Summary of "Exam Recall Series (INI-CET May '25) - Paediatrics"

Summary of “Exam Recall Series (INI-CET May ‘25) - Paediatrics” by Dr. Singarum

Overview

Dr. Singarum reviews pediatric recall questions from the INI-CET May 2025 exam, covering a range of topics from common to new and challenging questions. The session emphasizes understanding concepts, clinical features, and management strategies relevant to exam preparation.

Main Ideas and Lessons

1. Tetralogy of Fallot (TOF) Components

TOF consists of four components:
- Overriding aorta
- Pulmonary infundibular stenosis (correct answer)
- Ventricular septal defect (VSD)
- Right ventricular hypertrophy (not left ventricular hypertrophy)
The systolic murmur in TOF is due to pulmonary infundibular stenosis.
Transposition of great vessels and interatrial septal defect are not part of TOF.

2. Breast Milk Jaundice Mechanism

Occurs as late-onset jaundice (after 3–4 weeks).
Two main theories explain the mechanism:
- High free fatty acids inhibit conjugation of bilirubin.
- Beta-glucuronidase in breast milk deconjugates bilirubin, increasing unconjugated bilirubin.
Breast milk jaundice is benign; breastfeeding should not be interrupted.

3. Metabolic State in Marasmus

Characterized by severe calorie deficit with normal serum protein.
Differentiated from kwashiorkor, which presents with edema due to protein deficiency.
Features include:
- Decreased insulin
- Increased lipolysis
- Negative nitrogen balance
- Increased cortisol

4. Developmental Milestones and Delay

Sitting without support is typically achieved by 8 months.
Delay is diagnosed if not attained by 10 months.
A 9-month-old unable to sit but able to roll over, say “mama/dada,” and showing stranger anxiety is likely normal.
Management: Reassure parents; no immediate referral or intervention needed.

5. Proper Breastfeeding Attachment (Latching)

Signs of good attachment include:
- Wide-open mouth with full cheeks
- Chin touching the breast
- Lips everted (turned outward)
- More upper areola visible than lower areola
Incorrect signs include lower areola being more visible or lips not everted.

6. Transient Tachypnea of Newborn (TTN)

Seen in late preterm (35–36 weeks) or term babies, especially after cesarean section.
Chest X-ray shows a “sunburst” appearance with fluid in lungs (perihilar streaks).
Differentiated from Respiratory Distress Syndrome (RDS), which occurs ≤34 weeks and shows full whiteout on X-ray.
TTN requires minimal oxygen (<40% FiO₂).

7. Causes of Non-bilious Vomiting in Infants

Case: 6-week-old with failure to thrive and non-bilious vomiting starting 3 weeks after birth.
Differential diagnoses ruled out:
- Intestinal obstruction (usually bilious vomiting, abnormal abdomen)
- Cow milk protein allergy (usually earlier onset, irritability, blood in stool)
- Pyloric stenosis (would have palpable olive-shaped epigastric mass)
Most probable diagnosis: Gastroesophageal reflux disease (GERD).

8. Lupus Nephritis Induction Therapy in Children

Severe lupus nephritis (class IV) presents with proteinuria and rising creatinine.
Induction therapy: Intravenous cyclophosphamide plus corticosteroids.
Maintenance therapy: Mycophenolate mofetil preferred over cyclophosphamide.
Rituximab reserved for refractory cases.

9. Vaccines Contraindicated in Severe Combined Immunodeficiency (SCID)

Live vaccines are contraindicated due to risk of uncontrolled replication.
MMR vaccine is contraindicated.
Killed/inactivated vaccines (Hepatitis B, inactivated polio, DTaP) are safe but may have reduced efficacy.

10. Unusual Diagnosis in Child with Leg Pain and Fatigue

Differential includes:
- Ewing sarcoma
- Metastatic renal clear cell sarcoma
- Metastatic neuroblastoma
- Metastatic retinoblastoma
Bone metastasis is more common in renal clear cell sarcoma than retinoblastoma.
Retinoblastoma rarely metastasizes to bone.
Unusual diagnosis: Metastatic retinoblastoma.

11. Diagnosis of Child with Difficulty Walking, Hyperreflexia, Positive Babinski

Symptoms:
- Broad-based gait
- Inability to heel-to-toe walk
- Clinging to mother (anxiety)
- Hyperreflexia
- Positive Babinski sign
Ruled out:
- Guillain-Barré Syndrome (hyporeflexia, acute onset)
- Acute disseminated encephalomyelitis (encephalopathy, seizures)
- Spinal cord lesion (would have sensory or bladder/bowel signs)
Most probable diagnosis: Cerebral palsy (likely spastic diplegia).

Key Methodologies / Instructional Points

Approach to Clinical Questions:
- Identify key clinical features.
- Use textbook criteria (e.g., Nelson’s Textbook of Pediatrics) for differential diagnosis.
- Understand typical age of onset and presentation.
- Analyze imaging findings carefully.
- Rule out diagnoses by absence of hallmark signs.
- Know management protocols including induction vs maintenance therapies.
Developmental Milestone Evaluation:
- Know upper limits of milestone attainment before labeling delay.
- Reassure parents when within normal variant range.
Breastfeeding Assessment:
- Use visual clues (mouth opening, lip eversion, chin position, areola visibility) to assess attachment.
Immunization in Immunodeficiency:
- Avoid live vaccines in severe immunodeficiencies.
- Understand vaccine types (live vs killed/subunit).

Speakers / Sources Featured

Dr. Singarum – Pediatrics faculty, primary speaker and presenter of the session.
Nelson Textbook of Pediatrics – Referenced repeatedly for clinical guidelines and evidence.
OPGA Textbook – Referenced for developmental milestones.

This summary captures the core teaching points and clinical reasoning presented in the video to aid exam preparation for pediatrics in the INI-CET May 2025 exam.