Summary of "Exam Recall Series (INI-CET Nov '23) - Paediatrics"

Summary of Pediatrics Recall Questions from INI-CET Nov 2023 Exam

This session, led by Dr. Singaram, reviews pediatric questions from the November 2023 INI-CET exam, highlighting key concepts, diagnostic criteria, and management principles. The questions primarily cover common and important pediatric topics, with some repeated from previous exams.

Below is a detailed outline of the main ideas, lessons, and methodologies discussed:

1. Perinatal Asphyxia Criteria

Definition: Condition during delivery causing hypoxia/decreased perfusion leading to organ dysfunction.
American Academy of Pediatrics criteria:
- Umbilical arterial blood pH < 7.0 (prolonged acidosis)
- Apgar score 0-3 at >5 minutes after birth
- Neurological manifestations: seizures, coma, hypotonia
- Multi-organ dysfunction (e.g., kidney oliguria, elevated liver enzymes)
Key point: Hypotonia (neurological sign) is a criterion; hypocalcemia is not.

2. Management of Diabetic Ketoacidosis (DKA) in Children

Presentation: Acidosis + hyperglycemia (e.g., blood sugar ~400 mg/dL)
Management principles:
- Classify dehydration:
  - Minimal: oral fluids
  - Moderate/severe: IV fluids
  - Shock: IV fluids + bolus
- Fluid therapy:
  - Use Normal Saline (0.9% NaCl)
  - Shock: bolus 20 ml/kg normal saline rapidly
  - Moderate dehydration: infusion 10-20 ml/kg over 20-30 minutes
- Insulin therapy:
  - Start IV insulin infusion 1 hour after starting IV fluids (not immediately)
  - Dose: 0.05-0.1 units/kg/hour
  - Avoid insulin bolus during resuscitation phase to prevent cerebral edema
- Minimal dehydration: subcutaneous insulin possible
- Moderate/severe dehydration or shock: IV insulin infusion preferred

3. Down Syndrome Comorbidities

Common associations:
- Congenital heart defects (40%), especially endocardial cushion defect
- Conductive hearing loss (40-60%), frequent otitis media; hearing screening recommended twice in first year, then annually
- Hypothyroidism (13-54%), congenital and acquired (autoimmune); test for anti-thyroid antibodies in older children
- Short stature (linear growth retardation)
Not associated: Caudal regression syndrome (associated with infants of diabetic mothers)

4. Congenital Diaphragmatic Hernia (CDH) and Resuscitation

Presentation: Neonate with respiratory distress and scaphoid abdomen
Resuscitation contraindication:
- Bag and mask ventilation (BMV) is contraindicated (causes intestinal air distension, worsening lung compression)
Recommended:
- Endotracheal intubation and positive pressure ventilation (PPV)
- Oxygen supplementation

5. Management of Pneumonia in a 9-Month-Old (IMNCI Guidelines)

Classification based on respiratory rate and chest signs:
- No pneumonia: no fast breathing or chest indrawing
- Pneumonia: fast breathing or chest indrawing
- Severe pneumonia: hypoxia (low SpO₂) or danger signs (lethargy, convulsions, inability to feed)
Respiratory rate thresholds for fast breathing:
- 2-12 months: >50 breaths/min
Case example: RR 48/min, no chest indrawing → no pneumonia
Management:
- No pneumonia: home care, symptomatic treatment, educate parents on danger signs
- Pneumonia: oral antibiotics (amoxicillin)
- Severe pneumonia: urgent referral to hospital, IV antibiotics

6. Congenital Cytomegalovirus (CMV) Infection

Epidemiology: ~10% symptomatic at birth; 90% asymptomatic
Sequelae: Sensorineural hearing loss (SNHL) is the most common, especially in symptomatic infants (50% risk vs 13.5% in asymptomatic)
Diagnosis:
- PCR testing on blood, urine, or saliva samples within first 2-3 weeks of life (to differentiate congenital vs postnatal infection)
- Screening: saliva PCR
- Confirmation: urine PCR (gold standard)
Note: CMV is the most common congenital infection (not second to syphilis)

7. Cystic Fibrosis (CF) Pathophysiology and Diagnosis

Pathophysiology:
- CFTR gene mutation affects chloride ion transport
- Pancreatic secretions: decreased chloride (due to defective secretion)
- Sweat: increased chloride (due to defective reabsorption)
Diagnostic criteria:
- Two elevated sweat chloride tests
- Genetic testing for CFTR mutations (best test)
- Abnormal nasal potential difference measurement (less commonly used)

8. Modes of Inheritance - Matching

Mode of Inheritance Disease Autosomal recessive Cystic fibrosis Autosomal dominant Myotonic dystrophy X-linked recessive Duchenne muscular dystrophy Mitochondrial inheritance Leber hereditary optic neuropathy

9. Differential Diagnosis of Diarrhea with Altered Sensorium/Seizures in a Child

Possible causes:
- Severe dehydration leading to cerebral venous thrombosis
- Electrolyte disturbances (hyponatremia)
- Hemolytic uremic syndrome (excluded here)
Other considerations:
- Febrile seizures due to infection
- Hypoglycemia due to decreased intake
Correct differentials: severe dehydration, cerebral venous thrombosis, hyponatremia

Final Remarks

The pediatric paper was standard with some repeat questions.
Emphasis on reviewing previous years’ questions (PYQs) and focusing on expected topics.
Encouragement to study from main video lectures and standard textbooks for comprehensive preparation.

Speakers / Sources Featured

Dr. Singaram (primary speaker and lecturer throughout the session)
References made to:
- American Academy of Pediatrics (AAP) guidelines
- Nelson Textbook of Pediatrics
- IMNCI (Integrated Management of Neonatal and Childhood Illness) guidelines

This summary captures the main clinical concepts, diagnostic criteria, and treatment protocols discussed in the video, providing a concise revision resource for pediatric exam preparation.