ET

PE
D
IA
TR
IC
S
(W
O
LT
ER
S
KL
U
W
ER
)-
AR
U
N
BA
BU
SA
M
PL
E
 Abbreviations Used in the Book

E
PL
M
*—Important keyword MCC—Most common cause

SA
AD—Autosomal dominant MC—Most common
AKA—Also known as MOA—Mechanism of action
AR—Autosomal recessive PR—Pulse rate

BU
BP—Blood pressure Rx—Treatment
C/b—Characterized by S/o—Suggestive of

BA
Ca—Cancer Sx—Surgery”
Cl/f—Clinical features USG—Ultrasound
CT—Computed tomography XLD—X-linked dominant

N
DD—Differential diagnosis XLR—X-linked recessive

U
HR—Heart rate

AR
)-
ER

Recurring Themes and Special Segments

W
U
KL

Extra Edge—for “high-yield concepts”

S
ER

AIIMS KEY NEET PG KEY JIPMER KEY AIIMS, NEET PG, and JIPMER Keys—for “frequently
asked one-liners in previous exams”
LT

CONTROVERSY
O

CLEARED
Controversy cleared—segment for “doubtful and controversial areas”
(W

Image-based questions for NEET-PG, DNB-CET, and NEET-SS exams

S
IC
TR
IA
D
PE
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 Contents

E
PL
M
Foreword vii

SA
Preface ix
Contributors xi
Acknowledgments xiii

BU
Abbreviations Used in the Book xiv
Recurring Themes and Special Segments xiv

BA
Chapter 1 Growth, Development, and Behavioral Disorders 1

N
Chapter 2 Nutrition 48

U
Chapter 3 Fluid, Electrolytes, and Acid–Base Disturbances 85

AR
Chapter 4 Genetics 123

Chapter 5 Neonatology
)- 166
ER

Chapter 6 Rheumatology, Immunology, and Allergic Disorders 237

Chapter 7 Pediatric Infectious Diseases 279

W
U

Chapter 8 Pediatric Gastroenterology 333

KL

Chapter 9 Pediatric Pulmonology 375

Chapter 10 Pediatric Cardiology 434

S
ER

Chapter 11 Pediatric Hematology 486

Chapter 12 Pediatric Oncology 549

LT

Chapter 13 Pediatric Nephrology 602

O

Chapter 14 Pediatric Endocrinology 657

(W

Chapter 15 Pediatric Neurology 720

S

Chapter 16 Metabolic Disorders 771

IC

Chapter 17 Pediatric Surgery 822

TR

Appendix 844
IA
D

Two Free Pediatric NEET-PG Pattern Mock tests available online.

PE
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 Chapter 2 Nutrition 49

Storage of breast milk*

EXTRA EDGE
Temperature Duration

E
Room temperature 6–8 hours* Drugs that can suppress
lactation

PL
Refrigerator 24 hours* yNicotine
Frozen 3 months* yOral pills
yThiazides

M
Advantages of breast milk yBromocriptine
yPyridoxine

SA
Content Use
Lactalbumin Rich in tryptophan—neurotransmitter
*Lactoferrin Ensures absorption of iron and makes it EXTRA EDGE

BU
unavailable for bacteria Indicators of adequate
Bacteriostatic, inhibits E.coli breastfeeding
yPassing plenty of pale urine

BA
LCP (long chain polyunsaturated Promotes brain growth and reduces dyslexia yPassing 1–6 liquid stools
fats) and hyperactivity per day
Ca: P > 2 Ensures Ca absorption yWeight gain

N
Binding proteins Binds thyroxine, B12, vitamin D
*BSSL (bile salt stimulated lipase) Kills amoeba and giardia

U
*PABA Protects against malaria AIIMS KEY

AR
Bifidus factor and acidic pH Colonization by lactobacillus bifidus
yBreast milk is a good
Ig A Surface protection to GIT and respiratory source of all vitamins
tract )- except Vitamin D and K
Bioactive factors Neurotransmitters, promotes growth
ER
Breastfeeding—good positioning vs attachment
AIIMS KEY
Good positioning Good attachment
yFatty acid present in
W

yWhole body supported yLips everted breast milk which is

important for growth and
yHead and body in straight line yMouth wide open
U

CNS development is
yBaby’s abdomen touching mothers yChin touching breast Docosahexaenoic acid*
KL

yMouth facing nipple and areola yLower areola not visible

Difference between cow’s milk and human milk
IMAGE 1
S

Content Human milk Cow’s milk

All the following are
ER

Nonprotein nitrogen 0.2 g 0.03 g

indicators of good
*Protein 1.1 g 3.0 g attachment except:
*Caesin: Whey 40:60 80:20
LT

*Lactose 7g 4.5 g
EFA 13% 2%
O

P/S 1.2:1 1:2

(W

Ca:P >2 <2

Sodium 0.7 mEq 2.2 mEq
Energy: protein 70:1 25:1
S

Iron 0.29–0.45 mg 0.01–0.38 mg

IC

Folic acid 0.14–0.36 µg 0.01–0.06 µg A. Lips everted

Vitamin K 1.5 µg 6 µg B. Mouth wide open
TR

Calories 67 67 C. Chin touching breast

D. Baby’s mouth covers nipple
Nutritional composition of different sources of milk covers nipple.
IA

Answer: D. Baby’s mouth

Milk source Quantity (mL) Energy (Kcal) Protein (g)
D

Cow 100 67 3.3

PE

Buffalo 100 117 4.3

Goat 100 72 3.7
Human 100 65 1.1
ET

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 Chapter 4 Genetics 143

Other procedures
IMAGE 16
yKaryotyping:

E
– Cells are cultured and cell division is arrested in prophase/metaphase and What is the most likely
then stained diagnosis of the picture

PL
– Trypsin: Giemsa stain is used to study G bands* shown below?

– Quinacrine stains for Q bands*

M
yMicroarray

SA
yWhole genome sequencing (WGS)
yWhole exome sequencing (WES)
– It targets the subset of the human genome that is protein coding

BU
A. Down syndrome
Gene therapy B. Pierre-robin syndrome
C. Noonan syndrome

BA
yTherapy includes the following: D. Williams syndrome
– Replacing a defective gene with a functional version syndrome
– Enhancing the baseline expression level of a gene Answer: B. Pierre Robin

N
– Suppressing the expression of genes that cause the pathologic process

U
EXTRA EDGE

AR
Chromosomal disorders
Enzyme replacement
Chromosome 1 Charcot–Marie–Tooth disease, Rh system, neuroblastoma, therapy available for:
NPHS -2 )- yGaucher disease
yPompe disease
Chromosome 2 Cystinuria, abetalipoproteinemia yFabry disease
Chromosome 3 RCC, von Hippel Lindau syndrome, alkaptonuria, orotic yMucopolysaccharidosis
ER

aciduria types I and II

Chromosome 4 Huntington’s chorea, achondoplasia, Parkinson’s disease

W

Chromosome 5 FAP, colorectal carcinoma, Cri-du-chat syndrome IMAGE 17

Chromosome 6 HLA system/ MHC system, diabetes mellitus,
U

hemochromatosis A six-year-old boy presents

with mental retardation and
KL

Chromosome 7 Cystic fibrosis, Ehlers–Danlos syndrome seizures. Facial picture is

Chromosome 8 Osteopetrosis shown. What is the likely
Chromosome 9 ABO blood group, Friedreich’s ataxia, galactosemia diagnosis?
S

Chromosome 10 Hirschsprung’s disease, Ret proto-oncogene (Medullary Ca

ER

of thyroid)
Chromosome 11 Beta thalassemia, Wilms’ tumor, ataxia telangiectasia
Chromosome 12 Phenyketonuria, von Willebrand disease
LT

Chromosome 13 Retinoblastoma, Wilson’s disease, osteosarcoma, BRCA-

2
O

Chromosome 14 Alpha-1-antitrypsin deficiency, Familial HOCM

Chromosome 15 Marfan syndrome, Prader–Willi syndrome, Angelman
(W

A. Cerebral palsy
syndrome, albinism B. Sturge–Weber syndrome
Chromosome 16 Alpha thalassemia C. Tuberous sclerosis
D. VHL disease
S

Chromosome 17 BRCA-1, ovarian carcinoma, neurofibromatosis 1,

medulloblastoma sclerosis
IC

Answer: C. Tuberous
Chromosome 19 Myotonia dystrophica, Insulin receptor, NPHS -1
TR

Chromosome 20 Mody type I DM, Prions diseases

Chromosome 21 Homocystinuria, amyloidosis
Chromosome 22 Meningioma, acoustic neuroma, neurofibromatosis -2, EXTRA EDGE
IA

Digeorge syndrome Gene therapy available for:

Chromosome Xq Androgen receptor gene, testicular feminization, fragile x yADA-SCID
D

yLeber’s congenital
syndrome amaurosis
PE

yMultiple myeloma
yAdenoleukodystrophy
yParkinson’s disease
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 172 TARGET Pediatrics

Instruments used to administer positive pressure ventilation (PPV)

EXTRA EDGE

E
Adrenaline in neonatal
resuscitation

PL
yUsed in 1:10000 dilution
yIV dose: 0.01–0.03 mg/kg
yET dose: 0.05–0.1 mg/kg

M
SA
EXTRA EDGE

yPop off valve or pressure Self inflating bag Flow inflating bag T piece resuscitator

BU
release valve is a safety
valve set to release at
pressures exceeding Pressure to be applied while using Ambu bag
40 cm H2O*

BA
yInitial breath to expand fluid-filled alveoli—40 cm H2O
ySubsequent breaths: 15–20 cm H2O

N
NEET PG KEY FiO2 delivered by self-inflating bag
yApproximately 10% of yWhen used without O2 source or reservoir—21%

U
neonates require some
yWhen used with O2 source and without reservoir—40%

AR
resuscitation
yApproximately 1% yWhen used with O2 source and reservoir—90–100%
of neonates require Fish mouth valve: Opens when the bag is compressed to deliver air/oxygen to
extensive resuscitation the baby. During exhalation, it closes to prevent rebreathing.
)-
CONTROVERSY Neonatal resuscitation
ER
CLEARED
y10% of the babies require some form of resuscitation
As per NRP Update 2015, y<1% require extensive resuscitation (chest compressions, medications)
Routine tracheal suctioning yColor—not recommended as a useful indicator of oxygenation or effectiveness
W

is NOT indicated anymore

in nonvigorous babies with
of resuscitation
U

meconium-stained liquor. yAdequate ventilation—key to affective neonatal resuscitation

yHeart rate—the most sensitive indicator of response to resuscitation
KL

yAmbu bag can be used without oxygen/air source but a ‘flow inflating bag’
EXTRA EDGE requires a compressed gas source
S

Primary versus secondary

yCord clamping to be delayed for at least 30–60 seconds for infants not
requiring resuscitation (delayed cord clamping)
ER

apnea
yPrimary apnea—revived yRoutine suction is NOT required. Secretions when excessive can be wiped
with tactile stimulation with cloth
ySecondary apnea—
LT

not revived by tactile ySuction pressure should not exceed 100 mmHg*
stimulation. Absent yRatio of chest compressions to ventilation—3:1 (120 events/1 minute)
respiratory efforts at
O

yImmediately after birth, preterm neonates < 32 weeks old should be completely
birth to be considered
as secondary apnea and
covered in a plastic wrap
(W

resuscitated. yAdministration of naloxone is NOT recommended as part of initial

resuscitative efforts in the delivery room for newborns with respiratory
depression
S

yIf there is no return of heart rate after 10 minutes of adequate resuscitation, it

IC

AIIMS KEY
is acceptable to discontinue resuscitation
yIn meconium-stained yBabies born out of meconium-stained amniotic fluid are said to be vigorous or
TR

liquor, the term
“vigorous” baby is
based on tone, HR, and
respiration and not color.
IA
nonvigorous at birth based on heart rate, respiratory efforts, and tone
yEven nonvigorous baby need not be routinely intubated for tracheal suctioning
at birth

APGAR score
D

yDevised by Virginia Apgar, an anesthesiologist in 1952, to assess effect of

PE

obstetric anesthesia on babies.

ET

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 Chapter 5 Neonatology 187

Definite NEC Same as Same as I + Ileus, NPO, IV

yStage II A above absent bowel pneumatosis antibiotics for

E
yMildly ill sounds intestinalis 7–10 days
yStage II B Acidosis, Same as Portal vein NPO, IV

PL
yModerately thrombocyto- above gas shadows antibiotics for
ill penia 14 days

M
Stage IIIA Respiratory Generalized Same + NPO, IV
Advanced distress, peritonitis definite antibiotics

SA
NEETPG KEY
ySeverely ill, metabolic and abscess for 14 days,
acidosis, tenderness resuscitation, Radiographic findings of
bowel intact
NEC
respiratory inotropic

BU
Stage IIIB yPneumatosis
acidosis, support, intestinalis—stage 2A
ySeverely NEC
DIC, laser therapy,
ill, bowel yPortal vein gas

BA
neutropenia paracentesis
perforated ± pneumatosis
Same as Same as Pneumoperi- Same as above intestinalis—stage 2B
above above toneum + surgery NEC

N
Sequelae: Strictures, fistula, short bowel syndrome, dumping syndrome,
malabsorption, chronic diarrhea

U
AR
Umbilical hernia
yFailure of closure of umbilical ring. Strangulation and obstruction are rare
)-
complications. Surgery required only after 2 years.
ER
Gastroschisis Omphalocele IMAGE 16
yFailure of migration and fusion of yFailure of midgut to return to the
the lateral folds of the embryonic abdominal cavity during early A 10-day-old 26-week
W

infant presents with

disc on the 3rd—4th week of weeks (10th week)
abdominal distension and
gestation yThe omphalocele is a large defect
U

blood in stools. Abdomen

yDefect of anterior abdominal wall of the umbilical ring into which X-ray is shown. What is
KL

to right of midline the abdominal contents herniate the likely diagnosis?

y10–15% associated with covered by a peritoneal sac but no
congenital anomalies such as skin
S

CHD (VSD), cleft palate, and y>70% association with congenital

ER

intestinal atresia anomalies such as bowel atresia

and imperforated anus
yAssociated with trisomies 13,
LT

18, 21, Beckwith–Wiedemann

syndrome and pentalogy of
O

Cantrell
A. NEC stage II B
(W

B. NEC stage II A
C. NEC stage II B
D. NEC stage III
Diagnosis is NEC stage II A
S

intestinalis (white arrow).

IC

y AXR shows pneumatosis

Answer: B. NEC stage II A.
TR
IA
D
PE
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 Chapter 13 Pediatric Nephrology 635

Multiple Choice Questions

E
Questions

PL
Renal physiology

M
C. Weight of child
1. Nephelometry is a technique used in the D. Height of child

SA
measurement of (Recent JIPMER) 8. In SCHWARTZ formula, calculation of creatinine
A. Refraction of light clearance in a child, the constant depends on the
following except: (Recent Question 2016)

BU
B. Immunoglobulins
A. Age
C. Size of renal stones
B. Method of estimation of creatinine
D. Optical density of fluids

BA
C. Mass
2. Which of the following will not decrease
Glomerular filtration rate (GFR)? (Recent Dec D. Severity of renal failure
Exam 2016) 9. Biomarker not involved in acute kidney injury is

N
A. Increased hydrostatic pressure in tubule (AllMS Nov 2013)

U
A. NGAL
B. Increased capillary oncotic pressure

AR
B. KIM-I
C. Hypoproteinemia
C. Micro RNA122
D. Mesangial cell contraction
D. Cystatin-C
3. Effective renal plasma flow (ERPF) is calculated )-
by (Recent Dec Exam 2016) 10. The GFR of a child does not approximate adult
values until the age of (Recent Question-2016)
ER
A. DTPA
A. 1st year of life
B. MAG 3
B. 5th year of life
C. Inulin
W

C. 3rd year of life

D. Hippurate I131
D. 4th year of life
U

4. Glomerular capillary permeability, which substance

11. The neonatal kidney achieves concentrating
KL

is least lost in urine? (Recent Dec Exam 2015)

ability equivalent to adult’s kidney by (Al 04)
A. Albumin
A. One year of age
B. Hemoglobin
B. Three to six months of age
S

C. Myoglobin
C. Just before puberty
ER

D. Inulin D. Nine months of age

5. Each kidney contains about ______ nephrons. 12. The maximum urinary concentration capacity in
LT

(JIPMER 2008) full term neonates is (Recent Dec Exam 2016)

A. One million A. >1000 mOsm/L
O

B. Two million B. 350–450 mOsm/L

C. Four million
(W

C. 900–1000 mOsm/L
D. Half million D. 700–800 mOsm/L
Tests of renal function
S

Diagnostic imaging
6. Most sensitive marker of early GFR decline is
IC

13. In a child, non-functioning kidney is best

(Recent Question 2016) diagnosed by (Recent Dec Exam 2016)
TR

A. Serum creatinine A. Ultrasonography

B. Inulin B. IVU
IA

C. B2 microglobulin C. DTPA renogram

D. Cystatin-C D. Creatinine clearance
D

7. Estimation of GFR in pediatrics by SCHWARTZ 14. Method of choice for a newborn child not passing
PE

formula includes all except (Recent Question 2015) urine for 36 hours is (AllMS May 95)
A. Serum creatinine A. Ultrasound of kidney and bladder
B. Age of child B. CT scan
ET

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 Chapter 13 Pediatric Nephrology 653

“The serum C3 level is significantly reduced in >90% A91. B. Hypophosphatemia (Nelson 20th ed/2496)
of patients in the acute phase and returns to normal yRhabdomyolysis is associated with myoglobinuria
6-8 week after onset.” (Ref: Nelson) and hypophosphatemia

E
“Renal biopsy should be considered only in the presence A92. C. IgA nephropathy (Nelson 20th ed/2497)

PL
of acute renal failure, nephrotic syndrome, absence A93. C. Renal vein thrombosis (Nelson 20th ed/2496)
of evidence of streptococcal infection, or normal
yExcept RVT, all other options causes

M
complement levels. In addition, renal biopsy is considered glomerulonephritis and proteinuria
when hematuria and proteinuria, diminished renal

function, and/or a low C3 level persist more than
2 month after onset” (Ref: Nelson)
>> Serum triglyceride levels are increased in nephrotic
SA
A94. D. Lupus nephritis (Nelson 20th ed/2504)
A95. A. RBC cast (Nelson 20th ed/2498)
A96. D. Hypercholesterolemia (Nelson 20th ed/2521)

BU
syndrome not in nephritis yHypercholesterolemia is seen in nephrotic
A81. B. Hemolytic uremic syndrome (Nelson 20th syndrome
A97. A. Acute G.N (Nelson 20th ed/2521)

BA
ed/2496)
Hemolytic uremic syndrome A98. A and D (Nelson 20th ed/2498)
yAcute onset. A99. C. Mild proteinuria, high hematuria, high ASO

N
yDoes not present with recurrent gross titer (Nelson 20th ed/2499)
hematuria A100. B. Not elevated (Nelson 20th ed/2498)

U
yClinical triad yASLO titers are elevated after pharyngeal

– $FXWHUHQDOLQVXIÀFLHQF\
– Microangiopathic hemolytic anemia
– Thrombocytopenia
A82. C. Lymphatic obstruction (Nelson 20th ed/2496)
A83. C. Class 4 (Nelson 20th ed/2504)
ER
yClass 4 (Diffuse nephritis) lupus nephritis is
the most common type and carries the worst
W
AR
infection but only rarely after skin infection
A101. C. 6–8 weeks (Nelson 20th ed/2498)
A102. A. Epithelial humps (Nelson 20th ed/2498)
)-
A103. C. Hypoalbuminemia (Nelson 20th ed/2499)
A104. B. Caused by non-group A hemolytic streptococci
(Nelson 20th ed/2500)
A105. D. Bleeding diathesis (Nelson 20th ed/2501)

prognosis. A106. D. Steroids are indicated if there is gastrointestinal

A84. A. Lupus nephritis (Robbins 8th ed/918) involvement (Nelson 20th ed/2496)
U

Subepithelial deposits Subendothelial deposits ySteroids are indicated only in life-threatening

KL

cases and in serious GI involvement, not in all

yPostinfectious yMembranoproliferative
cases of GI involvement.
glomerulonephritis glomerulonephritis
(lumpy bumpy (MPGN) type I A107. C. CD 71 (Nelson 20th ed/2498)
S

deposits) yLupus nephritis Immunoglobulin A (IgA) nephropathy or Berger

ER

yMembranous yPostinfectious disease

glomerulopathy glomerulonephritis yMC form of primary glomerulonephritis in the
(rarely) world
LT

A85. A. Capillary wall thickening (Robbins 8th ed/918) yAccumulation of immune complexes containing
polymeric IgA1 in mesangial areas.
O

“Prominent subendothelial deposits create a

homogeneous thickening of the capillary wall, which yAbnormal IgA induce the release of soluble
(W

are seen by light microscopy as a “wire-loop” lesion. CD89 which is responsible for the formation of
Such wire loops are often found in both focal and diffuse circulating IgA complexes.
proliferative (class III or IV) lupus nephritis, which yThese complexes may be trapped by CD71
S

reflects active disease”(Ref: Robbins) that is overexpressed on mesangial cells in IgA

nephropathy patients allowing pathogenic IgA
IC

A86. D. 50 (Nelson 20th ed/2494)

complex formation.
A87. B. Microscopic polyangitis (Robbins 8th ed/918)
TR

A108. D. HSP nephritis (Nelson 20th ed/2505)

Cause of pauci-immune RPGN
“Whereas IgA nephropathy is typically an isolated
yANCA-associated
renal disease, similar IgA deposits are present in
IA

yIdiopathic a systemic disorder of children, Henoch–Schonlein

yWegener granulomatosis purpura, which has many overlapping features with
D

yMicroscopic polyangiitis IgA nephropathy” (Ref: Robbins)

PE

A88. A. Crescent formation (Robbins 8th ed/918) “IgA is deposited in the glomerular mesangium in
A89. A. >20% (Nelson 20th ed/2495) a distribution similar to that of IgA nephropathy.
A90. D. Rhabdomyolysis (Nelson 20th ed/2493) This has led to the concept that IgA nephropathy and
ET

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