Summary of "Exam Recall Series (INI-CET May '24) - Paediatrics"

Summary of “Exam Recall Series (INI-CET May ‘24) - Paediatrics”

This video features a detailed discussion by Dr. Singaram, a Pediatrics faculty member, reviewing key pediatric recall questions from the INI-CET May 2024 exam. The session emphasizes understanding core pediatric concepts, clinical signs, and exam-focused facts, with special attention to commonly tested topics and recent exam patterns.

Main Ideas, Concepts, and Lessons

1. Types of Dehydration in Children with Diarrhea

There are three types of dehydration:

No dehydration
Some dehydration
Severe dehydration

Key clinical parameters:

Thirst
Mental status
Skin pinch
Sunken eyes

For some dehydration:

Increased thirst (child eagerly drinks)
Child is irritable/restless, not lethargic
Skin pinch delayed but returns within ≤ 2 seconds
Sunken eyes present

Mental status recap:

Dehydration Type Mental Status No dehydration Alert Some dehydration Irritable/restless Severe dehydration Lethargic/unconscious

Skin pinch reaction times:

Dehydration Type Skin Pinch Response No dehydration Quick Some dehydration Delayed ≤ 2 seconds Severe dehydration Very delayed > 2 seconds

2. Dehydration Assessment in Severe Acute Malnutrition (SAM)

Dehydration is often overdiagnosed in SAM due to altered clinical signs.
The most reliable sign of some dehydration in SAM is increased thirst.
Sunken eyes and delayed skin pinch are unreliable because of low subcutaneous fat.
Other reliable signs in dehydration with SAM include:
- Dry oral mucosa
- Weak pulses
- Oliguria (seen in severe dehydration)

3. Anthropometric Measurements

Head circumference growth:

At birth: ~34 cm
First 3 months: Increases by 2 cm/month
Next 3 months: 1 cm/month
Next 6 months: 0.5 cm/month
By 12 years: Adult head circumference ~52 cm

Upper Segment/Lower Segment (US/LS) Ratio:

Normal after 10 years: ~0.9:1
Decreased ratio (e.g., 0.8:1) indicates short upper segment (trunk)
Short trunk suggests vertebral problems like spondyloepiphyseal dysplasia

Other conditions:

Achondroplasia: Short limbs (lower segment affected)
Growth hormone deficiency: Normal US/LS ratio
Hypothyroidism: Short limbs

4. Nutritional Rickets

Caused by vitamin D deficiency → low phosphate and calcium absorption
Serum calcium may be low or normal (normal due to secondary hyperparathyroidism)
High parathyroid hormone (PTH) levels
Urine calcium/creatinine ratio is decreased in nutritional rickets (not increased)
Increased urine calcium/creatinine ratio (>0.2 mg/kg) seen in idiopathic hypercalciuria

5. Malnutrition Diagnosis (WHO Criteria)

Malnutrition defined as values below -2 SD
Severe malnutrition below -3 SD
Acute malnutrition = low weight-for-height (wasting)
Chronic malnutrition = low height-for-age (stunting)
Weight-for-age alone indicates underweight but cannot differentiate acute vs chronic malnutrition

Example: Height-for-age below -2.5 SD = chronic malnutrition (moderate stunting)

6. Neonatal Respiratory Distress and Scoring

Downes Score (Downes Vidyasagar Score) assesses respiratory distress in term neonates.

Components:

Respiratory rate
Retractions (chest indrawing)
Cyanosis
Grunting
Air entry

Feeding difficulty is not part of the Downes score.

7. INSURE Technique

INSURE = Intubation, SURfactant administration, Extubation
Used in Respiratory Distress Syndrome (RDS) of preterm infants
Indicated in severe RDS with worsening distress on CPAP
Not all RDS cases require surfactant

8. Free Flow Oxygen Delivery in Newborns

Methods include oxygen tube near nose/mouth, oxygen mask
Self-inflating bag and mask is NOT used for free flow oxygen; it is for positive pressure ventilation
Reservoir bag attached to oxygen mask can be used for free flow oxygen

9. Maintenance Fluids in Children

Ideal maintenance fluid contains water, glucose, sodium, and potassium
Normal saline + 5% dextrose + potassium chloride is recommended
Among available options, 5% dextrose with normal saline is the best choice

10. Cannabinoids in Pediatric Seizures

Cannabinoids (CBD) are adjunct, not first-line therapy
FDA approved for:
- Lennox-Gastaut syndrome
- Dravet syndrome
- Tuberous sclerosis
Not indicated for Rett syndrome

11. MRI Findings in Cerebral Palsy with Quadriplegia

Quadriplegic cerebral palsy is associated with multicystic encephalomalacia on MRI

Other MRI findings:

Basal ganglia calcification → extrapyramidal/dyskinetic CP
Periventricular leukomalacia → diplegia, common in preterm infants
Cerebellar degeneration → ataxia, not quadriplegia

12. Congenital Adrenal Hyperplasia (CAH) - 11 Beta Hydroxylase Deficiency

Clinical features:

Precocious puberty (sexual maturity rating 5 at 10 years)
Hyperpigmentation (due to high ACTH)
Hypertension (due to accumulation of 11-deoxycorticosterone, a mineralocorticoid)
Short stature

Pathophysiology:

Deficiency leads to low cortisol and aldosterone
Increased androgens cause virilization

13. Febrile Seizures

Simple febrile seizure characteristics:

Generalized tonic-clonic
Lasts <15 minutes
Occurs once in 24 hours
Age 6 months to 5 years
Recurrence risk after first episode ~30% (not 54%)
Long-term anticonvulsants not indicated for simple febrile seizures
Neuroimaging (CT/MRI) indicated only if high risk of structural/metabolic abnormalities or complex febrile seizures

Methodologies and Lists Presented

Dehydration Assessment Parameters

Parameter No Dehydration Some Dehydration Severe Dehydration Mental status Alert Irritable/restless Lethargic/unconscious Thirst Normal Increased Absent (due to lethargy) Skin pinch Quick Delayed ≤ 2 seconds Very delayed > 2 seconds Eyes Normal Sunken Very sunken and dry

Anthropometric Growth Rates (Head Circumference)

0–3 months: +2 cm/month
3–6 months: +1 cm/month
6–12 months: +0.5 cm/month
1–2 years: +2 cm/year
Adult value (~52 cm) by 12 years

Downes Score Components

Respiratory rate
Retractions
Cyanosis
Grunting
Air entry

Malnutrition Definitions (WHO)

Malnutrition: < -2 SD
Severe malnutrition: < -3 SD
Acute malnutrition = wasting = low weight-for-height
Chronic malnutrition = stunting = low height-for-age
Underweight = low weight-for-age (not diagnostic alone)

INSURE Protocol

Intubation → Surfactant administration → Extubation

Speakers and Sources Featured

Dr. Singaram – Pediatrics faculty and main speaker throughout the video
References to Nelson Textbook of Pediatrics for clinical guidelines and definitions
Mention of Opa Textbook for malnutrition and dehydration in SAM
Guidelines from Resuscitation Council for neonatal oxygen delivery

Final Notes

Emphasis on revising previous year questions and basics of Pediatrics for exam success
Understanding pathophysiology and clinical correlation is critical
Focus on clinical signs, diagnostic criteria, and treatment protocols commonly tested in exams

This summary encapsulates the core teaching points and detailed explanations given by Dr. Singaram during the INI-CET May 2024 Pediatrics recall question discussion.