Live vaccines

Live attenuated vaccines

Mnemonics - BOYs Love The CRIME

B= BCG
O=OPV
Y=YELLOW FEVERLove= LIVE ATTENUATED
The= TYPHOID
C=CHICKEN POX
R=RUBELLA
I=INFLUENZA
M=MUMPS,MEASLES
E=EPIDEMIC TYPHUS

Paediatrics seizures

-- Drug of choice for absence seizures is Ethosuximide. No relation with age. And it is NOW AVAILABLE in India and has been marketed for clinical use.
-- Drug of choice for Infantile spasm/West syndrome is ACTH. And it is also easily available in India since past many years.
Vigabatrin is used as DOC only in Tuberous sclerosis associated infantile spasm.
-- Drug of choice for ADHD is Methylphenidate. Atomoxetine is used only in refractory cases or some assc disorders like CVS problems in ADHD. Methylphenidate is also available in India.
-- All natural Surfactant prep are available in India. Synthetic surfactant are not available in India. Natural are superior to synthetic preparations.
-- Pyridoxine is drug of choice for empirical therapy in refractory neonatal seizures. Its not biotin, as mentioned in some of the guides in the market.
-- TOF does not cause cyanosis at birth. Only TOF with pulm atresia does ( which is different from TOF).
-- I.V. Ceftriaxone is Drug of choice in meningitis caused by H.influenzae, even if the bacteria is beta lactamase producing.
-- Carbamazepine & Oxcarbazepine are first line drugs for partial epilepsy in children. Lamotrigine is not first line drug, as in adults.

ORS

Oral rehydration solution (ORS)

-Oral rehydration solution (ORS) should preferably be given with a teaspoon or consumed in small ships from a cup or tumbler .
-A child with profuse vomiting is more likely to retain the fluid if it is consumed in small sips.
-Large gulps of fluids stimulate gastrocolic reflex resulting in a quick passage of stool and Vomiting.
-"The discovery that sodium transport and glucose transport are coupled in the small intestine so that glucose accelerates absorption of solute and water (is) potentially the most important medical advance this century."

-ORT is the giving of fluid by mouth to prevent and/or correct the dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home remedies to prevent dehydration must be started. If adults or children have not been given extra drinks, or if in spite of this dehydration does occur, they must be treated with a special drink made with oral rehydration salts (ORS).

INDIA NEWBORN ACTION PLAN

🔹 Peri conceptional folic acid
🔹Administer corticosteroids in preterm labour and Antibiotics for PROM
🔹Delayed cord clamping and vit K at birth
🔹 care of healthy newborn by ASHA for 6 wks (42 days)
🔹 care of small/sick Newborn (like inj. Gentamicin to prevent sepsis to be given by ANM)
🔹 care beyond Newborn survival

- Screen for 4 Ds  i.e. Defects or birth defects, development delays, deficiency, diseases
- Follow up of SNCU babies by ASHA for 1 year and LBW babies for 2 year

Kindly correct previous one - LBW for 2 years

Myelination mile stones

Myelination mile stones :

Before term birth - brain stem
Term birth - brain stem, cerebellum, post limb of int capsule
2 months : ant limb of int capsule
3 months : splenium of corpus callosum
6 months : genu of corpus callpsum
Cortico spinal tract : starts at 2 months of age & get completed at 2 years

Paediatric updates

Pediatrics Important one-liners & latest points from Nelson 20th ed for quick revision.

- Absence seizures to be treated with ethosuximide, as effective and less toxic than Valproate. Ethosuximide is more effective than lamotrigine. Lamotrigine & Valproate are more effective in atypical absence seizures/absence seizures associated with GTCS.
- In a preterm neonate at risk for RDS, CPAP started at birth is as effective as surfactant therapy & is the approach of choice for initial management in delivery room. In other words, first step in management of suspected RDS is CPAP. (No difference for mild, moderate or severe HMD).
- Indications to start mechanical ventilation in neonates & infants:
1. Arterial blood pH <7.20
2. Arterial blood pCO2 of 60 mm Hg or higher
3. Oxygen saturation (SpO2) <90% even at inhaled oxygen concentration of 40-70% & CPAP of 5-10 cm H2O.
4. Persistent apnea
Points 1, 2 and 3 are measures of respiratory failure in infants and children.
- A major breakthrough in Cystic Fibrosis therapy is IVACAFTOR, a small molecule potentiator of the CFTR mutation, G551D. Available as oral therapy in CF patients with G551D mutation (seen in 5 % patients). Improves FEV1 by 10%, decreases pulmonary exacerbations by 55% and also decreases sweat chloride levels. Given only at or above 6 yrs of age.
- Most common complication of pancreatic enzyme replacement therapy is colonic strictures.
- Hypoglycemia in neonates: Random whole blood glucose less than 45 mg/dl. (AIIMS-WHO definition). Any value below 55 should be viewed with suspicion. Hypoglycemia in infants and children is random whole blood glucose below 55 mg/dl. (Nelson 20th ed )
- MC symptom of hypoglycaemia in neonates is jitteriness & tremors.
- MC form of childhood hypoglycaemia is Ketotic hypoglycaemia, seen due to inadequate feeding. More common in malnourished with intercurrent illness.
- A new potential treatment, but still under investigation in Duchenne’s muscular dystrophy is use of antisense oligonucleotide drugs. Two drugs effective: Drisapersen & Eteplirsen. Both are exon-51 skipping antisense oligonucleotides, that can produce a shorter but potentially functional dystrophin protein.
- Microorganisms causing Infective endocarditis in children: Viridans streptococci, followed by Staph aureus are most common. Staph more common in no underlying heart disease, whereas viridans more common in children with underlying heart disease who undergo invasive dental procedures. Pseudomonas and Serratia more common with IV drug abuse & Coagulase negative Staph more common in those with indwelling central venous catheter. Fungal IE seen after open heart surgeries.
- Children with RHD: Mitral insufficiency is more common than Mitral stenosis (rarely seen before adolescence).
- Corrective surgery in TOF is done as soon as possible in TOF presenting early or having frequent cyanotic spells. For well tolerated TOF, age of corrective surgery is between 4 to 6 months of age. Palliative surgeries less common now.
- Right sided aortic arch seen MC in TOF, followed by Truncus arteriosus.
- MC cause of sudden cardiac death in children is valvular AS
- MC cause of sudden cardiac death in adolescents is HOCM
- Duration of antibiotic therapy in post neonatal & childhood meningitis has been decreased to 10-14 days maximum. For meningococcal meningitis its as short as 5-7 days and for H. influenzae its 7-10 days. 
- Streptococcus milleri is now MC organism causing brain abscess in children (more than Staph aureus). 
- HSP is MC vasculitis in childhood (Yes! Nelson finally says it clearly!)
- MCC of hematuria/gross hematuria in children is UTI (Overall)
- MC glomerular cause of hematuria in children is Post streptococcal GN
- Microscopic hematuria is rare in UTI. Recurrent hematuria raises suspicion of IgA nephropathy.
- The primary immunodeficiency disease with excellent prognosis even without specific therapy is Myeloperoxidase (MPO) deficienc

Newborn Electrolytes

Hypoglycemia in new born:-
Operational threshold fr hypoglycemia-<40mg/dl

WHO definatn of hypoglycemia-<45mg/dl

Hyperglycemia in newborn->125mg/dl

Mx of asymptomatic hypoglycemia-Trial of oral feed-5g glucose/100ml

Symptomatic hypoglycemia(<20mg/dl)
IV 10% dextrose
2ml/kg bolus then 6mg/kg/min infusion
Never use glucose>12.5% to peripheral veins

Hypocalcemia:-
Total sr ca <7mg/dl
Ionised ca <4mg/dl
Rx-IV calcium glucobate 10%
Precaution-causes bradycardia n arrythmias
Therefore slowly given
Diluted with 5%dextrose 1:1

Congenital TB

CONGENITAL TUBERCULOSIS 

Infection  with tubercle  bacilli  either during intrauterine  life  or before  complete  passage through birth canal  is termed  as  congenital  tuberculosis.   Three  possible  modes  of infection of fetus:-

1)  Hematogenous  infection  via  umbilical vein
2)  fetal  aspiration of infected  amniotic  fluid  

3)  fetal  ingestion of infected amniotic  fluid

 Most common primary site  -----  LIVER  (  primary complex in liver is suggestive   of  congenital  TB) 

Most common   site  ---  LUNG ( prognosis  is poor )

Revised  criteria for diagnosis  of congenital  tuberculosis ( by Cantwell  ) :-

 Proven tuberculosis lesions  in the  infant  plus  one  of the  following:

i.  Lesions  occurring in the  first  week of life,

ii. A  primary hepatic  complex

iii.  Maternal genital tract or  placental tuberculosis,  and

iv.  Exclusion of postnatal  transmission by thorough  investigation of contacts.

Prognostic factors in neuroblastoma:

Prognostic factors in neuroblastoma:

Age – Less than 1 year have good prognosis
Stage – I and II have good prognosis
Ploidy – Triploid and hyperploid tumours have good prognosis
Cytogenetics – Chromosome 1 / Chromosome 14 deletions have worse prognosis
n-myc oncogene amplification – associated with bad prognosis
Trk A expression – high levels are associated with favourable outcome

Neonatal Tetanus

Tetanus Neonatorum : Generalized paucity of movement associated with stiffness and rigidity or spasms (Opisthotonos).Trismus (lockjaw) is the reason of feeding difficulty. Baby is on Oxygen due to affection of respiratory muscles.
2. Management:
1. Ensure patent airway
2. Respiratory support as required
3.Ensure nutrition and hydration
4. Human tetanus immunoglobulin (TIG) as soon as possible to neutralize the toxin
A single IM of 500 U of TIG is sufficient to neutralize systemic tetanus toxin, but total doses as high as 3,000–6,000 U are also recommended. Tetanus toxin cannot be neutralized by TIG after it has begun its axonal ascent to the spinal cord.
5. Diazepam for both muscle relaxation and seizure control. Other muscle relaxants can be used like Baclofen as well.
6. Penicillin G to eradicate Clostridium tetani. 100,000 U/kg/day divided every 4–6 hr IV for 10–14 days
7. Excision of the umbilical stump is no longer recommended but, good cleaning

Maturity Staging

👫PUBERTAL DEVELOPMENT👫

📌 DEVELOPMENT OF 2° SEXUAL CHARACTERS:
👩 In Females:
✔ T (Thelarche) ➡ P (Pubarche) ➡ M (Menarche)
▶ Thelarche - Breast enlargement
▶ Pubarche - Development of pubic hair
▶ Menarche - Onset of menstrual cycles
👨 In Males:
✔ T (Thelarche) ➡ P (Pubarche) ➡ A (Adrenarche)
▶ Thelarche - Testicular enlargement
▶ Pubarche - Penile enlargement
▶ Adrenarche - Features of maleness

📌 TANNER STAGING OF THELARCHE IN FEMALES:
🔰 Stage 1 - prepubertal elevation of papilla only
🔰 Stage 2 - elavation of breast tissue & papilla as a small mound, enlagement of areola
🔰 Stage 3 - further enlargement of breast & areola
🔰 Stage 4 - projection of areola & papilla to form a secondary mound
🔰 Stage 5 - secondary mound disappears, adult breast with typical contours develops

📌 STAGING OF PUBARCHE IN FEMALES:
🔰 Stage 1 - no sexually stimulated pubic hair present, some non-sexual hair maybe seen in the genital area
🔰 Stage 2 - appearance of coarse, long, crinkly hair along labia majora
🔰 Stage 3 - coarse, curly hair extending onto mons pubis
🔰 Stage 4 - adult hair in thickness & texture, extending laterally onto mons pubis giving the vulva an inverted triangular appearance
🔰 Stage 5 - hair may extend further laterally onto inner aspects of thighs & perineum
👉 Axillary hair appears a little later in sequence.
👉 Secondary hair growth is under control of adrenal cortex.

📌 SEXUAL MATURITY RATING (SMR):
👩 In females:
💃 Stage 1 -
● prepubertal,
● no terminal hair
💃 Stage 2 -
● appearance of breast bud;
● sparse straight hair along the labia majora
💃 Stage 3 -
● generalised breast enlargement (extending beyond the areola);
● pigmented, coarse pubic hair, begins to curl
💃 Stage 4 -
● nipple & areola form a second mound over breast;
● hair increases in amount & spread over entire mons
💃 Stage 5 -
● mature adult type breast, nipple projects & areola recedes;
● adult type pubic hair in triangle shaped area, spreading over to medial thighs
👨 In males:
🏃 Stage 1 -
● testicular size <2.5cm, vol. <3ml;
● prepubertal
🏃 Stage 2 -
● testicular size 2.5-3.2cm, vol. reaching 4ml, reddening of scrotum;
● scanty hair at penile base
🏃 Stage 3 -
● testicular size 3.3-4.0cm, further increase in vol. to 10ml
● increase in length of penile shaft
● hair begins to curl & darken
🏃 Stage 4 -
● testicular size 4.1-4.5cm, vol. 16ml
● increase in girth of penis & glans, darkening of scrotum
● coarse, abundant & curly hair, less than in adult
🏃 Stage 5 -
● testicular size >4.5cm, vol. 25ml
● adult size scrotum & penis
● adult type hair, spreading over to medial thighs

📚 References:
📖 Shaw's TB of Gynaecology, 15th Edition
📖 Ghai Essential Pediatrics, 8th Edition

Lung Tumors ( Paediatric Age Group):

1) most common tumor of the pediatric lung ---metastases

( most commonly from
a) osteosarcoma
b) wilms tumour

2) most common benign tumor of the pediatric lung (both infants and children) is----- inflammatory myofibroblastic tumor

3)most common benign lung tumor in infants
-----pleuropulmonary blastoma

4) most common primary malignant tumor of the pediatric lung is----bronchial carcinoid

High yield fevers

FIRST DISEASE : ---> Measles.

SECOND DISEASE : ---> Scarlet Fever.

THIRD DISEASE :---> Rubella or German Measles.

FOURTH DISEASE :---> Duke's Disease

FIFTH DISEASE :---> Erythema Infectiosum caused by Parvovirus B19

SIXTH DISEASE :---> Exanthem Subitum / Roseola Infantum (HHV-6)(HHV-7 also mentioned)

Congenial heart diseases

✅Most common symptomatic cyanotic heart disease at birth: TGV

✅Most common cyanotic heart disease: TOF
✅Most common congenital Heart defect: VSD

✅Most common valvular anomaly: BAV
✅Most common anomaly associated with COA: BAV >> PDA

✅Most common cardiac anomaly associated with turner syndrome: BAV > COA(More specific)

✅Most common cardiac defect associated with Noonan syndrome: Pulmonary stenosis

✅Most common cardiac defect associated with Down's syndrome: AVSD > VSD > ASD

✅Most consistent feature of TOF : Infundibular stenosis > Pulmonary stenosis

✅Most common valvular abnormality associated with ankylosing spondylitis:  incompetent aortic valve

✅Most common valve involved in Rheumatic heart disease: Mitral valve

✅Most common valve abnormality in acute rheumatic fever: Mitral incompetence/ Regurgitation

✅Over all most common heart valve abnormality in rheumatic heary disease: MR

✅Most common valve abnormality in chronic rheumatic heart disease: Mitral stenosis

✅Most common valve affected with carcinoid syndrome: Tricuspic Valve

CHARGE Association

CHARGE Association

Nonrandom association of
C = Coloboma (from isolated iris to anophthalmos; retinal most common)
H = Heart defects (TOF, PDA, and others)
A = Atresia choanae
R = Retardation of growth and/or development
G = Genital hypoplasia (in males)
E = Ear anomalies and/or deafness

VACTERL

VACTERL Association

Nonrandom association of
V = Vertebral defects
A = Anal atresia (imperforate anus)
C = Cardiac defects (VSD and others)
T = TE fistula
E = Esophageal atresia
R = Renal defects
L = Limb defects (radial)

Milestones

Developmental milestone can be hard, especially if u dnt have kids 

Gross Motor
2 lifts head
4 front to back 5 back to front ( just think back to front is more muscle)
6 imagine the "6" as baby sitting
9 number "9" doesnt have good base so crawls
11 "11" has 2 good base so baby is able to stand/cruise/walk
12 now good base plus 2 legs can walk for sure (alone)
15 "5" is mirror image of "2" so baby can walk backwards
2yr u need to use both legs to go up/down stairs
3 "TRI-cycle"
4 HOPS 4 letters

Fine Motor
"9ince12" = PINCER Before pincer comes raking which is more immature
9 mo = non specific ( 3 finger) also nonspecific mom and dad
12 mo = specific (2 fingers) also specific mom and dad 
15 mo = 2block
18 = 3blocks
2yr = 6 blocks 
Also playstation controler 0 --> X --> Square --> triangle 3 4 5 6 yrs

Language/social
2 coos and smiles because recognizes parents.
4 coos and laughs
6 babbles and anxiety, because recognizes strangers
1 yr alone so plays ALONE/ follow ONE step command, One word besides mom dad
2 yrs now 2 so PARALELL play, follows TWO step command, 2 word PHRASES
3 4 5 6 number of sentences with years
Bowel control at 4 Pee control at 5 

Birthweight x 2 every 6mo/ 1 yr Then x2 the next year = so x4 by 2yrs 
Lenght doubles every 4 yrs so x4 by puberty

Reflex
Palmar is first to come ( US baby always has his palm close) 
Rooting is first to go 
Parachute always stays

Fetal development

Fetal swallowing earliest-10wks

Fetal urine production begins by-12wks

Fetal urine is-hypoosmotic to fetal plasma

Fetal urine production at term-650ml

Fetal suckin reflx earliest at-24wks

Fetus can hear inutero-24wks

Fetal light perception-28wks

Gross body movemnt as early as by-8wks

Gonads-7wks

Internal genitalia into male n female-10wkspog

External gentalia into male n femald-12wkspog

Malnutrition

🈸Weight-for-Height (wasting)--
▶The index of weight-for-height reflects recent weight loss or gain.
It is the best indicator of assessing the level of acute malnutrition in children.
In order to assess malnutrition, individual measurement of height and weight are compared to an international reference value for a normal and well-fed child population.

🈸Height-for-Age (Stunting)--
▶The index of height-for-age reflects longstanding nutritional defficiencies and is the method used to assess the level of chronic malnutrition in children.
Individual measurement of height and age are compared to an international reference value for a normal and well-fed child population.

🈸Weight-for-Age (underweight)--
▶The index of Weight-for-Age reflects both the long-term (stunting) and short-term (wasting) nutritional status of children.
Individual measurement of weight and age are compared to an international reference value for a normal and well-fed child population. The measurement of weight-for-age is used in the Millennium Development Goals to assess progress in reducing the proportion of the world’s people who suffer from hunger.

Congenital TB

CONGENITAL TUBERCULOSIS
Infection with tubercle bacilli either during intrauterine life or before complete passage through birth canal is termed as congenital tuberculosis.
Three possible modes of infection of fetus:-
1) Hematogenous infection via umbilical vein
2) fetal aspiration of infected amniotic fluid
3) fetal ingestion of infected amniotic fluid
Most common primary site ----- LIVER ( primary complex in liver is suggestive of congenital TB)
Most common site --- LUNG
prognosis is poor
Revised criteria for diagnosis of congenital tuberculosis ( by Cantwell ) :-
Proven tuberculosis lesions in the infant plus one of the following:
i. Lesions occurring in the first week of life,
ii. A primary hepatic complex
iii. Maternal genital tract or placental tuberculosis, and
iv. Exclusion of postnatal transmission by thorough investigation of contacts