of fever often reaching 40.6"C. The fever then ceases
abruptly and a characteristic rash may appear. The rashes are maculopapular. Are non pruritic tend
to coalesce and disappears in 1-2 days without pigmentation or desquamation.
r Erythema infectiosum or fifth disease can be easily ruled out because thefirst sign of illness is the rash no fever.
The rashes are masculopapular and they coalesce to given a slapped check appearance. One half of the infected
children have some rash remainingfor 10 days fine desquamation may be present.
o In measles the rashes last for 6-7 days.
r In typhoid the rashes appear on the 7h day of illness.
23. Ans. is'b'i.e., Caused by HHV 6 & 7 [Re/ A. P, Ghai B,hle p. 216 6 6thle p. 2081
o Roseola infantum is caused by HHV-6. During defervescence (disappearance offever) rash appears (defervescence
does not follow rash rather rash follows defervescence).
r Rash starts from trunk.
o Slapped cheek appearance is seen in er1'thema infectiosum (not in roseola infantum).
. Otitis media is not a compiication.
24. .A.ns. is'b'i.e., Caused by HHV 6 & 7; t'i.e., Rash appears in trunk; t'i.e., During defeverescence> rash
appear$ tR6l O. P. Ghai 9tkle p. 216 dr #hle p. 2ASl
)q Ans. is 'a'i,e., Slapped check appearanee seen; ob' i.e", Causd by parvovirus & t' i.e., Defervescene before
rash [.eel o. P. Ghai 8.hle p. 216 & 6th/e p. 2A8l
c Er1'thema infectiosum is caused by Parvovirus and is characterized by slapped cheek appearance. Defervescence
(disappearance of fever) occurs 1 week before rash. Rash appears on cheek.
TUBERCULOSIS
27. Ans. is 'a' i.e., Commonly sputum negative & t' i.e., Clinically child does not $how sign of florid TB
lRef: Nelson 18th/e p. 1246, 12471
o Cases of pediatric tuberculosis represent 5- 15% of all TB cases.
r The most common type of pediatric TB is pulmonary TB, of which sputum smear-negative disease is most frequent.
r Most cases of pediatric TB develop no signs or symptoms at any level.
28" Ans. is'None' lRef: Nelson 18th/e p, 1246, 12471
c All may occur (See text of the chapter).
7q Ans. is t' i.e., Futrmonary T.B. tRd CMDT 2002/e p. 310; APl6h/e, p. 2441
r The history and tuberculin test strongly suggests the diagnosis of T.B.
o Do not get confused by negative sputum cytology because negative sputum cgology does not rule out pulmonary
tuberculosis.
" Sputum cytology is just a presumptivg diagnosis" - Harrison
The definitive diagnostic of T.B. depends upon the culture of bacteria obtained from respiratory
-"specimen" - Harrison
r The presence of
.induration
> 15 mm in size strongly indicates T.B. infection.
30. Ans. is t' i.e., Lymphnode lRef Ghai Vh/e p. 2121
r Most common site of extra pulmonary TB is lymphnode
31. Ans. is'a' i.e., Liver lRef: Nelson 18th/e ch. 212|{EJM 1994)
e Overall liver is most commonly involved in congenital tuberculosis.
32. Ans. is 'd i.e., ELISA fRef: o.P Ghai 6th/e p. 2351
35. Ans. is 'H i.e., Continue for 3 month (WHO & RNTCP guideline) fRef: rlMR 2ila fuly edition)
"Indian academy of Pediatrics (IAP) suggests INH prophylaxis for at least 6-9 months or minimum for 3 months until mother
is culture negative".
t)iij
tl.
reH..At'p..TBR,
PERTUSSIS
-r6 -{ns. is 'tr' i.e., 7-\4 &*y* lRef: 0"P. Gfuai $tt'/e p" 243 d' Thle p. 221)
J) Ans. is'b'i.e., < 5 IRe/ A"P. Ghai Yft/e p. 24j & 7h/e p' 221]
r In prevaccine era, and in countries where immunization is limited the peak incidence of pertussis is in children 1-5
years ofage, infant accounts for < 15% ofcases.
r In recent years, where vaccination is employed, approximately one half of cases have occuured in infants younger
than 1 year ofage and one fourth in adolescent and adults.
38. Ans. is'H i.e.n Cerebellar ataxia [,Ref 0.P' Ghai 9th/e p. 24j & Vh/e p. 221)
a Although ataxia is seen in Pertusis, it is not of cerebellar origin There is no involveoment of cerebellum in Pertusis.
nt)'
-i9. Ans" is i.e", Fert&ssis tRel 0.p. Gkai &'t'/e p. 243 6 6il'le p" 193)
r Protective Antibodies against pertussis doe not corss plecenta.
e So, early immunization is desired.
"Culture of nasopharyngeal secretion remains the gold stadard for diagnosis of whooping cough" - Harrison
ua,
41. Ans is i.e., Nasopharyngeal swab lRel Skerr's Meilical Micrabiolagy Sthle p. 56jl
* presenceofrecurrentboutsofseverecoughfollowedbyanauiliblewhoopsuggestsadiagnosisofpertusis(Whooping
cough).
* Nasoltharyngeal Swab is the single best specimen to isolate the organismfrom the options provided,
42. Ans. is 'c' i.e.n Erjthrornyein [Ref CI.P. Ghai *'hlc p' 24j & Vh/e p. 222)
Treatrnent of Perttlssis
DOC -) Macrolides (Ery'thromycin, Azithromycin, Clarithromycin)
Alternative -) Cotrimoxazole
DIPHTHEK'A
od' Medicine 6't'/e
.13. Ares" is i.e,, Lyurphadenopethy {Re!: APtr p^ 127)
c A small percentage of patients present with massive swelling of the tonsils and uvula with cervical lymphadenopathy
(butl neck) and severe toxemia -+ Malignant diphtheria,
M. Ans" is'd'i.e", Hepatic failure l&ef: API6hle p. 1271
Cormplications
e Obstruction of the respiratory tract by pseudomembrane
* Myocarditis
o Polyneuropathy
r Post diphtheritic paralysis
w Occurs in the 3rd or 4th week
a Palatine and pupillary paralysis is characteristic
e Spontaneous recoverY is the rule,
o Pneumonia
e Other less common complications are renal failure, encephalitis, cerebral infarction, pulmonary embolism and
bacteremia or endocarditis.
HIV- INFECTION
47. Ans. is t' i.e., Exclusively top feeding &'d' i.e., Breast feeding for 6 months & then rapid weaning [Rel.Netsom
ISth/e p. 14291
49, Ans, is'd'i.e., Kaposi Sarcoma fRef: Avery's disease of Newborn 8th/e p.488)
rady in children",
"Kaposi sarcoma, commonly seen in men with advanced HIV disease, has been reported only
50. Ans. is'c' i"e., Recurrent Chest infection with atypical organism fRef: Ananthanarayan Vh/e p. j03l
a " Pneumonia caused by pneumocystis carinii is the most common AIDS defining diagnosis in children with
unre co gni ze d H IV infe cti o n"
51. Ans. is t' i.e., HIV Elisa fflef. A.F. Ghai 8'h/e p. 23,4 {r Vh/e p. 207; Nelsaw l6thle p. 1A28, C.P.D.T" Id,t,/e p. g44l
52. Ans. is 'b' i.e., Vaginal cleansing before delivery lRef:OP Ghai 8th/e p. 235-237 6 Vh/e p.207; Williams Ob* 2l't/e
P. 15A3, 1504)
54. Ans. is 'a'i.e., Neviraphine lRef: O.P. Ghai }th/e p, 2j5 6 Vh/e p, 202; Nelson tVh/e p, 11201
55. Ans. is t' i.e., Transmission rate during pregnancy exceeds gAYo
lRef: O,P, Ghai Sthle p, 234 & Vhle Xt" 203,
207)
56. Ans. is'a' i.e., OpV IRel Ghai 9th/e p. 237 6 Vh/e p. 20fl
o The vaccines that are recommended in the national immunization schedule can be administered to HIV infected
children except that symptomatic HIV infected children should not be given OpV and BCG.
5/. Ans. is'None' lRel Ghai Yth/c p. 2j4 6 6th/e p, 2A4, 205; Nelson t9th/e p. 1430-1432)
Cells/uL o/
/o
2. Clinicalclassification
N No (asymptomatic)
A .. .,,,.,r.',.,Mild . :;
B Moderate
c Seveie:"'. '
Clinical categories are further subdivided depending on the immunological categories for example, If a 3 years
old child has mild signs and symptoms (clinical category A) and CD4 T cells between 500-999/mL or l5-24o/o
(immunological category - 2), then it is classified as clinical category A2. Following table will help to remember
this division :-
pediatric HIV classification for children younger than 13 years
lmmunologic Categories
Clinical classification
Age-Specific CD4 + T' Lymphocyte count and
Percentage of total lYmPhocYtes
of suppression
2. Evidence of 750-1499 15-24 500-999 15-24 200-499 15-24 A2 c2
moderate
suppression
3. Severe <750 <15 <500 <15 <200 <15 N3 A3 B3 c3
suppression
yohle
Ans. is i.c., All symptomatic HIV infeeted children >5 years of age irespective of CD4 [Ref Glraj
.a' p'
Sg.
2i5 & */e P. 2as-2071
HEPATITIS
59" Ans. is'd i.e., 2 wk - 2 nraonths lQef: A.P. Ghai Sthle p' 22$ {r Vhle p' }91}
6t" Ans. is 'd'i.e., Elood transfusion lReJ: A,p, Ghai Bth/e p, 221 & Vh/e p" 192]
"Children usually acquire infection indirectly, through parenteral route
from hepatitis B contaminated blood
transfusion".
Ans. is'b'i.e., HBs poeitive and rtrbe Ag positive l&ef: o,p, Ghai rth/e p" 221 & vhlc p. 19s)
Most important riskfactor that determines perinatal transmission is HBe Ag. HBs Ag carrier mothers
' Ag positive almost invariably (> 90%) transmit hepatitis B infection to their offspring, where as
who are HBe
carrier mothers with
anti HBe rarely (10 to 15%) infect their offspring.
63. Ans. is'd'i.e., Immunoglobulins & Hepatitis B Vaccine l%ef: A"p, Ghai Yth/e p. 222 & ?k/ep. t9S]
"Infants born to Hbs Ag positive mothers should receive both HBIG and
HB vaccine intramuscularly at seperate sites
within 12 hours of birth, followed by 2nd and 3rd dose of vaccine at 1 and 6 months respectively''
64. Ans. is '{ i,e,, Both active ond passive immunization soon aftcr birth p,
[Ref Nelson lgth/e 16g5]
uU
65. Ans. is i.e., Obtain anti HBs levels [Rel Nelsan tSthle p. 1684]
The child in question has received complete vaccination for Hepatitis B, is currently asymptomatic
but has tested
positive for HBsAg.
The aim in avestigating the child further is to establish his immune status which can
be best revealed by obtaining anti
HBsAg levels.
c If the tests shows inadequate levels of anti-HBsAg it would indicate that the vaccine had failed
to mount an
adequate immune response. Such a child should consult a pediatric hepatologist.
I If the test shows adequate levels of anti-HBs Ag, the adequacy of vaccinition is confirmed and as the child is
asymptomatic no further intervention is required.
e Positivity of HBsAg indicates that the child is a carrier of the antigen. Vaccination does not
effect the HBsAg
carrier state.
TETAIIIUS
a./. Ans. is'd'i"e", I"P" is variable lRef : Nclson t&th/e p. t2Zg, t22g)
tIncubation period - is variable from two days to several weeks, but is commonly 6-12 days.
Note : It is tetanus toxin not bacilli that spread along the nerve.
PCILIO
68. ,dns" is nd' i"e,, Rc*piratory failurc tgh/e p, t7A; Ghat &th/e p, 2tg & Vh/e p" i90l
[F.cf: Pnrke
r Death is usually due to complications arising from respiratory dysfunction.
69. Ans. is 'd' 1.e., Faralysis in > 78 of casce l&cf: A,p" 6hal &eh/e p. 2t B & Vhle p, 19A!
c Paralltic polio is seen in less than l% ofpolio infections.
71, Ans, is ne'i"c., 0-15 years {Rcf: A,P, Ghnt th/e p, 218 & Vk/c p, 190}
Acute faccid paralysis (AFP) surveillance
r Every case ofacute falccid paralysis in any child under 15 years is to be reported promptly.
c Fecal samples of all these cases are obtained (2 samples) and transported to the laboiatory within 72 hrs of
collection at 4-80 C or frozen at -200C. The process is also knwon as reverse cold chain.
72. Ans. is 'c' i.e., IM injecfions and increased muscular activity lead to increased paralysis [ReJ 0.P. Ghai 8*/e
p. 215 6 Vhlep. 190)
o Risk of paralytic polio is increased by:-
r Tonsillectomy r Strenous physical exercise I Tooth extraction r Cortisone administration
r Adenoidectomy r Injection (intramuscular) r Fatigue
CONGENITAL SYPHILIS
?5. Ans. is'd i.e., VDRL for mother and Baby lRef CPDT 18e/a p. 56)
r Bullous lesion and periostitis suggest the diagnosis of congenital syphilis.
r The only option related to slphilis is option'al
r Following evaluations are recommended: -
1. physical examiation 2. A quantitative nontreponemal test for syphilis (VDRL).
3. CSF for cell count, protein & VDRL. 4. Long bone radiograph
5. AntitrePonemal IgM.
INFCCTIOUS MONONUCLEOSIS
7?, Ans. is.b, i.e.r lnfectious Mononucleosls [ReJ o.P, GhatSe/ep. 216 6 fllep. 18fi
r Cervical lyrnphadenopathy, fever, history of sore throat and > 20o/o atlpical lymphocytosis (lympho-plasmacytoid
cells) suggest the diagnosis of IMN. Hepatomegaly may be absent (occurs only in 30% cases)'
78. Ans. is b' i.e., Infectious mononueleiosis IR€J A. P, Ghat #lc p. 216 & flle p. 1871
MISCELLANEOUS
79. Ans. is 'c' i.e,, Streptococcal pyogenes lRef: Nelson 18th/e ch. 664)
80. Ans. ls U t.c" IgG eiUV antibodles in blood lRef llarrlson lffle p. fi51; Nelssn lfrlc p. 10681
,,
Ig G antibody test is oflittle diagnostic value as positive results also reflects maternal antibodiesl'
Diagnosis of Congenital CMV infection
J + +
Yirus islolation Serology PCRfor viral genome (DNA)
t Definitive diagnostic r Not very useful
r Specimens r IgM test lacks sensitivity
s Urine and specificity
r Saliva r IgG tests are not diagnostic
r Blood (buffycoat)
r Bronchoalveolar washing
r Amniotic fluid
About option C
CMV infected cells contain large intranuclear and smaller intracltoplasmic inclusions which are pathognomic.
81. Ans. is? i.e., Avidity testing must be done to differentiate b/w IgA & IgM lRef Cloharty 18th/e p. 3191
c Avidity test is used to measure the strength of antigen-antibody reaction for IgG antibody (not to differentiate
between IgA & IgM)
Ans. is't) > c'i.e., IgM antibodies to toxopXasma > trgA antibodies to toxoplasma
lRef: See above explanationl
r IgA has greater sensitivity, but IgM is the test of choice.
83. Ans. is t' i.e., Rubella end HSV {Ref": Nearologlt Vu$e ?d/e p. 63)
c CNS involvement is common feature from infection with all agents of TORCH group.
e With most infections, patients remain asymptomatic in neonatal period and serious neurological consequences
become apparent after neonatal period.
r CNS manifestations that are symptomatic in neonatal period are most commonly seen in -
i) HSV (76-100o/o)
ii) Rubella (26-600/o)
o CMV toxoplasma, and syphillis become symptomatic in less than llo/o-Llo/o of cases.
84. Ans" is 'a- i"e., Caused by HSV-II [ReJr Nelsoa {frlc p. rufi, ru541
o It is commonly caused by HSV-2 (70% cases are caused by HSV-2 and 30% caused by HSV-1 )
85. Ans" is'b' 1.e., Pedieulosis eapitis {Ref: Radalph Pedtstrics 21*/e p. 1155)
o Posterior or suboccipital ceryical lymphadenopathy without obvious disease ot' secondary infection is character-
istic oflice.
86. Ans. is t'i.e., eomplete hemogram {ReJ Nelson 1*/e p. 16V7, 1678,1A62-10661
c Cervical lymphadenopathy with signs of infection such as fever and sore throat points towards any infectious
etiology.
r In this. case the most likely investigation to be done should be complete hemogram.
r Complete hemogram can provide useful datas for diagnosis of :
s Pyogenic infections t Viruses such as EBV CMV (y HIV: Leukemias (acute or chronic)
r Biopsy should be done if the patients history and physical findings suggest malignancy. These features are :-
r Solitary, hard non-tender cervical nodes in an older patient.
r Neck X-ray does not provide much information except for giving some idea about swollen soft tissues of neck
r Radical neck dissection is absurd option.
87. Ans. is'b" i.e., Multiple papillomatosis [ReJ NeJson 18e/e p. 140j)
r Multiple warts are common.
88. Ans. is 'b' i.e., > l0 [Rel Park 22a/e p. SjZ, SS21
o An infant from 1 weekto 2 months is evaluated for possible bacterial infection under IMNCI (integrated management
of neonatal & childhood illnesses) guidelines.
Lethargic, unconscious
tess than'normal movements :. : -;
89. Ans. is t' i.e., Clindamycin [Rel: Nelson 18th/e p. 1421, 14221
o An infant from 1 week to 2 months is evaluated for possible bacterial infection under IMNCI (integrated management
of neonatal & childhood illnesses) guidelines.
l.m ceftriaxone
infection Severe chest indrawing o2
Nasal flaring and grunting Rectal diazepam
Convulsions Check and treat blood sugar
Bulging fontanelle Refer urgently to hospital
Fever (axillary temperature) > 37.5o C or Continue breast feeding
low body temperature < 35.5o C Keep the child warm
Many or severe pustules (>10)
Lethargic, u nconscious
Less than normal movements
TUI
$PKCXAL TOPXCS
Kawasaki disease
o Kawasaki disease, also known as lymph node syndrome, mucocutaneous-lymph node syndrome, and infant
polyarteritis, is a poorly understood self-limited vasculitis that affects many organs, including the skin mucous
membrane, lymph nodes, heart and blood vessel walls.
o It is usually in children younger than 5 years.
seen
a Kawasaki disease predominantly affect medium sized vessels, but may also affect small or large vessels.
a Presentation may be -
1) Mucocutaneous, lymph node involvement l Conjunctival injection, erlthema, strawberry tongue, rash with
perineal desquamation, Beau's line (transverse grooves on nails), cervical lymphadenopathy.
2) Heart: Coronaryvas cuhlis, coronary artery aneurysm (in 25o/o patientsanus11'At08)), coronary ectasia, MI, vah,.r.riar
regurgitation.
r Treatment of choice for acute phase is intravenous immunoglobulinattMsll'At0r) along with high dose of aspirin. For
subacute phase low dose aspirin is given.
o So, hemodynamic changes in septic shock occur in two characteristic patterns, Early hyperdynamic and late
oe),
hYPo dYnamic shock(Pct
1) Early hyperdynamic shock
1 Hypotension is a late feahffe(Pcl,e) of septic shock and early hyperdynamic stage is characteriz ed.by normal or
increaseil BP@cror). Qflrs1 features are : -
t) TachYcardia@Gloe)
ii) Normal or increased cardiac output
iii) Tachlpnea
iv) Warm extremities
v) Decreased systemic vascular resistance
vi) Increased pulmonary vascular resistance
2) Late hypodynamic stage
i) Decreased cardiac output
ii) Hypotension
iii) Increasedvascular resistance
iv) Cool, mottled and often cyanotic extremities
v) Oliguria, renal failure
vi) Hypothermia
Pedlatric traGheostomy
r In most of the cases tracheostomy is performed with general anaesthesia and the patient intubated and. paralyzed..
r Neck is extended.
t A horizontal incision is made halfway between the cricoid cartilage and the sternal notch@cl 08).
o Subcutaneous fat and tissues are reflected, and deep cervical facia, is cut to expose thyroid isthmus.
o A vertical cut is'given in 2-3 or 3-4 rings in midline@Gr\8) and no part of the tracheal wall is removed.
I The endotracheal tube is withdrawn and a suitable size tracheostomy tube is simultaneously inserted.
o Post-operatively neck & chest radiograph are obtained to evaluate the position of the tube and to identify the
subcutaneous(Pcro8) emphysema & pneumothorax that could have developed as complication.
r Tube must be cleaned at frequent intervals.
c Patient should be nursed in and atmosphere of moist air@clo9).
Retrolantal broplasla
fi
o Retinopathy ofprematurity (Previously called as retrolental fibroplasia) is a characterized by abnormal proliferation
of small retinal blood vessels due to a variety of causes.
r The complication is related to high oxygen tension in the arterial blood (Hyperoxygenemia@cree)) rather than the
concentration ofoxygen in the inspired air.
r The condition is limited to preterm babies with a birth weight of less than 1500 gmArrMso2) or gestational age of less
than32 weeks.
Lowe's syndrome
o It is also known as oculocerebrorenal syndromearrMs02) of Lowe.
o It is X-linkedqllMs 02) disorder.
e It is characterizedby:-
1) Congenital cataract@IlMs02)
ii)
Mental retardationallMso2)
lii)
Fanconi syndrome-) AminoacidurinAqilMs 02)
o The disease is caused bymutation in the OCRLI geneAuusoz), which encodes the phosphatidylinositalpolyphosphate
5 -Pha sPh at as euilMS 02 )
.
Clinical features
o Progressive growth failure e Fanconi syndrome
o Blindness o Behavioural problems
. Hypotonia o Significant proteinuria
o Renal infuficiency
Ataxia telangiectasia
o Ataxia Telangiectasia (AT) is an autosomal recessive disorder. It is due to mutation of AT genelocated on chromosome
II. There is defective DNA repair that results in muitiple chromosomal breaks.
o Patients present in first decase oflife. Features are : -
i) Oculocutaneoustelengiectasia
ii) I'leurolo$ical -+ Ataxia, dysarthria, extensor plantar response, myoclonic jerks, areflexia, distal sensory deficity.
iii) Immunodeficeincy -+ Thymic hlpoplasia with celluIar and humoral (IgA and IgG2) immunodeficeincy.
iv) Recurrentpulmonaryinfections
v) Endocrine disorders -+ Tye I DM
vi) Premature aging
vrl) Malignancles -+ Lymphoma, Hodgkin's disease, acute T cell leukemia, breast cancer.
c a-feto protein and carcino-embryonic antigen are increasedAl 0a) .
Feature ofCHH
o Short limb dwarfism.
: Very fine thin light hairsremaseT) ar'd eyebrows.
r Hlperextensible joints of hands and feet but an inability to extend.
o Abnormalities of spine.
r Neutropenia4lluseT)
r Defective antibody mediated immunity.
. Severe combined immunodeflciency and combined immunodeficiency.
o Decreased number of T cells and defective T cell proliferation, cell mediated immunity is also decreased.
Pentalogy of cantrell
e Pentalogy of Cantrell is named after James R. Cantrell, a pediatric surgeon llgg2-lgS3). The pentalogy of Cantrell
is an extremely rare phenomenon with an incidence estimated at around 6 per million live births.
r It encompasses the following 5 main features.
i) Pericardial or distal sternal cleft s
ii) Supraumbilicalomphalocele
iii) Diaphragmatichernia
iv) Defect in apical pericardium causing ectopia cordia (Abnormal location of heart).
v) Congenitalintracardiacdefects(VSDr"u"), ASDI@NB13),Tetralogyoffallot@NB 13),Leftventriculardiverticulum).
r Palm is the area ofhand from wrist crease to the finger crease.
o Entire burned hand represents 2.5o/o of BSA: llo/o for palm; to/o for dorsum of the hand (excluding fingers);0. 5o/o for
the fingers.
Sandifer syndrome
I Sandifersyndromemanifestswithbrief(aboutl-3min)NEPEs(NonEpilepticParalyticEvent)ofdystonicposturing
associated with gastro-oesophageal reflux; hiatal hernia is common.
o The attacks of torticollis with arching of the back and rigid ophisthotonic posturing, mainly involving the neck,
back and upper extremities. During the attack, the infant may become very quiet, or less commonly, very restless or
uncomfortable.
o It is most commonlyconfusedwith seizures(DNB'3). However, NEPEs of Sndifert syndrome occur within t hour after
feeding, often following and imposed change of posture, and the babies frequently have a history of vomiting, failure to
thrive and repeated chest infections. The EEG is normal, barium esophagogram or pH probe may dimonstrate reflux.
Williams syndrome
o Williams syndrome is a rare neurodevelopmental disorder characterized by -
i) Unusual facial features: Elfin facial6'*t ") upp"urance, widely spaced teeth, a long philthrum along with a low
nasal bridge, an unusually cheerful demeanor and ease with strangers'
ii) Heart defects: Supravalvular aortic stenosisarrMs
11).
r Other features include GI problems (Colic, abdominal pain, diverticulitis), nocturnal enuresis, dental irregularities,
hypothyroidism, hlperacussis and photophobia.
Neuroenteric cysts
o These cysts result from incomplete separation of the notochord from the foregut which causes a persistant
communication or adhesion between the ectoderm of spinal cord and endoderm of the foregut.
o The lining epithelium of these cysts are enilodermal in origin.
o These cysts are associated with -
i) Vertebral anomaliesal0s) -+ Hemivertebrae, spina bifida, fused vertebrae, absent vertebrae,
(mostcommon) diastematomYelia.
ii) lntestinal aiomalies -+ Duplication, malrotation, imperforate anus.
iii) Others -) Cloacal / bladder exstrophy, renal agenesis.
ttt
QUESTIONS
Cantrell pentology include all exce?l - (CET Nov. lj Pauern) c) Bradycardia d) Arrhythmia
a) VSD b) ASD 12. In children, catecholarnine resistance shock man-
c) TOF d) Trisomy 21 aged by - (CET July 15 Pattern)
) Right Sided Isomerisrn is associated with - (Ar 1t) a) Activated protein-C
a) Asplenia b) Hydrocortisone
b) One spleen c) Nor-adrenaline
c) Two spleens d) Vasopressin
d) Polysplenia 13. Retrolental fibroplasia has association with-
-r. Cat bites in child treatment-true is - a) Prolonged labour (AIIMS May 02)
(All India Dec15 Pattern) b) Intrauterine infection
a) Cleaning the wound thoroughly c) Meconium aspiration
b) Puncture wound most common d) Low birth weight
c) May require rabies vaccination 14. Retrolental fibroplasia is due to ^ (All India Dec.14 Pattern)
d) All of above a) Hlpocapnia
4. A fiveyear old child presents to the ernergencyde- b) co2
partment with burns. The burn area corresponding c) Hlpoxia
to the size of iris palm is equal to (Ar 11) d) Hyperoxygenemia
a) 1% BSA b) 5%o BSA 1-5. Retinopathy of prematurity is cornmonly predis-
c) 10% BSA d) 20% BSA posed by - (AIIMS lune 2000)
5. Sandifer syndrome due to GARD in infants is con- a) Less gestation age
fused with ? (CET Nov. 13 Pattern) b) Low birth weight
a) Seizures c) 02 toxicity
b) Recurrent vomiting d) Carbohydrate excess
c) Acute otitis media 1$. Gliorna o{ optic nerye is usually - (NEET Dec. 12 Pattern)
d) Sinusitis a) Gemistocltic b) Pilocltic
6. All of the following about Yitamin D metabolisrn c)* Fibrillary d) Lamellar
are true except - (AIIMSNov 11) 17. n owe's syndrome is characterised try the following
a) 21-a,hydroxylation takes place in liver except - (AtrMS 02)
b) 1-<r hydroxylation takes place in kidney a) Mental retardation
c) Daily requirement in the absence of sun-light is b) Undescended testes
4s0-600lUlday c) Defect in the CNS and eyes
d) Williams syndrome is associated with obesity, d) Aminoaciduria
mental retardation, precocious puberty lo A 15 days old baby is brought to the hospital with
7. What is the protratrle diagnosis for a cyst in a child complains of seizures. Blood tests revealed serum
which is located at and associated with vertebral Ca++= 5 mg/dl, Phosphorous levels = 9mg/dl, and
defects - (Ator) PTH levels 3Opg/ml (normal range= f 0-60 pg/ml).
a) Myelocele What is the most probable diagnosis? (Ar 11)
b) Bronchogenic cyst a) Pseudohlpoparathyroidism
c) Neuroenteric cyst b) Vitamin D deficiency
d) Neuroblastoma c) Hlpoparathyroidism
8. Capilary rcfilI time ia child with shock is ? d) Hypoxic ischemic encephalopathy
(CET Aug. 12 Pattern)
19. Stroke bite lesion are seen in - (PGl lune 09)
a) >1 second b) >2 second a) Sturge weber syndrome
c) >3 second d) >4 second b) Blue rubber bleb ner,us syndrome
o Best site to demonstrate capillary filling in infants- c) Macular staining of infant
(CET June 14 Pattern) d) Craniofacial neurs
a) Nail bed b) Sternum 20. P<rsterior iliac horns are seen in - (AUMS May 02)
c) Ear lobule d) Great toe a) Fishert syndrome
10. Best artery to palpate for pulse in infants is - b) Crouzan syndrome
a) Femoral a b) Radial a @Gt Dec 2k) c) Nail patella syndrome
c) Carotid a d) Brachial a d) Pierre Robbins syndrome
11" The most common fetal response to acute hlpoxia 21. In neoaate, intra rnuscular injection given at -
ls- (All India Dec15 Pattern)
a) Tachycardia b) Tachypnea (Ar oe) a) Deltoid b) Gluteal
c) Thigh d) Abdomen c) Hypocalcemia
22. Drug dosage best decided in child by - d) Tacrolimus Toxity
a) Weight (CETluly 15Pattern) 30. Single unrblical artery is cssociated vrith-
b) Age a) NTD (All India Dec15 Pattern)
c) Height b) Hydrops fetalis
d) Investigation c) Congenital heart disease
23. Ataxia telangiectasia is characterised by all ofthe d) In utero death
followingexcept - (Ar04) 31. A study under Australian collaborative trial on
a) Chronic sinopulmonary disease steroids use in neonates was done. Which of the
b) Decreased level of q-fetoprotein following is true - (AIIMS May 11)
c) Chromosomalbreakage a) No difference between placebo & corticosteroid
d) IgA deficiency b) Corticosteroid to children causes behavioural
24. Chromosomal anomalies more than 20/o is associat- worsening
edwith - (AIIMS Nov 09) c) Corticosteroid to children causes reduction in head
a) Gastroschisis circumference
b) Omphalocele d) Corticosteroid to children causes neuro sensitivity
c) Spina Bifida degradation
d) Cleft Palate GBSin addldtreatonent- (NEET Dec.12 Pattern)
Which of the following statements regarding Kawa* a) IVIg
saki disease is true - (AIIMS Nov 11. AI 08) b) Ventilation
a) Associated with coronary artery aneurysm in up to c) Plasmapharesis
of untreated cases
250/o d) All of above
b) It is the mostcommon cause of vasculitis in Iron poisoning in 4 year child, Rx includes -
children a) Stomach lavage (PGl lune 2000)
c) IV immunoglobulins are recommended only if b) Desferrioxamine IV 100 mg
coronary artery is involved c) X-ray abdomen
d) Lymph node biopsy is used for diagnosis d) Blood transfusion
Treatment of kawasaki disease in children is - 34. Increased sweat chloride is seen in all except - (AI 9s)
a) Oral steroids (AIIMSNoy 11, AI 01) a) Ectodermaldysplasia
b) IV steroids b) Nephrogenic diabetes insipidus
c) IVIg c) Glucose 6 phosphatase deficiency
d) Mycophenolate mefentil d) Obesity
1,7 The most common leukocytoclastic vasculitis affect- A 5 yearotrdc&ildwith ge$ u&derdiaphragm is see*
ing children is - (AIIMS May 03, Al 0s) tn- (All India Decl5 Pattern)
a) Takayasu disease a) Enteric fever with intestinal perforation
b) Mucocutaneous lymph node slmdrome. (Kawasaki b) Chilaiditi'ssyndrome
disease) c) Iatrogenicpneumoperitoneum
c) Henoch Schonlein purpura d) All of above
d) Polyarteritis nodosa
36. Grisel syndromeis- (All India Dec15 Pattern)
28. A child with an obvious rash presents with recurent a) Glucosaminidasedeficiency
infections. Investigation revealed decreased platelet b) Atalanto-axial dislocation
count and reduced lgM. Which of the following is c) Hexosaminidasedeficiency
the most likely diagnosis - (Ar 12) d) L4 - L5 displacement
a) Idiopathic Thrombocytopenic Purpura 37. Thirteen pair af Ribs are seen in ? (All India Decj5 pattern)
b) Thrombotic Thrombocytopenic Purpura a) Down slmdrome
c) Wiskott-AldrichSyndrome b) Holt oram
c) Tirrner d) Fibrous dysplasia
d) Di'George anomaly
29. A sixyear old child is admitted to the Paediatric ICU
for seizures. He has been on tretment with Tacroli-
mus and Prednisolone. On investigations his blood
urea is 68 mg/dl, Serum Sodium is 136 meqll likely
cause ofhis seizures- (Ar 12)
a) Uremia
b) Hyponatremia
III
Cse..p.tE.n :r.7
ANSWERS
l. A.ns, is X'
i.e", Trisomy 21 {Ref: Rennie d* Il.aberton's {exth*ak al neawatalogy by tra*et M. Rennie Tth/e Chap 6,
Newbarn swrgery 2"d ed l3y Frew Furi Z't/e p" 24A; t{01?"L) guide ta r*re disarders 28{}3 e p. 2341
r Pentalogy of Cantrell encompasses the following 5 main features.
i) Pericardial or distal sternal cleft
ii) Supraumbilicalomphalocele
iii) Diaphragmatic hernia
iv) Defect in apical pericardium causing ectopia cordia (Abnormal location of heart).
v) Congenital intracardiac defects (VSD, ASD, Tetralogy of fallot, Left ventricular diverticulum)"
,,
Ans is 'd i.e., Asplenia lRef: Nelson 1.8'h/e p. 1929)
tuit,,:i:re*ttili
Absent Multiple
iidedness (isomerism) B,]Jatgral.right't,,.,',,,, :
Bilateral left
Lungs Bilateral trilobar with eparterial Bilateral bilobar with hyparterial
bronchi bronchi
5ex Male (657o) Female > male
r The palm of patients hand represents 7o/o of BSA. Palm is the area of hand from wrist crease to the finger crease.
5. Ans. is '* i.e., Seizures tRel A clinical guide to epileptic syndromes and their treatmeut by C"P. Panayiotopoulos p.
1121
o It most commonly confused with seizures. However, NEPEs of Sndifer's qmdrome occur within t hour alfter feeding,
is
often following and imposed change of posture, and the babies frequently have a history of vomiting, failure to thrive
and repeated chest infections.
6. Ans is t' i.e., Williams syndrome is associated with obesity, mental retardation, precocious puberty
lRef: Chilil development by Berk 4th/e p. 6421
o In Williams syndrome there is failure to gain weight (not obesity) and delay in development (not-precocious puberty)
o 2S-hydroxylation of vitamin D occurs in liver.
o Thefinalhydroxylationinthekidneybyenzymel-ahydroxylaseistheratelimitingstep-enhancedbyparatharmone.
o 7, 25 dihydroxy Vit Dr(calcitriol) is the activeform of Vit Dr.
o Recommended dietary allowance (RDA) per day for children and adults is 600 IU (15 p g).
7. Ans. is t' i.e., Neuroenteric cyst lRef.: Sahiston 18th/e p. 1696; Internet)
o Vertebral defect in
association with intraspinal cyst suggest the diagnosis ofneuroenteric cyst.
o Any cyst in mediastinum (posterior), abdomen or intraspinal, in association with vertebral defect, suggest the diagnosis
of neuroentric cyst.
8. Ans. is'c' i.e., >3 second {Ref: hUp//ww,unicef.org/india/F8C_Participants_!4anual,pdfl
o It should be less than 3 seconds.
9. Ans. is'b- i.e., Sternum {Ref: O.P. Ghai 6h/e p. 652 6 //e p. 688)
o It is carried out by applying pressure to the pink part of the nail bed of the thumb or big toe in a child and over the
sternum or forehead in a young infant for 3 seconds.
10. Ans. is 1d' i.e., Brachial Artery fRef: Nelson 18th/e p. 1860; MyungKPark Sth/e p. 15, 16]
o It is most commonly confused with seizures. However, NEPEs of Sndifert sl.ndrome occur within t hour after feeding,
often following and imposed change of posture, and the babies frequently have a history of vomiting, failure to thrive
and repeated chest infections.
6. Ans is 'd' i.e., Williams syndrome is associated with obesitp mental retardation, precocious puberty
lRef: Chilil development by Berk 4th/e p. 6421
o In Williams syndrome there is failure to gain weight (not obesity) and delay in development (not-precocious puberty)
o 25-hydroxylation of vitamin D occurs in liver.
o Thefinalhydroxylationinthekiilneybyenzymel-ahydroxylaseistheratelimitingstep-eflhancedbyparatharmone.
o 7, 25 dihydroxy Vit Dr(calcitriol)-is the activeform of Vit Dr.
o Recommended dietary allowance (RDA) per day for children and adults is 600 IU (1S p g).
7. Ans. is t' i.e., Neuroenteric cyst fRef; Sabiston 18'h/e p. 1696; Internetl
o Vertebral defect in association with intraspinal cyst suggest the diagnosis of neuroenteric cyst.
o Any cyst in mediastinum (posterior), abdomen or intraspinal, in association with vertebral defect, suggest the diagnosis
o[ neuroenlric cyst.
8. Ans. is 'c' i.e." >3 second {ReJ: http//ww.unicef.org/india/FBC-Participants-Manual.pi$)
o It should be less than 3 seconds.
9. Ans. is'-o- i.e., Sternum {Rel O"P Ghai 6h/e p. 652 (t 7/e p. 6881
r It is carried out by applying pressure to the pink part of the nail bed of the thumb or big toe in a child and over the
sternum or forehead in a young infant for 3 seconds.
10. Ans. is 1d' i.e., Brachial Artery lRef: Nelson 18th/e p. 1860; Myung K Park Sth/e p. 15, 16j
Recognise shock
Give bolus 20 ml/kg NS opto 60 ml/kg
Start dopamine/Dobutamine
+
Dopamine/dobutamine resistance
shock
shock
Warm
++
Startnorepinephrine Startepinephrine
Cold shock
Give hydrocortisone
+
Add vasodilator or iype lll PDE
inhibitor with epinephrine/
norepinephrine
+
Persistent catecholamine
resistant shock
+
Consider ECMO
13. Ans. is 'd' i.e., Low birth weight lRef: Meharban Singh 6h/e p. 404; O.P. Ghai 8'h/e p. 666 6 7h/e p. 6451
c "Retrolental fibroplasia (retinopathl of prematurity) is generally noted some weeks after birth in premature
infants who have been given high concentration of oxygen, and is usually confineil to those under 1.7 Kg in weight at
birthl' --- Parson, l8/e
14" Ans. is 'd' i.e., Hyperoxygenemia lRef: O.P. Ghai Bth/e p. 665 b Vh/e p. 6451
15. Ans. is 'a' i.e., Less gestation age lRel O.P. Ghai 8th/e p. 665 b 7/e p. 6451
16. Ans. is'b'i.e., Pilocytic fR.ef: Nelson 18'h/e p. 26081
17. Ans. is'b' i.e., Undescendended testes fRef Nelson 18th/e p. 2198)
r It is characterized by : (r) Congenital cataract (i1) Mental retardation (111) Fanconi syndrome -+ Aminoacidut'ina
23. Ans. is 'b' i.e., Decreased levels of cr fetoproteins lRef: Nelson lVh/e p. 699; Harrisan lVh/e p. 25711
"Persistance of very high levels of oncofetal proteins, including alpha fetoproteins and carcinoembryonic antigens
is of diagnostic value" - Harrison
24. Ans. is 'b' i.e., Omphalocele fRef. Nelson 18th/e p. 776, Cloherty 6*/e p. 6271
r Chromosomal abnormalities have been reported in as many as 43% fetuses with omphalocele. The most common
being trisomy 13,18,21 and Turner syndrome.
25, Ans. is 'd i.e., Associated with coronary artery aneurysm in up to 25Yo lRef: Nelson 18th/e p. 10381
"Coronary artery aneurysm develop in up to 250/o ofuntreated patients" - Nelson
r Most common cause of vasculitis in children is HSP.
r IV immunoglobulin is the treatment of choice for Kawasaki disease.
Lymph node biopsy does not aid the diagnosis of Kawasaki disease (not used)
26. Ans. is t' i.e., I.V. immunoglobulins lRef: Nelson 18th/e p. rc40, 10411
27. Ans. is t' i.e., Henoch Schonlein purpura fRef. Rudotph's 21il/e p. 1117]
28. Ans. is t' i.e., Wiskott Aldrich Syndrome lRef. Harrison lVh/e p. 206A; Hffiman 4th/e p.B47j
o The classical triad of rash, thrombocytopenia and recurrent infection (immunodeficiency; tr tgfulS suggest a
diagnosis of Wi skott- Aldr ich Sy ndrome.
30. Ans. is'c' i.e., Congenitatr heart diseaselRef: Nelson lSth/e p. 1(|5\
o Approximately j0% of infants with a single umbilical artery have congenital abnormalities.
o Trisomy 18 is one of the more frequent abnormalities.
most common congenital anomalies in chromosomally normal
' The
1) Genitourinary (6.480/o)
fetuses and neonates were.
-1J. Ans. is 'd' i.e., All of above fRef: BMI case report 2012, I. pediatric surgery 19911
r Chilaiditi's syndrome : Condition characterised by interposition of small or large bowel between
liver and right
diaphragm. Radiologically it gives gas under diaphragm.
o Iatrogenic pneumoperitoneum : In certain procedures like peritoneal dialysis,
Iatrogenically air pushed before putting
PD cannula to avoid injury ofviscera in such case gas under diaphragm can be seen
and all cases when intestine or
viscera perforate we can get gas under diaphragm.
q
36. Ans. is'H i.e., Atalento axial dislocation [Ref Netsan l&*le Chapter 679]
Grisel's syndrome
o Spontaneous subluxation of the atlanto-axial joint following peri-pharyngeal inflammation is known as Grisel's
syndrome.
o Children are most frequently afected and classically have torticollis associated with neck stiffness or pain upon neck
movement.
37. Ans. is 'a' i"e., Down syndrome lRef Abnonnel number affetuI rtbs in USG by Liet Gtudes et.al.j
ITI