Pedi Flashcards
A 16-hour-old male neonate was presented to a
hospital with a complaint of failure to suck of five
hours duration. He was delivered in a hospital at
gestational age of 35-week. On examination, he has
grunting, respirations were 68/min, pulse rate was
178/min, and has pale skin color. On laboratory
investigations, hemoglobin level was 5g/dl, and
blood group is A+ and 0+ for him and his mother
respectively. What is the most likely cause of the
neonate’s condition?
• a. Rh incompatibility
• b. ABO incompatibility
• c. Vitamin K deficiency
• d. Anemia of prematurity
The most likely cause of the neonate’s condition is:
b. ABO incompatibility
Explanation:
• Clinical Features: The neonate has pale skin, grunting, tachypnea (respirations 68/min), tachycardia (pulse 178/min), and severe anemia (hemoglobin 5 g/dL). These symptoms are consistent with hemolysis and anemia.
• Maternal and Neonatal Blood Groups: The mother’s blood group is O+, and the neonate’s blood group is A+. This is a classic setup for ABO incompatibility, where the mother’s anti-A or anti-B antibodies cross the placenta and attack the neonate’s red blood cells, causing hemolysis and anemia.
• Rh Incompatibility (Option a): Rh incompatibility is less likely because both mother and neonate are Rh-positive, and this condition typically occurs in an Rh-negative mother with an Rh-positive baby.
• Vitamin K Deficiency (Option c): While vitamin K deficiency can cause bleeding, it does not explain the severe anemia or the hemolytic findings.
• Anemia of Prematurity (Option d): While prematurity can cause anemia due to insufficient erythropoiesis, the rapid onset (16 hours post-birth) and severity of anemia (hemoglobin 5 g/dL) point more strongly to hemolysis from ABO incompatibility.
Summary:
The findings of hemolysis, severe anemia, and the blood group mismatch (O+ mother and A+ neonate) strongly support ABO incompatibility as the most likely cause.
A 10-minute-old baby was delivered from a 30-year-
old P-III mother with an assisted vacuum delivery.The baby’s fifth minuteAPGAR score was 5 and is
currently on resuscitation with bag and face mask
ventilation. The heart rate is 55/min. What is the
most appropriate next step in the management of
the newborn?
a. Continue to resuscitate with bag and face
mask
• b. Stop resuscitation and give the baby to
parents
• c. Intubation and Epinephrine
• d. Chest compressions coordinated with PPV
The correct answer is: d. Chest compressions coordinated with PPV (Positive Pressure Ventilation).
Explanation:
In neonatal resuscitation, if the heart rate remains <60/min after 30 seconds of effective positive pressure ventilation (PPV) with a bag and mask, the next step is to initiate chest compressions coordinated with PPV. This follows the Neonatal Resuscitation Program (NRP) guidelines:
1. Initial Steps: Ensure adequate ventilation with proper technique (effective mask seal and appropriate ventilation pressures).
2. Assess Heart Rate:
• If ≥100/min: Continue supportive care.
• If 60-99/min: Continue effective ventilation.
• If <60/min despite 30 seconds of effective PPV: Proceed to chest compressions.
3. Chest Compressions: Compressions should be coordinated with PPV at a ratio of 3:1 (3 compressions to 1 ventilation) at a rate of 120 events per minute (90 compressions + 30 breaths).
4. Reassess Heart Rate after 60 seconds of chest compressions and ventilation:
• If still <60/min, administer epinephrine and consider intubation.
Why not the other options?
• a. Continue to resuscitate with bag and face mask: If the heart rate is still <60/min, continuing PPV alone is inadequate. Chest compressions are necessary.
• b. Stop resuscitation and give the baby to parents: This is not appropriate unless the resuscitation is deemed futile (e.g., no signs of life after prolonged efforts), which is not the case here.
• c. Intubation and Epinephrine: These are not the immediate next steps. Epinephrine is indicated only if the heart rate remains <60/min despite 60 seconds of coordinated chest compressions and PPV.
Key Takeaway:
For a newborn with a heart rate <60/min after effective ventilation, initiate chest compressions coordinated with PPV as the next step.
A 30-minute-old male neonate was presented with a
complaint of fast breathing for 10 minutes. On
physical examination, the neonate is in respiratory
distress, respiration rate is 75/min, pulse rate is
154/min, temperature is 36.5 degree centigrade and
gestational age is 43 weeks. Chest X-ray shows
patchy infiltrates. What is the most likely diagnosis?
• a. Neonatal sepsis
• b. Birth asphyxia
• c. Meconium aspiration syndrome
• d. Hyaline membrane disease
C -because baby is born at 43 weeks , the clinical presentation plus the X-ray findings go with it
A female neonate, who was delivered at gestational
age of 43 weeks, has been admitted toa NICU for the
last five days after being referred due to respiratory
distress immediately after delivery. Physical
examination findings at admission revealed over-
distended chest and Meconium stained extremities.
Currently, she has severe hypoxia with clear chest
and good air entry. Otherwise, she has no detected
abnormality. The chest radiograph is normal. What is
the most likely diagnosis for the current problem?
a. Spontaneous tension Pneumothorax
• b. Bacterial superimposed infection
• c. Congenital diaphragmatic hernia
• d. Persistent pulmonary hypertension
The correct answer is: d. Persistent Pulmonary Hypertension (PPHN).
Explanation:
Clinical Features Supporting PPHN:
1. Post-term delivery (43 weeks): PPHN is more common in post-term infants due to factors like chronic uteroplacental insufficiency, meconium aspiration syndrome, or birth asphyxia.
2. Respiratory distress shortly after birth: This is a hallmark of PPHN due to failure of the pulmonary vasculature to transition from high resistance (fetal circulation) to low resistance (neonatal circulation).
3. Severe hypoxia with normal chest examination and radiograph: PPHN causes hypoxemia due to right-to-left shunting through the ductus arteriosus and/or foramen ovale, despite clear lungs and good air entry.
4. Meconium-stained extremities: Suggests a history of meconium aspiration syndrome, a common trigger for PPHN.
Why Not the Other Options?
• a. Spontaneous tension pneumothorax:
• A pneumothorax would present with asymmetrical chest findings, diminished air entry on the affected side, and signs of tension (e.g., tracheal deviation). None of these are present here, and the chest radiograph is normal.
• b. Bacterial superimposed infection:
• A bacterial infection would likely present with systemic signs (e.g., fever, lethargy) and abnormal radiographic findings (e.g., infiltrates or consolidation). This neonate has a clear chest and normal radiograph.
• c. Congenital diaphragmatic hernia:
• This condition typically presents with severe respiratory distress immediately after birth, scaphoid abdomen, and abnormal radiographic findings (e.g., bowel loops in the thoracic cavity). None of these features are present here.
Pathophysiology of PPHN:
• In PPHN, pulmonary vascular resistance remains high, causing right-to-left shunting through the ductus arteriosus and/or foramen ovale, leading to hypoxemia despite adequate ventilation and a structurally normal heart and lungs.
Management:
• Oxygenation: Optimize oxygen delivery with high-flow oxygen or mechanical ventilation.
• Pulmonary vasodilators: Medications like inhaled nitric oxide (iNO) or sildenafil may reduce pulmonary vascular resistance.
• Supportive care: Maintain normal temperature, glucose levels, and acid-base balance.
Key Point:
The combination of post-term gestation, meconium exposure, severe hypoxia with normal radiograph and chest exam, and no other significant abnormalities strongly suggests persistent pulmonary hypertension of the newborn (PPHN).
P Flag question
A female neonate, who was delivered at gestational
age of 43 weeks, has been admitted toa NICU for the
last five days after being referred due to respiratory
distress immediately after delivery. Physical
examination findings at admission revealed over-
distended chest and Meconium stained extremities.
Currently, she has severe hypoxia with clear chest
and good air entry. Otherwise, she has no detected
abnormality. The chest radiograph is normal. What is
the most likely diagnosis for the current problem?
a. Spontaneous tension Pneumothorax
• b. Bacterial superimposed infection
• c. Congenital diaphragmatic hernia
• d. Persistent pulmonary hypertension
Previous page
The correct answer is: d. Persistent Pulmonary Hypertension (PPHN).
Explanation:
Clinical Features Supporting PPHN:
1. Post-term delivery (43 weeks): PPHN is more common in post-term infants due to factors like chronic uteroplacental insufficiency, meconium aspiration syndrome, or birth asphyxia.
2. Respiratory distress shortly after birth: This is a hallmark of PPHN due to failure of the pulmonary vasculature to transition from high resistance (fetal circulation) to low resistance (neonatal circulation).
3. Severe hypoxia with normal chest examination and radiograph: PPHN causes hypoxemia due to right-to-left shunting through the ductus arteriosus and/or foramen ovale, despite clear lungs and good air entry.
4. Meconium-stained extremities: Suggests a history of meconium aspiration syndrome, a common trigger for PPHN.
Why Not the Other Options?
• a. Spontaneous tension pneumothorax:
• A pneumothorax would present with asymmetrical chest findings, diminished air entry on the affected side, and signs of tension (e.g., tracheal deviation). None of these are present here, and the chest radiograph is normal.
• b. Bacterial superimposed infection:
• A bacterial infection would likely present with systemic signs (e.g., fever, lethargy) and abnormal radiographic findings (e.g., infiltrates or consolidation). This neonate has a clear chest and normal radiograph.
• c. Congenital diaphragmatic hernia:
• This condition typically presents with severe respiratory distress immediately after birth, scaphoid abdomen, and abnormal radiographic findings (e.g., bowel loops in the thoracic cavity). None of these features are present here.
Pathophysiology of PPHN:
• In PPHN, pulmonary vascular resistance remains high, causing right-to-left shunting through the ductus arteriosus and/or foramen ovale, leading to hypoxemia despite adequate ventilation and a structurally normal heart and lungs.
Management:
• Oxygenation: Optimize oxygen delivery with high-flow oxygen or mechanical ventilation.
• Pulmonary vasodilators: Medications like inhaled nitric oxide (iNO) or sildenafil may reduce pulmonary vascular resistance.
• Supportive care: Maintain normal temperature, glucose levels, and acid-base balance.
Key Point:
The combination of post-term gestation, meconium exposure, severe hypoxia with normal radiograph and chest exam, and no other significant abnormalities strongly suggests persistent pulmonary hypertension of the newborn (PPHN).
P Flag question
A five-year-old female child with complaints of fever
and rash of three days duration is brought to a
hospital. She also has cough, nasal discharge and
diarrhea. On physical examination, her temperature
is 37.8 degree centigrade, respirations are 43/min,
pulse rate is 123/min, and there is diffuse red
maculo-papular rash from face to leg. What
complication will be expected in her third decade of
life?
• a. Pneumonia
• b. Severe malnutrition
• c. Subacute sclerosing panencephalitis
• d. Measles encephalitis
The correct answer is: d. Persistent Pulmonary Hypertension (PPHN).
Explanation:
Clinical Features Supporting PPHN:
1. Post-term delivery (43 weeks): PPHN is more common in post-term infants due to factors like chronic uteroplacental insufficiency, meconium aspiration syndrome, or birth asphyxia.
2. Respiratory distress shortly after birth: This is a hallmark of PPHN due to failure of the pulmonary vasculature to transition from high resistance (fetal circulation) to low resistance (neonatal circulation).
3. Severe hypoxia with normal chest examination and radiograph: PPHN causes hypoxemia due to right-to-left shunting through the ductus arteriosus and/or foramen ovale, despite clear lungs and good air entry.
4. Meconium-stained extremities: Suggests a history of meconium aspiration syndrome, a common trigger for PPHN.
Why Not the Other Options?
• a. Spontaneous tension pneumothorax:
• A pneumothorax would present with asymmetrical chest findings, diminished air entry on the affected side, and signs of tension (e.g., tracheal deviation). None of these are present here, and the chest radiograph is normal.
• b. Bacterial superimposed infection:
• A bacterial infection would likely present with systemic signs (e.g., fever, lethargy) and abnormal radiographic findings (e.g., infiltrates or consolidation). This neonate has a clear chest and normal radiograph.
• c. Congenital diaphragmatic hernia:
• This condition typically presents with severe respiratory distress immediately after birth, scaphoid abdomen, and abnormal radiographic findings (e.g., bowel loops in the thoracic cavity). None of these features are present here.
Pathophysiology of PPHN:
• In PPHN, pulmonary vascular resistance remains high, causing right-to-left shunting through the ductus arteriosus and/or foramen ovale, leading to hypoxemia despite adequate ventilation and a structurally normal heart and lungs.
Management:
• Oxygenation: Optimize oxygen delivery with high-flow oxygen or mechanical ventilation.
• Pulmonary vasodilators: Medications like inhaled nitric oxide (iNO) or sildenafil may reduce pulmonary vascular resistance.
• Supportive care: Maintain normal temperature, glucose levels, and acid-base balance.
Key Point:
The combination of post-term gestation, meconium exposure, severe hypoxia with normal radiograph and chest exam, and no other significant abnormalities strongly suggests persistent pulmonary hypertension of the newborn (PPHN).
Flag question
A four-year-old male child was brought by his mother
to a clinic accompanied with a complaint of being
unable to speak clear words. He clearly points to the
thing he wants to have. He is able to ride tricycle and
copies cross and circle on paper. Routine physical
examinations did not show any abnormality. What is
the most appropriate measure to be taken for the
baby?
• a. Referring the child for mental retardation
a s s e s s m e n t
O b. Reassuring the mother to send him to
regular school
c. Reassuring the mother as it is normal
• d. Referring the child for hearing assessment
The correct answer is: d. Referring the child for hearing assessment.
Explanation:
The child’s inability to speak clear words despite otherwise normal development (e.g., pointing, riding a tricycle, and copying shapes) raises concern about a potential speech or language delay. One of the most common and reversible causes of delayed speech development is hearing impairment. Even mild or intermittent hearing loss (e.g., due to recurrent otitis media) can significantly affect language acquisition.
Why refer for hearing assessment?
1. Speech Delay:
• The inability to speak clear words at 4 years old is concerning, as most children at this age can form clear sentences and express themselves verbally.
2. Normal Physical Examination:
• With no other abnormalities, the first step is to rule out hearing impairment, which is a key factor in language development.
3. Normal Motor Skills and Cognition:
• The child’s ability to ride a tricycle and copy a cross and circle indicates age-appropriate fine and gross motor skills, making hearing assessment the most logical next step.
Why not the other options?
• a. Referring for mental retardation assessment:
• The child’s cognitive abilities seem intact based on their ability to perform age-appropriate tasks like copying shapes and riding a tricycle. There is no evidence of intellectual disability here.
• b. Reassuring the mother to send him to regular school:
• While the child might attend school, the speech issue needs to be addressed first to ensure effective communication and learning.
• c. Reassuring the mother as it is normal:
• Delayed speech at 4 years old is not normal and requires investigation.
Key Point:
The most appropriate step is to refer the child for hearing assessment, as early identification and intervention for hearing loss are critical to improving language development and overall communication skills.
A mother has brought her three-month-old male
infant to a clinic to get advice about his growth
status. Anthropometry is done and all parameters
are unaffected. What is the normal growth pattern to
inform the woman?
• a. Head circumference increases by 2 cm per
month for the next three months
• b. Weight increases by 30 g/day for the next
t h r e e m o n t h s
c. Length increases by 0.5 cm per month for
the next three months
• d. Weight doubles the birth weight at 4-5
months
The correct answer is: d. Weight doubles the birth weight at 4-5 months.
Explanation:
At three months of age, the infant’s growth typically follows these patterns:
1. Weight:
• Infants gain approximately 20–30 grams/day during the first 3–4 months.
• By 4–5 months, the infant’s weight usually doubles the birth weight.
2. Length:
• The length increases by 2.5 cm/month during the first 6 months, not just 0.5 cm/month (making option c incorrect).
3. Head Circumference:
• The head circumference increases by about 1 cm/month for the first 6 months, not 2 cm/month after three months (making option a incorrect).
4. Growth milestones:
• Weight gain slows down after 6 months, and by 12 months, the weight typically triples the birth weight.
• Length increases more slowly after 6 months, reaching about 50% of birth length by 1 year.
Why not the other options?
• a. Head circumference increases by 2 cm per month for the next three months:
• This rate of growth is too rapid after the neonatal period. It is about 1 cm/month from 3–6 months.
• b. Weight increases by 30 g/day for the next three months:
• While 30 g/day is appropriate for the first 3 months, the rate begins to slow slightly after this period.
• c. Length increases by 0.5 cm per month for the next three months:
• The length increases at about 2.5 cm/month during the first 6 months, much faster than stated here.
Key Counseling Point for the Mother:
The infant’s weight is expected to double the birth weight by 4–5 months and triple by 12 months. Both weight and height should continue to be monitored at regular check-ups to ensure normal growth and development.
A nine-hour-old male neonate was brought to a
hospital with a complaint of failure to suck since
birth. He was delivered at home and did not cry
immediately after delivery. On physical examination,
he has seizure on arrival; all neonatal reflexes are
depressed, and lethargic. What is the first line
treatment for this neonate?
a. Phenytoin
b. Phenobarbital
c. Valproic acid
• d. Diazepam
The correct answer is: b. Phenobarbital.
Explanation:
This neonate’s presentation of seizures, lethargy, and depressed neonatal reflexes suggests neonatal encephalopathy, likely due to birth asphyxia (hypoxic-ischemic encephalopathy, HIE) given the history of failure to cry immediately after birth.
First-line treatment for neonatal seizures:
• Phenobarbital is the first-line drug for managing seizures in neonates because:
• It is effective in controlling neonatal seizures.
• It has a well-established safety profile in neonates.
• It is the preferred anticonvulsant according to neonatal resuscitation and seizure management guidelines.
Why not the other options?
• a. Phenytoin:
• Phenytoin is considered a second-line treatment for neonatal seizures if phenobarbital fails.
• c. Valproic acid:
• Valproic acid is contraindicated in neonates because of the risk of hepatotoxicity and other adverse effects.
• d. Diazepam:
• Diazepam is not commonly used in neonates for seizure management because it has a short duration of action and can cause respiratory depression, especially in this age group.
Additional Steps:
• Supportive care: Ensure adequate oxygenation, ventilation, and glucose levels (correct hypoglycemia if present).
• Investigation: Identify and treat the underlying cause of seizures (e.g., hypoxia, hypoglycemia, infection, metabolic disturbances).
Key Point:
Phenobarbital is the first-line treatment for neonatal seizures due to its efficacy, safety, and long history of use in neonates.
A nine-hour-old male neonate was brought to a
hospital with a complaint of failure to suck since
birth. He was delivered at home and did not cry
immediately after delivery. On physical examination,
he has seizure on arrival; all neonatal reflexes are
depressed, and lethargic. What is the first line
treatment for this neonate?
a. Phenytoin
b. Phenobarbital
c. Valproic acid
• d. Diazepam
The correct answer is: b. Phenobarbital.
Explanation:
This neonate’s presentation of seizures, lethargy, and depressed neonatal reflexes suggests neonatal encephalopathy, likely due to birth asphyxia (hypoxic-ischemic encephalopathy, HIE) given the history of failure to cry immediately after birth.
First-line treatment for neonatal seizures:
• Phenobarbital is the first-line drug for managing seizures in neonates because:
• It is effective in controlling neonatal seizures.
• It has a well-established safety profile in neonates.
• It is the preferred anticonvulsant according to neonatal resuscitation and seizure management guidelines.
Why not the other options?
• a. Phenytoin:
• Phenytoin is considered a second-line treatment for neonatal seizures if phenobarbital fails.
• c. Valproic acid:
• Valproic acid is contraindicated in neonates because of the risk of hepatotoxicity and other adverse effects.
• d. Diazepam:
• Diazepam is not commonly used in neonates for seizure management because it has a short duration of action and can cause respiratory depression, especially in this age group.
Additional Steps:
• Supportive care: Ensure adequate oxygenation, ventilation, and glucose levels (correct hypoglycemia if present).
• Investigation: Identify and treat the underlying cause of seizures (e.g., hypoxia, hypoglycemia, infection, metabolic disturbances).
Key Point:
Phenobarbital is the first-line treatment for neonatal seizures due to its efficacy, safety, and long history of use in neonates.
A seven-month-old infant is brought to a hospital for
a routine follow up. Growth and development of the
infant are optimal. A WBC count of 7,000/mm3,
hemoglobin level of 6.7g/dl with MCV of 60fl, and
RDW of 20percent were noted from laboratory work
up. What is the most likely diagnosis of the child?
• a. Thalassemia
• b. Lead poisoning
• c. Iron-deficiency anemia
• d. Folate deficiency anemia
The correct answer is: c. Iron-deficiency anemia.
Explanation:
This 7-month-old infant presents with laboratory findings suggestive of microcytic anemia, most likely due to iron-deficiency anemia (IDA), which is the most common cause of anemia in infants and young children.
Supporting Features for Iron-Deficiency Anemia:
1. Low hemoglobin (6.7 g/dL):
• Significantly low for age (normal: ≥10.5 g/dL at 6–12 months).
2. Low mean corpuscular volume (MCV = 60 fL):
• Indicates microcytic anemia (normal MCV: 70–86 fL for this age).
3. High red cell distribution width (RDW = 20%):
• Elevated RDW indicates variability in red blood cell (RBC) size, which is typical in IDA.
4. Optimal growth and development:
• Suggests nutritional causes (like iron deficiency) rather than genetic disorders like thalassemia, which might affect growth.
5. Age (7 months):
• This is a common age for iron deficiency to manifest, especially in infants transitioning to complementary feeding, as breast milk alone may no longer meet iron requirements.
Why Not the Other Options?
• a. Thalassemia:
• While thalassemia also causes microcytic anemia, RDW is usually normal in thalassemia, as RBC size is uniformly small. Additionally, thalassemia is less likely in a healthy child without a family history or physical abnormalities.
• b. Lead poisoning:
• Lead poisoning can cause microcytic anemia, but it is less common and is usually associated with environmental exposure and basophilic stippling on a peripheral blood smear, which is not mentioned here.
• d. Folate deficiency anemia:
• Folate deficiency causes macrocytic anemia, with an increased MCV, not microcytic anemia.
Key Point:
The combination of microcytic anemia, elevated RDW, and age strongly suggests iron-deficiency anemia, which should prompt dietary evaluation and possible iron supplementation.
A seven-year-old known cardiac patient, with
atrioventricualr septal defect and who is on follow
up, is planning to undergo dental correction with
manipulation of gingival tissue. He has no known
history of drug allergy. What is the best first-line
endocarditis preventive strategy for this child?
• a. Cefepime
b. Amoxicillin
c. Azithromycin
d. Clindamycin
The correct answer is: b. Amoxicillin.
Explanation:
Children with congenital heart defects, such as an atrioventricular septal defect (AVSD), are at increased risk for infective endocarditis during certain dental procedures that involve manipulation of gingival tissue. This is because bacteria from the mouth can enter the bloodstream and infect the heart valves or the endocardial lining. Therefore, prophylactic antibiotics are recommended before dental procedures.
Best Choice for Endocarditis Prophylaxis:
• Amoxicillin is the first-line antibiotic for endocarditis prophylaxis in children without any known drug allergies. It is effective against the most common organisms that cause infective endocarditis (such as viridans group streptococci), and it is the preferred drug for dental procedures in patients at risk for endocarditis.
Dosing for Amoxicillin:
• The usual dose for children is 50 mg/kg given orally, typically 30–60 minutes before the procedure.
Why Not the Other Options?
• a. Cefepime:
• Cefepime is a broad-spectrum cephalosporin typically used for more severe infections, but it is not the first choice for routine endocarditis prophylaxis in this case. Amoxicillin is preferred due to its proven efficacy against the organisms typically responsible for infective endocarditis in dental procedures.
• c. Azithromycin:
• Azithromycin can be used in patients who are allergic to penicillin, but it is not the first-line agent. It is generally used when the patient has a documented penicillin allergy.
• d. Clindamycin:
• Clindamycin is another alternative for patients allergic to penicillin, but again, it is not the first choice for endocarditis prophylaxis. Like azithromycin, it is typically reserved for those with penicillin allergy.
Key Point:
For a child with no known drug allergies who is undergoing a dental procedure with manipulation of gingival tissue, the best first-line prophylactic antibiotic is amoxicillin.
A seven-year-old known cardiac patient, with
atrioventricualr septal defect and who is on follow
up, is planning to undergo dental correction with
manipulation of gingival tissue. He has no known
history of drug allergy. What is the best first-line
endocarditis preventive strategy for this child?
• a. Cefepime
b. Amoxicillin
c. Azithromycin
d. Clindamycin
The correct answer is: b. Amoxicillin.
Explanation:
Children with congenital heart defects, such as an atrioventricular septal defect (AVSD), are at increased risk for infective endocarditis during certain dental procedures that involve manipulation of gingival tissue. This is because bacteria from the mouth can enter the bloodstream and infect the heart valves or the endocardial lining. Therefore, prophylactic antibiotics are recommended before dental procedures.
Best Choice for Endocarditis Prophylaxis:
• Amoxicillin is the first-line antibiotic for endocarditis prophylaxis in children without any known drug allergies. It is effective against the most common organisms that cause infective endocarditis (such as viridans group streptococci), and it is the preferred drug for dental procedures in patients at risk for endocarditis.
Dosing for Amoxicillin:
• The usual dose for children is 50 mg/kg given orally, typically 30–60 minutes before the procedure.
Why Not the Other Options?
• a. Cefepime:
• Cefepime is a broad-spectrum cephalosporin typically used for more severe infections, but it is not the first choice for routine endocarditis prophylaxis in this case. Amoxicillin is preferred due to its proven efficacy against the organisms typically responsible for infective endocarditis in dental procedures.
• c. Azithromycin:
• Azithromycin can be used in patients who are allergic to penicillin, but it is not the first-line agent. It is generally used when the patient has a documented penicillin allergy.
• d. Clindamycin:
• Clindamycin is another alternative for patients allergic to penicillin, but again, it is not the first choice for endocarditis prophylaxis. Like azithromycin, it is typically reserved for those with penicillin allergy.
Key Point:
For a child with no known drug allergies who is undergoing a dental procedure with manipulation of gingival tissue, the best first-line prophylactic antibiotic is amoxicillin.
A six-week-old male infant was brought to a hospital
with a complaint of rash for one hour. He took his
first vaccine 12 hours back. On physical
examination, his pulse rate is feeble, respirations are
65/min, he has stridor and wheezing over the chest,
diffuse urticurial rash all over the body, and lip and
oral mucosa swelling. What is the appropriate initial
treatment for this infant?
• a. Blood transfusion
• b. Prednisolone
c. Antihistamine
d. Epinephrine
The correct answer is: d. Epinephrine.
Explanation:
The infant’s presentation of feeble pulse, tachypnea (respirations 65/min), stridor, wheezing, diffuse urticarial rash, and swelling of lips and oral mucosa is highly suggestive of anaphylaxis, a severe and potentially life-threatening allergic reaction. This likely occurred as a reaction to the vaccine administered 12 hours earlier.
First-line treatment for anaphylaxis:
• Epinephrine is the drug of choice for anaphylaxis. It acts rapidly to:
• Relieve airway obstruction by reducing bronchospasm, laryngeal edema, and mucosal swelling.
• Improve cardiovascular status by increasing heart rate, cardiac output, and vasoconstriction to counteract hypotension.
Dose of Epinephrine:
• Intramuscular (IM) injection:
• Dose: 0.01 mg/kg (maximum 0.3 mg per dose) of 1:1000 (1 mg/mL) solution.
• Administered into the mid-anterolateral thigh.
• Repeat every 5–15 minutes as needed, based on response.
Why Not the Other Options?
• a. Blood transfusion:
• There is no indication for a blood transfusion in this scenario. The symptoms are due to anaphylaxis, not blood loss or anemia.
• b. Prednisolone:
• Corticosteroids, like prednisolone, can be used as an adjunct treatment to prevent biphasic reactions, but they have a delayed onset of action (hours). They are not appropriate as initial treatment for anaphylaxis.
• c. Antihistamine:
• Antihistamines (e.g., diphenhydramine) can help with skin symptoms (e.g., rash, itching) but do not address the life-threatening respiratory or cardiovascular components of anaphylaxis. They are secondary treatments, not initial ones.
Key Point:
Epinephrine IM is the initial and life-saving treatment for anaphylaxis. Other supportive measures, like oxygen, fluid resuscitation, and adjunctive medications (e.g., antihistamines and corticosteroids), may be used after stabilization.
A three-year-old boy presented with inadequate
intake and diarrhea of three days duration. His
growth and development were optimal. On
examination, skin pinch goes back very slowly and
he is lethargic. His weight is 15kg. What is the most
appropriate fluid therapy to this child?
• a. 1500ml RL over 24 hours
• b. 450ml RL over 30 minutes, followed by
1050ml over the next 2½ hours
• c. 450ml RL over 1 hour, followed by 1050ml
over next 5 hours
• d. 300ml RL rapid bolus, followed by 450ml RL
over 30minutes
The answer is B . The child is 3 years old so hydrate with 100 ml /kg … 30 ml/kg the first 30 minutes and 70 ml/kg the next 2.5 hrs
If the child is am Infant it is given over 1 hr then 5 hrs
P Flag question
A three-year-old female child was presented to a
hospital with a complaint of fear of light
(photophobia) for three months. She also has skin
rash more on the arm, leg and buttocks areas. On
physical examination, she has foamy appearing
plaques on conjunctiva and dry, scaly, hyperkeratotic
patches over the leg, arm and buttocks. What is the
most likely diagnosis?
• a. Thiamine deficiency
• b. Vitamin A deficiency
• c. Zinc deficiency
• d. Riboflavin deficiency
The correct answer is: b. Vitamin A deficiency.
Explanation:
The child’s presentation is characteristic of Vitamin A deficiency, which is commonly associated with:
1. Photophobia (fear of light): Due to impaired retinal function and early eye involvement in vitamin A deficiency.
2. Foamy plaques on the conjunctiva (Bitot’s spots): A hallmark sign of vitamin A deficiency.
3. Dry, scaly, hyperkeratotic skin (follicular hyperkeratosis): Caused by abnormal keratinization of epithelial tissues, commonly on the arms, legs, and buttocks.
Why Not the Other Options?
• a. Thiamine deficiency:
• Thiamine deficiency causes beriberi, which is characterized by neurological symptoms (dry beriberi) or cardiovascular issues (wet beriberi). It does not cause eye or skin findings as described here.
• c. Zinc deficiency:
• Zinc deficiency can cause acrodermatitis enteropathica, presenting with periorificial and acral dermatitis, diarrhea, and alopecia, but it does not cause Bitot’s spots or photophobia.
• d. Riboflavin deficiency:
• Riboflavin deficiency causes symptoms such as angular stomatitis, glossitis, and corneal vascularization, but it does not lead to conjunctival plaques or follicular hyperkeratosis.
Key Points:
• Vitamin A deficiency primarily affects the eyes (night blindness, photophobia, and Bitot’s spots) and skin (follicular hyperkeratosis).
• It is most common in children with malnutrition or poor dietary intake, especially in developing countries.
• Treatment involves vitamin A supplementation and improvement of the child’s diet to include foods rich in vitamin A, such as liver, eggs, dairy, and dark green or orange vegetables.
A three-year-old male child was presented to a
hospital with a complaint of fever for five days. He
also has a yellowish discoloration of the eye and
frequent abnormal body movement of one day
duration. He is from malaria endemic area. On
physical examination, icteric sclera, splenomegaly
and hepatomegly were found. What is the best first
line treatment for this child?
• a. Artesunate
b. Coartum
• c. Quinine
• d. Arthemeter
The correct answer is: a. Artesunate.
Explanation:
This child has symptoms consistent with severe malaria, including:
1. Fever for five days: A hallmark of malaria.
2. Yellowish discoloration of the eye: Indicates jaundice, often due to hemolysis or liver dysfunction caused by severe malaria.
3. Frequent abnormal body movements: Suggests seizures, likely due to cerebral malaria.
4. Splenomegaly and hepatomegaly: Common findings in severe malaria due to increased immune response and sequestration of infected red blood cells in the spleen.
Given these features, the child meets the criteria for severe malaria, which requires parenteral therapy with a rapidly acting antimalarial drug.
First-Line Treatment:
• Parenteral Artesunate is the drug of choice for severe malaria in children, as per WHO guidelines. It is more effective and has fewer side effects compared to quinine.
• Dosage: Administer intravenously or intramuscularly, usually at 2.4 mg/kg at 0, 12, and 24 hours, followed by once daily until the patient can tolerate oral therapy.
Why Not the Other Options?
• b. Coartem (artemether-lumefantrine):
• Coartem is an oral therapy used for uncomplicated malaria. It is not suitable for severe malaria or when the patient cannot tolerate oral medications.
• c. Quinine:
• Quinine is an alternative for severe malaria but is less effective than artesunate. It has a higher risk of side effects, including hypoglycemia and cardiotoxicity, especially in children.
• d. Artemether:
• Artemether is an intramuscular drug but is less preferred compared to artesunate for severe malaria because artesunate has superior efficacy in reducing mortality.
Key Points:
• For severe malaria, the first-line treatment is parenteral artesunate.
• After the patient improves and can tolerate oral medications, the treatment is switched to a complete course of oral antimalarial therapy (e.g., Coartem).
• Supportive care, including seizure control and management of complications like hypoglycemia, jaundice, or dehydration, is essential.
A three-year-old male child was presented to a
hospital witha complaint of generalized body
swelling of five days duration. On examination, he
had puffy face, and his blood pressurewas between
the 50th and 90th percentile. On urinalysis, +3protein
was revealed. Cholesterol level of 400 mg/di,
triglyceride level of 250 mg/d|,serum creatinine level
of 0.4mg/dl, and BUN level of 15 mg/d were noted
on laboratory investigations. What is the most
appropriate management for the child?
• a. Start Amoxcillin 40 mg/kg/day
• b. Start Furosemide 4 mg/kg/day
• c. Start Enalapril 200 microgram/kg/day
• d. Start Prednisolone 60 mg/m2/day
The correct answer is: d. Start Prednisolone 60 mg/m²/day.
Explanation:
This child presents with clinical and laboratory findings consistent with nephrotic syndrome, characterized by:
1. Generalized body swelling (edema): Puffy face is a classic finding.
2. Proteinuria (+3 on urinalysis): A hallmark of nephrotic syndrome.
3. Hypercholesterolemia (400 mg/dL) and hypertriglyceridemia (250 mg/dL): Common in nephrotic syndrome due to increased hepatic lipid synthesis.
4. Normal blood pressure: Suggests minimal kidney injury.
5. Normal serum creatinine (0.4 mg/dL) and BUN (15 mg/dL): Indicates preserved kidney function.
Management:
The first-line treatment for idiopathic nephrotic syndrome (most commonly Minimal Change Disease) in children is high-dose corticosteroids, specifically:
• Prednisolone at a dose of 60 mg/m²/day, given daily for 4-6 weeks, followed by a gradual taper over several weeks to avoid relapse.
Corticosteroids help reduce proteinuria by modulating the immune response, which is thought to contribute to the permeability changes in the glomerular basement membrane.
Why Not the Other Options?
• a. Start Amoxicillin 40 mg/kg/day:
• There is no indication for antibiotics unless there is evidence of an infection, such as peritonitis or cellulitis, which are complications of nephrotic syndrome.
• b. Start Furosemide 4 mg/kg/day:
• Diuretics like furosemide may be used to manage severe edema, but they are adjunctive and not first-line therapy. They should be used cautiously to prevent intravascular volume depletion.
• c. Start Enalapril 200 microgram/kg/day:
• ACE inhibitors like enalapril are used in hypertensive patients with proteinuria. This child has normal blood pressure, so it is not indicated here.
Key Points:
• Idiopathic nephrotic syndrome in children is most commonly due to Minimal Change Disease.
• The cornerstone of treatment is corticosteroids.
• Monitor for complications (e.g., infections, thromboembolism) and side effects of steroids during treatment.
A two-hour-old male neonate was brought to a NICU
after delivered from Hepatitis B surface antigen
positive mother. On physical examination, his weight
is 1500 gm; otherwise no other pertinent finding was
detected. What is the most appropriate vaccination
time of hepatitis B vaccine for this neonate?
• a. After weight reach 2.5kg
b. c. At six weeks of age
Within 12 hour of birth
• d. After one month of age
The correct answer is: c. Within 12 hours of birth.
Explanation:
Neonates born to mothers who are Hepatitis B surface antigen (HBsAg)-positive are at high risk of acquiring perinatal hepatitis B infection, which can lead to chronic liver disease. Immediate postnatal prophylaxis is critical, regardless of the neonate’s birth weight.
Recommended Management:
1. Within 12 hours of birth:
• Administer Hepatitis B vaccine (first dose).
• Administer Hepatitis B immunoglobulin (HBIG) at a different injection site to provide passive immunity.
2. Follow-up doses of the hepatitis B vaccine:
• A total of three doses should be administered as per the routine immunization schedule (e.g., at 0, 1–2 months, and 6 months of age).
3. Testing for hepatitis B status:
• Perform HBsAg and anti-HBs testing at 9–12 months to confirm the success of immunization and absence of infection.
Why Not the Other Options?
• a. After weight reaches 2.5 kg:
• Delaying vaccination until the neonate gains weight increases the risk of hepatitis B transmission.
• b. At six weeks of age:
• Waiting until six weeks significantly delays protection and puts the neonate at risk of early infection.
• d. After one month of age:
• Delaying the first dose beyond 12 hours of life is not recommended as it compromises the effectiveness of preventing perinatal transmission.
Key Points:
• For neonates born to HBsAg-positive mothers, Hepatitis B vaccine and HBIG must be administered within 12 hours of birth, regardless of birth weight or gestational age.
• The timing is crucial to prevent perinatal hepatitis B transmission.
A two-month-old male infant presented with fast
breathing and feeding interruption of two weeks
duration. On examination, his pulse rate is 160/min,
respirations are 60/min, temperature is 37.3 degree
centigrade, oxygen saturation is 95percent, he has
sub-costal and inter-costal retractions and total liver
span is 9cm. What is the most likely diagnosis of
this child?
a. Pneumonia
b. Perinatal tuberculosis
C. Large VSD
d. Severe a n e m i a
The correct answer is: c. Large VSD (Ventricular Septal Defect).
Explanation:
This infant presents with signs of heart failure, likely due to a large ventricular septal defect (VSD):
1. Fast breathing and feeding interruption:
• Symptoms of congestive heart failure in infants.
• Feeding interruption occurs because of fatigue from increased respiratory effort.
2. Respiratory rate of 60/min with sub-costal and intercostal retractions:
• Suggestive of respiratory distress due to pulmonary congestion caused by increased blood flow to the lungs (left-to-right shunting through the VSD).
3. Liver span of 9 cm:
• Hepatomegaly is a common finding in heart failure in children.
4. Pulse rate of 160/min:
• A compensatory tachycardia due to increased cardiac workload.
5. Oxygen saturation of 95%:
• Normal oxygen saturation indicates no significant hypoxemia, which makes cyanotic heart diseases less likely.
Why Not the Other Options?
• a. Pneumonia:
• While respiratory distress is present, pneumonia would typically be associated with fever, crepitations, or decreased air entry on chest examination. These are not mentioned in this case.
• b. Perinatal tuberculosis:
• Tuberculosis in neonates typically presents with systemic symptoms such as fever, weight loss, lymphadenopathy, and possibly hepatosplenomegaly, but respiratory distress alone is not characteristic.
• d. Severe anemia:
• Severe anemia can cause tachycardia and fatigue but does not usually cause hepatomegaly or respiratory distress unless it leads to heart failure, which would still be secondary to another underlying condition.
Key Points:
• Large VSD leads to left-to-right shunting, causing pulmonary overcirculation, respiratory distress, and signs of heart failure in infants.
• Management includes:
• Medical therapy: Diuretics and afterload reduction to manage heart failure.
• Nutritional support: To meet increased metabolic demands.
• Definitive surgical repair: Usually planned when the child is older, but may be expedited if symptoms are severe.
A two-year-old female child presented to a hospital
with a complaint offensive nasal discharge of three
days duration. She also has a history of low-grade
fever, cough and bad breath. Physical examination
revealed bilateral erythematous and swollen nasal
mucosa with purulent discharge. What is the most
likely diagnosis in this child?
O a. Sinusitis
• b. Foreign body
c. Lymphadenitis
• d. Periodontitis
The correct answer is: a. Sinusitis.
Explanation:
This child’s presentation is consistent with acute sinusitis, which is common in young children due to the anatomy and function of their upper respiratory tract.
Key Features:
1. Offensive nasal discharge of three days duration:
• Purulent nasal discharge is a hallmark of sinusitis.
2. Low-grade fever and cough:
• Fever and cough often accompany sinus infections due to inflammation and mucus drainage into the respiratory tract.
3. Bad breath (halitosis):
• Caused by bacterial overgrowth in stagnant mucus.
4. Physical examination findings:
• Bilateral erythematous and swollen nasal mucosa with purulent discharge strongly supports sinusitis.
Why Not the Other Options?
• b. Foreign body:
• Nasal foreign body often presents with unilateral purulent and foul-smelling nasal discharge, not bilateral symptoms.
• c. Lymphadenitis:
• Lymphadenitis typically presents with swollen lymph nodes, localized tenderness, and possibly systemic symptoms. There’s no mention of lymph node involvement here.
• d. Periodontitis:
• Periodontitis involves gum inflammation and oral symptoms (e.g., gingival swelling, bleeding, or pain). It doesn’t cause nasal discharge or swollen nasal mucosa.
Key Points:
• Acute sinusitis is a common complication of viral upper respiratory tract infections in children.
• Diagnosis is based on clinical symptoms, including purulent nasal discharge, nasal congestion, and facial pain or pressure.
• Management includes supportive care, and antibiotics may be indicated if symptoms persist for more than 10 days, worsen after initial improvement, or are severe from the outset.
A two-hour-old male neonate was brought to a NICU
because he had fast breathing. He was delivered at
38 weeks via cesarean delivery with birth weight of
3500 gm and Apgar score of 8 and 10 in the first and
fifth minutes respectively. Examination revealed a
respiratory rate of 65/min in otherwise vigorous
baby. What is the most likely diagnosis for this
baby?
a. Congenital pneumonia
• b. Pulmonary hypoplasia
O c. Transient tachypnea of the newborn
• d. Meconium aspiration syndrome
The correct answer is: c. Transient tachypnea of the newborn (TTN).
Explanation:
This neonate presents with tachypnea (respiratory rate of 65/min), which is common in the immediate postnatal period. However, the baby is otherwise vigorous and well-appearing, which points towards a diagnosis of Transient Tachypnea of the Newborn (TTN).
Key Features:
1. Fast breathing (tachypnea) in a term neonate (38 weeks):
• TTN typically occurs in term or near-term infants, especially those delivered by cesarean section.
2. Birth weight of 3500 gm and Apgar scores of 8 and 10:
• These suggest a well-grown and otherwise healthy baby, ruling out more severe conditions like congenital pneumonia or meconium aspiration syndrome.
3. Normal physical examination and a respiratory rate of 65/min:
• This suggests mild respiratory distress. TTN is characterized by mild respiratory distress in the first few hours of life, which typically resolves within 24–48 hours after birth.
Why Not the Other Options?
• a. Congenital pneumonia:
• This would typically present with more severe symptoms, including fever, poor feeding, and respiratory distress. The baby is vigorous, and the symptoms are not severe enough to suggest pneumonia.
• b. Pulmonary hypoplasia:
• Pulmonary hypoplasia is often associated with severe respiratory distress, abnormal chest findings, and typically occurs in the setting of congenital anomalies (e.g., diaphragmatic hernia or oligohydramnios). This baby’s normal examination and Apgar scores make this less likely.
• d. Meconium aspiration syndrome:
• Meconium aspiration syndrome typically presents with more significant respiratory distress, cyanosis, and grunting shortly after birth. It often presents with abnormal chest findings and requires more intensive respiratory support. This baby does not have those features.
Key Points:
• Transient Tachypnea of the Newborn (TTN) is a common cause of mild, self-limited tachypnea in the first hours of life. It occurs more commonly in cesarean deliveries and resolves within 24–48 hours.
• Management is typically supportive with oxygen and monitoring, and most infants improve without specific treatment.
