PAEDIATRICS 1.

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Table-1 Milestones
Age Gross motor Fine motor Language Personal & social

1 months Turns head to sound - - -

2 months - - - Social smile

3 months Neck holding - Cooing Recognize mother

4 months - Grasp a rattle or ring - -

when placed in hand

5 months Sitting with support, Roll Bidextrous grasp (holds - -

over object with both hands)

6 months Unidextrous Monosyllables Smiles at mirror

(ma; ba) image

7 months - Palmer grasp - Stranger’s anxiety

8 months Sitting without support - - Plays ‘peek a boo’.

9 months Standing with support Pincer grasp seen Bisyllables Plays a simple ball
crawling (picks a pellet with (data, mam) game
thumb & index finger)

10-11 Walking without, cruising - - Waves bye-bye

months

12 Standing alone/without Pincer grasp matures Two words with Plays- a simple ball
months support meaning ‘bye’ game

13 Walking without support - - -

months

18 Running with cup Can feed himself with 10 words with Almost dry by day
months slight spilling, spoon meaning
feeding

24 Walking upstairs & Draw a horizontal or Simple sentence -

months downstairs (2feet/step) vertical line

36 Riding tri-cylce walking Can draw a circle can Telling a story Knows gender
months upstairs alternative steps dress or undress himself (age,sex), full name

4 years Walking upstairs with - - -

alternative feet

Table-2 Development milestone in the first 2 year of life

Development milestone in the first 2 year of life

Milestone Average age of Developmental implications

attainment (MO)

Gross motor

Holds head steady while silting 2 Allows more visual interaction

Pulls to sit, with no head lag 3 Muscle tone

Brings hands together in midline 3 Self-discovery of hands

Asymmetric tonic neck reflex gone 4 Can inspect hands in midline

Sits without support 6 Increasing exploration

Rolls back to stomach 6.5 Truncal flexion, risk of falls

Walks alone 12 Exploration, control of proximity to parents

Runs 16 Supervision more difficult

Fine motor

Grasps rattle 3.5 Object use

Reaches for objects 4 Visuomotor coordination

Palmar grasp gone 4 Voluntary release

Transfers object hand to hand 5.5 Comparison of objects

Thumb finger grasp 8 Able to explore small objects

Turns pages of book 12 Increasing autonomy during book time

Scribbles 13 Visuomotor coordination

Builds tower of 2 cubes 15 Uses objects in combination

Builds tower of 6 cubes 22 Requires visual, gross, and fine motor

coordination
Development milestone in the first 2 year of life

Milestone Average age of Developmental implications

attainment
(MO)

Communication and language

Smiles in response to face, voice 1.5 More active social participant

Monosyllabic babble 6 Experimentation with sound, tactile sense

Inhibits to "no" 7 Response to tone (nonverbal)

Follows one step command with gesture 7 Nonverbal communication

Follows one step command without gesture 10 Verbal receptive language (e.g., "Give it to me")

Says "mama" or "dada" 10 Expressive language

Points to objects 10 Interactive communication

Speaks first real word 12 Beginning of labeling

Speaks 4-6 words 15 Acquisition of object and personal names

Speaks 10-15 words 18 Acquisition of object and personal names

Speaks 2-word sentences (e.g., "Mommy 19 Beginning grammaticization corresponds with

shoe") 50 + words vocabulary

Development milestone in the first 2 year of life

Milestone Average age of Developmental implications

attainment(MO)

Cognitive

Stares momentarily at spot where object 2 Lack of object permanence (out of sight, out
disappeared of mind) [e.g., yam ball dropped]

Stares at own hand 4 Self discovery, cause and effect

Bangs 2 cubes 8 Active comparison of objects

Uncovers toy (after seeing it hidden) 8 Object permanence

Egocentric symbolic play (e.g., pretends to 12 Beginning symbolic thought

drink from cup)

Uses stick to reach toy 17 Able to link actions to solve problems

Pretend play with doll (e.g., gives doll bottle) 17 Symbolic thought
Table-3 Emerging patterns of behavior during the 1st year of life
Emerging patterns of behavior during the 1st year of life
Neonatal period (1st 4 week)

Prone Lies in flexed attitude; turns head from side to side; head sags on ventral suspension

Supine Generally flexed and a little stiff

Visual May fixate face on light in line of vision; "doll's-eye" movement of eyes on turning of the body.

Reflex Moro response active: stepping and placing reflexes; grasp reflex active

Social Visual preference for human face.

At 1 Months

Prone Legs more extended, holds chin up; turns head: head lifted momentarily to plane of body on
ventral suspension.

Supine Tonic neck posture predominates; supple and relaxed; head lags when pulled to sitting position.

Visual Watches person; follows moving object

Social Body movements in cadence with voice of other in social contact; beginning to smile.

Emerging patterns of behavior during the 1st year of life

At 2 Months

Prone Raises head slightly farther: head sustained in plane of body on ventral suspension.

Supine Tonic neck posture predominates; head lags when pulled to sitting position

Visual Follows moving object 180 degrees

Social Smiles on social contact; lestens to voice and coos

At 3 Months

Prone Lifts head and chest with arms extended; head above plane of body on ventral suspension

Supine Tonic neck posture predominates; reaches toward and misses objects; waves at toy

Sitting Head lag partially compensated when pulled to sitting position; early head control with
bobbing motion; back rounded

Reflex Typical Moro response has not persisted; makes defensive movements or selective withdrawal
reactions

Social Sustained social contact; listens to music; says "aah, ngah"

At 4 Months

Prone Lifts head and chest, with head in approximately vertical axis, legs extended

Supine Symmetric posture predominates, hands in midline; reaches and grasps objects and brings
them to mouth

Sitting No head lag when pulled to sitting position; head steady, tipped forward; enjoys sitting with
 full truncal support

Standing When held erect, pushes with feet

Adaptive Sees pellet, but makes no move to reach for it

Social Laughs out loud; may show displeasure if social contact is broken; excited at sight of food

At 7 Months

Prone Rolls over; pivots; crawls or creep-crawls (Knobloch)

Supine Lifts hand; roll's over; squirms

Sitting Sits briefly, with support of pelvis; leans forward on hands; back rounded

Standing May support most of weight; bounces actively

Adaptive Reaches out for and grasps large object; transfers objects from hand lo hand; grasp uses radial
palm; rakes at pellet

Language Forms polysyllabic vowel sounds.

Social Prefers mother; babbles; enjoys mirror; responds to changes in emotional content of social
contact

At 10 Months

Sitting Sits up alone and indefinitely without support, with back straight

Standing Pulls to standing position; "cruises” or walks holding on to furniture

Motor Creeps or crawls

Adaptive Grasps objects with thumb and forefinger; pokes at things with forefinger; picks up pellet with
assisted pincer movement; uncovers hidden toy; attempts to retrieve dropped object; releases
object grasped by other person

Language Repetitive consonant sounds ("mamma", "dada")

Social Responds to sound of name; plays peek-a-boo or pat-a cake; waves bye-bye

Emerging patterns of behavior during the 1st year of life

At 1 Year
Motor Walks with one hand held (48 wk); rises independently, takes several steps (Knobloch)

Adaptive Picks up pellet with unassisted pincer movement of forefinger and thumb; releases object to
other person on request or gesture

Language Says a few words besides "mama", "dada"

Social Plays simple ball game; makes postural adjustment to dressing

Table-4 Emerging patterns of behavior from 1 to 5 year of age

Emerging patterns of behavior from 1 to 5 year of age

15 Months

Motor Walks alone; crawls up stairs

Adaptive Makes tower of 3 cubes; makes a line with crayon; inserts raisin in bottle

Language Jargon; follows simple commands; may name a familiar object (e.g., ball)

Social Indicates some desires or needs by pointing; hugs parcents

18 Months

Motor Runs stiffly; sits on small chair, walks up stairs with one hand held; explores drawers and
wastebasket

Adaptive Makes tower of 4 cubes; imitates scribbling; imitates vertical stroke; dumps raisin from bottle

Language 10 words (average); names pictures; identifies one or more parts of body

Social Feeds self; seeks help when in trouble; may complain when wet or soiled; kisses parent
with pucker

24 Months

Motor Runs well, walks up and down stairs, one step at a lime; opens doors; climbs on furniture; jumps

Adaptive Makes tower of 7 cubes (6 at 21 mo); scribbles in circular pattern; imitates horizontal stroke;
folds paper once imitatively

Language Puts 3 words together (subject, verb, object)

Social: Handles spoon well; often tells about immediate experiences; helps to undress; listens to
stories when shown pictures
Emerging patterns of behavior from 1 to 5 year of age

30 Months

Motor Goes up stairs alternating feet

Adaptive Makes tower of 9 cubes; makes vertical and horizontal strokes, but generally will not join them
to make cross; imitates circular stroke, forming closed figure

Language Refers to self by pronoun "I"; knows full name

Social Helps put things away; pretends in play

36 Months

Motor Rides tricycle; stands momentarily on one foot

Adaptive Makes tower of 10 cubes; imitates construction of "badge" of 3 cubes; copies circle; imitates
cross

Language Knows age and sex; counts 3 objects correctly; repeats 3 numbers or a sentence of 6 syllables

Social Plays simple games (m parallel" with other children); helps in dressing (unbuttons clothing
and puts on shoes); washes hands

48 Months

Motor Hops on one foot; throws ball overhand; uses scissors to cut out pictures; climbs well

Adaptive Copies bridge from model; imitates construction of "gate" of 5 cubes; copies cross and square;
draws man with 2 to 4 parts besides head, identifies longer of 2 lines

Language Counts 4 pennies accurately; tell story

Social Plays with several children, with beginning of social interaction and role-playing; goes to toilet
alone

60 Months

Motor Skips

Adaptive Draws triangle from copy; names heavier of 2 weights

Language Names 4 colors; repeats sentence of 10 syllables; counts 10 pennies correctly

Social Dresses and undresses; asks questions about meaning of words; engages in domestic role-
playing
Features Marasmus Kwashiorkor

Etiology Decreased intake of both proteins and calories and Decreased protein intake
other nutrients

Age Common below 1 year(0- 3 years) 1-4 years

Incidence More common Less common

History

Appetite Good Anorexia

Complementary Early Late

feeding (weaning)
Table-5 Difference between Marasmus and Kwashiorkor

Features Marasmus Kwashiorkor

Clinical examination

Appearance Old man appearance Moon face

Sensorium/activity Alert, playful, active/apathetic Apathy, dull, irritable

Weight Less than 60% 60%-80%

Oedema Absent Present

Mentation Alert Apathy, irritable

Mood Normal Irritable

Hair changes Absent/mild Present(flag sign)

Skin changes Absent Present(dermatosis, ulcers)

Muscle wasting More (seen all over the body) Less(seen only in the upper limbs as oedema
masks wasting in the lower parts)

Organomegaly Not present Hepatomegaly (fatty liver)

Anaemia Moderate More severe

Subcutaneous fat Grossly reduced Less reduced

 Hormones

Growth hormone Normal / Increased Increased

Cortisol Increased Increased

Insulin Normal Decreased

Glucagon Normal / Variable Normal / Variable

Thyroxine Normal / Variable Normal / Variable

Investigations

Serum proteins/albumin Reduced Markedly reduced

Serum enzymes Normal Decreased

Vitamin A absorption Normal Markedly reduced

Duodenal enzymes Normal concentration Reduced

Serum enzymes amylase Normal Reduced

Urinary excretion (17- Increased Low

hydroxysteroids)

Liver biopsy No vacuolation Fatty vacuolation

Complications Less common and moderate More common and severe

Response to treatment Good Variable

Mortality More Less

Table- 6 Classification of Acyanotic and Cyanotic heart diseases
Acyano
tic Defects
↓

↑P Normal
BF PBF
↓ ↓

↓ ↓ ↓ ↓
V ASD AS or AR
S
D
PDA (often RBBB) COA PS
ECD PAPVR Primary COA (in
myocardia infants)
l d/s (EFE)
(endo PVOD MR MS
cardial (secondary
cushion to L-R shunt
defect) lesions)

Cyanotic
Defects
↓
 ↑PB ↓PBF
F ↓
↓
↓
LVH or CVH RVH CVH LVH RVH
↓ ↓ ↓ ↓ ↓
Persistent TGA TGA+ Tricuspid TOF
PS
truncuts TAPVR Presiste atresis PVOD(seconda
nt ry
arterious HLHS truncus Pulmonary to L-R shunt
us Single arteriosus atresisa with lesions)
ventricle with hypoplastic Ebsteins’s
TGA+ hypoplastic RV anomaly
VSD PA Single (RBBB)
ventricle
with PS

Table-7 Difference b/w caput succedaneum and cephal hematoma

Difference b/w caput succedaneum and cephal hematoma
Characteristic Caput succedaneum Cephal hematoma
Incidence Common Less common
Location Subcutaneous plane Bony pnominence b/w skull and periosteum
Time of presentation Maximum size birth ↑ Sing size for 12-24 hrs and then stable
C/F Soften gradually and disapper Takes 3-6 weeks to resolve. Does not cross
within 2-3 days. Diffuse crosses suture line and has distinct margin
suture line
Association None (scalp edema) Fracture in 5 to 25% of cause. Prolonged
jaundice due to hemolysis, (hemorrhage)
Table-9 Clinical manifestations of congenital rubella syndrome (CRS) in 376
Children following maternal rubella

Deafness 67%

Ocular 71%

Cataracts 29%

Retinopathy 39%

Heart disease 48%

Patent ductus arteriosus 78%

Right pulmonary artery stenosis 70%

Left pulmonary artery stenosis 56%

Valvular pulmonic stenosis 40%

Low birthweight 60%

Psychomotor retardation 45%

Neonatal purpura 23%

Death 35%
Table-8 Pathologic findings of congenital rubella syndrome
System Pathologic findings

Cardiovascular Patent ductus arteriosus, Pulmonary artery stenosis, Ventriculoseptal defect,

Myocarditis

Central nervous system Chronic meningitis, Parenchymal necrosis, Vasculitis with calcification

Eye Microphthalmia, Cataract, Iridocyclitis, Ciliary body necrosis, Glaucoma,

Retinopathy

Far Cochlear hemorrhage, Endothelial necrosis

Lung Chronic mononuclear interstitial pneumonitis

Liver Hepatic giant cell transformation, Fibrosis, Lobular disarray, Bile stasis

Kidneys Interstitial nephritis

Andrenal glands Cortical cytomegaly

Bone Malformed osteoid, Poor mineralization of osteoid, Thinning cartilage

Spleen, lymph nodes Extramedullary hematopoiesis

Thymus Histiocytic reaction, Absence of germinal centers

Skin Erythropoiesis in dennis

 In ear causes cochlear damage & endothelial necrosis -So it cause Sensory Neural Hearing loss.
 Other finding in CRS
Table-10 Differential diagnosis of Short Stature
Features Constitutional Familial Hypopituitaris Hypothyroidism Turner syndrome
delay short m
stature

Family History Positive Positive Negative Negative Negative

Birth weight & Normal Low Normal Normal Low

height

Pattern of growth Slow from Slow from Slow from Slow from birth Slow from birth
infancy birth a few months
after birth

Epiphyseal Moderate Normal Progressive Severe Variable

 development progressive retardation retardation
retardation

Puberty Delayed Normal Delayed Delayed Delayed

GH levels Normal Normal Low Normal Variable

Gonadotropins Normal Normal Low, except in High

isolated GHD
Table-11 APGAR score
 Apgar scores are assigned at 1 and 5 minutes after birth
 If the score is <7 it is assigned every 5 min until 20 min or till two successive scores of ≥7
 Scores may be falsely low in preterm, maternal drug intake, congenital heart disease and CNS
malformations
Sign 0 1 2

Heart rate Absent <100/min >100/min

Respiration Absent Weak cry, hypoventilation Good strong cry

Muscle tone Limp Some flexion Active motion

Reflex irritability No response Grimace Cough or sneeze

Color Blue or pale Body, pink, extremities blue Completely pink

Table-12 Timing of Pediatric Surgery
Condition Time of surgery

Biliary atresia 4-6 weeks

Cleft lip 2-3 months (in the neonatal

period for good cosmetic results)

Cleft palate 10-12 months

Epispadias 1 year
Chordee correction 6 months- 1 year after chordee
Urethroplasty correction

Hypospadiasis Any time after birth

Meatotomy 6 months
Chrodee correction 18-24 months
Urethroplasty

Phimosis 1 year
Prepucial separation After 2-3 years
Circumcision

Exstropy of bladder Within 48 hrs

Bladder closure After 2 years
Bladder neck repair After achieving continence
Urethroplasty

Hirchsprung’s disease 12-15 months

 Undescended testis

Tongue tie 1 year

Table-13 Features in a new born that require no treatment

Milia White dots on face and nose

Erythema toxicum Trunk and face, appear on 2-3 days

Mongolian spots Bluish spots on buttocks and trunk, disappear before 1st birthday

Stork bites Capillary hemangiomas on neck, eyelid, forehead

Breast engorgement Due to transplacentally acquired hormones; seen on 3-4 days

Epstein pearls Epithelial mucinous cyst on palate and prepuce

Predeciduous teeth Shed before primary nutrition

Vaginal bleeding 3-7 days; due to withdrawal of maternal hormones

 Hymenal tags, physiological phimosis, Harlequin color change, pustular melanosis are also seen in
newborn which require no treatment
Table-14 Primitive Reflexes
Reflex Appearance Disappearance

Reflexes present at birth

Crossed extensor 28 weeks 1-2 months

Palmar grasp 28 weeks 2-3 months

Moro 28-32 wells 3 months

Rooting 32 weeks Less prominent after 1 month

Asymmetric tonic neck 35 weeks 6 months
Reflexes that appear after birth
Symmetric tonic neck 4-6 months 8-12 months
Parachute 8-9 months Remains throughout life
Landau 10 months 24 months

Table-18 Types of breastfeeding

Types Intake

Exclusive breastfeeding Only breast milk ; nothing else , not even water

Predominant breastfeeding Apart from breastfeeds ,small amount of other foods or fluids like water

Partial breastfeeding Small breastfeeds and some artificial feeds

 Token breastfeeding Mostly other feeds, occasionally breastfeeds

Table-15 Extracardiac anomalies and associated cardiac lesions

Pediatric anomalies Cardiac lesions

Bony abnormalities, absence of radius/ulna syndactyly, VSD

polydactyly, Trisomy 13-15

Trisomy 21 ASD of endocardial cushion type, VSD

Pierre Robin syndrome, Ehler Danlos syndrome ASD

Thrombocytopenia absent radius(TAR) syndrome

Turner syndrome PS,AS, CDA

Ellis-Van Creveld syndrome ASD, single atrium

Rubella syndrome PDA, PS

Moon facies and hypertension PS

Holt Oram syndrome, Lutembacher syndrome ASD+MS

Marfan syndrome MVP, aortic and pulmonary artery dilation

Hurler syndrome MR or AR

Trisomy 17-18 VSD, PDA

William's syndrome Supravalvar AS, Peripheral PS

Noonan syndrome and Alagille syndrome Peripheral pulmonic stenosis

Table-17 Optional vaccines given after discussion with parents
Optional vaccines Schedule

Varicella vaccine 15 months

Hepatitis A vaccine High risk selected infants , 18 months & 6 months later

Pneumococcal conjugate vaccine 6 weeks

Influenza vaccine 6 months of age to high risk selected infants annually

Japanese encephalitis vaccine 16 – 24 months ( endemic districts )

Table-16 Immunization Schedule
Age National Immunization Schedule Indian Academy of Pediatrics recommendation

At birth BCG , OPV0 , Hep B1 BCG , OPV0 , Hep B1

6 weeks DPT1 , OPV1 , Hep B2 , Hib1 DPT1 , IPV1 , Hep B2 , Hib1 , Rotavirus1 , PCV1

10 weeks DPT2 , OPV2 , Hib2 DPT2 , IPV2 , Hib2 , Rotavirus2 , PCV2

14 weeks DPT3 , OPV3 , Hep B3 , Hib3 DPT3 , IPV3 , Hib3 , Rotavirus3 , PCV3

6 months - OPV1 , Hep B3

9 months Measles , Vitamin A1 ( 1 Lac IU ) OPV2 , Measles

12 months - Hep A1

15 months MMR MMR1 , Varicella1 , PCV B1

16-24 months DPT B1 , OPV B1 , Vitamin A2 DPT B1 , IPV B1 , Hib B1 , Hep A2

2 years - Typhoid1
5-6 years DPT B2 DPT B2 , OPV3 , MMR2 , Varicella2 , Typhoid2
10 years TT1 TdaP / Td , HPV
16 years TT2 -
Pregnant TT1 and TT2 ( one month apart ) -
women TTBooster if TT2 doses received in
last 3 years
Vitamin A (2 Lac IU every 6 months till age of 5 years)

Table-19 Varying composition of breast milk

Type Time Appearance Composition Function
Colostrum First 3-4 Yellowish More antibodies and WBC Protection against
days after and thick Anti-infective agents (lactoferin, infection Has a mild
birth lysozyme, lactoperoxidase, laxative effect helps
complements , proline rich to pass early stools
polypeptides)
Rich in Vitamins A,D,E & K, Less fats
More proteins and IG (Ig A, Ig M, Ig G)
Rich in growth factors– EGF, FGF
Transitional 4 days to Thinner , More fat, sugar, calories & vitamins Less Supplies adequate
milk 10 -14 days lighter in IG & proteins calories needed by
color the baby
Mature milk 2 weeks Thinner More fat, protein, water, lactose, Supplies all the
after the energy(71 cal/100 mL ) nutrients needed for
baby is normal growth
delivered
Preterm milk When a More calories, fat, proteins, sodium, IG, Supplies more
preterm lactoferrin, Zn, macrophages, Less energy which is
baby is lactose, calcium, phosphorus needed for rapid
delivered growth

Foremilk At the start Watery Rich in proteins, sugar, vitamins, Satisfies baby’s thirst
of feed minerals and water
Hind milk At the end Thick Richer in fat content Provides energy ,
of feed satisfies baby’s
hunger and
nutritional demands
Table-20 Guidelines for positioning and attachment of the baby during breastfeeding
Proper positioning Proper attachment

 The infant’s head, neck and body should  The chin should touch the breast
be held in a straight line  The mouth of the baby should be wide open
 The whole of the baby’s body should be  The baby’s lower lip should be turned out
supported, not just the head and neck  Most areola and nipple should be in baby’s
 The baby’s face should be directly in front mouth. More areola should be visible above
of mother’s breast ( en face ) than below the baby’s mouth.
 The baby’s body should be close to the
mother’s body

Table-21 Criteria for response to Treatment of Nephrotic Syndrome

Response to treatment Criteria

Remission Urinary protein excretion <4mg/m2/hour ; nil or trace by dipstick on spot sample
for 3 consecutive days, Serum albumin more than 3.5 g/dL, No edema
 Relapse Urine albumin ≥3+ by dipstick for 3 consecutive days
Proteinuria > 40 mg/m2/hour for 3 consecutive days specimens

Frequent relapse 2 or more episodes in 6 months of initial response 4 or more episodes in any 12-
month period

Infrequent relapse Less than 3 episodes in 12 months, Less than 2 episodes in 6 months
Steroid sensitive Disappearance of proteinuria and all clinical and biochemical features within 8
weeks of starting a standard course of steroid therapy
Steroid resistance Failure to achieve remission after 4 weeks of daily therapy with oral prednisolone
at a dose of 2 mg/kg/day, Persistent proteinuria after completion of treatment
Steroid-dependent Occurrence of 2 consecutive relapses during steroid therapy or within 2 weeks of
cases its cessation, Relapse after stopping the drugs
Table-22 Criteria for Treatment Failure
Primary failure

No appetite regain Fourth day

Failure to start to lose edema Fourth day

Presence of edema Tenth day

Failure to gain weight at least 5g/day Tenth day

Secondary failure

Failure to gain weight of 5g/kg/day for 3 consecutive days During rehabilitation phase

GOBIFFF SHAPOBI NIMFES

Growth monitoring Status for women Nutrition and growth monitoring

Oral rehydration Health education Immunization
Breastfeeding Antenatal care Medical check-up and medical care during
Immunization Primary healthcare and perinatal care illness
Feeding (supplementary) Oral rehydration therapy Breastfeeding Family planning
Female child care Immunization Education-health education regarding
Family welfare
LOL LOL LOL LOL