Title: "DNB Exam: Past Papers and Answers - Your Comprehensive Guide"

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Dr. Krishna Chaitanya.
DNB PEDIATRICS THEORY ANSWERS
Dr. Krishna Chaitanya
MBBS (GMC, Hyd). DNB pediatrics (Aditya Birla Memorial Hospital)
[Pediatric Critical Care Fellowship (Narayana Hrudayalaya)]
This content is prepared for exam going students to create an insight into certain topics and set of
questions which are asked in recent DNB pediatric theory examination (past 4 years) and
included under miscellaneous sections from PSM, recent advances and pharmacology whose
references couldn‘t be got straight from Nelson Text book. The content not to be taken as mere
by hearting as it is. Students could elaborate further while writing as an answer in examination.
Material prepared with good intentions to be helpful for preparation for exam with references.
Suggestions are always welcome.
Funding : None. Open acess.
Dedicated to : Hard working Students.
Thanks to all my teachers.
Mail: drkcpeds@gmail.com.

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INDEX
Sl no Question Page no
1 Role of EEG in children 4
2 Cytokine storm 5
3 Cochrane review 6
4 Nutritional management in critical ill children 7
5 Suicide. Approach to suspect and prevent 9
6 Management of suspected sexual abuse 11
7 Digital media. Ill effects and prevention 13
8 Antibiotic stewardship. inpatient and outpatient 15
9 Telemedicine. Advantages and disadvantages 17
10 Umbilical cord banking. Pros and cons 18
11 Recent advances in diagnosis and management of
hypertension
20
12 IAP guidelines on junk food 22
13 Hidden hunger 23
14 District early intervention centre 24
15 INAP 25
16 Foetal onset adult diseases 26
17 Anemia mukth Bharath 27
18 Neonatal mortality severity scoring 28
19 Simulation. Newer teaching technology. 29
20 Indications of platelet transfusion 30
21 Selective hypothermia . HIE 31
22 Immunomodulator theraphy. Nephrotic syndrome 32
23 Combined vaccines 33
24 Newer treatment modalities in hemophilia 34
25 Prebiotics and probiotics 35
26 Indications of liver transplant 36
27 Intrauterine foetal theraphy 37
28 Human milk bank . indications 38
29 Indications of HFNC in neonates. 39
30 Indications of splenectomy in thalassemia 40
31 Role of immunophenotyping in leukemia 40
32 Anti cytokine drugs. Indications 41
33 Hematopoietic growth factors 41
34 SMA therapies 42
35 Diagnostic approach precocious puberty girl 42
36 Renal nuclear scans 43
37 Celiac disease. Serological tests 43
38 Pancreatic exocrine deficiency syndromes 44

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39 Childhood vertigo. Approach. 45
40 Dengue fever diagnosis tests 46
41 Scrub typhus diagnosis tests 46
42 TB meningitis diagnosis tests 47
43 SLE skin manifestations 48
44 JIA. Treatment approach 49
45 Management of corrosive ingestion 50
46 Hyper IgE syndromes 51
47 Plasmapheresis 52
48 Safe injection practices 53
49 Needle stick injury. Management 54
50 Sodium valproate mechanism 56
51 Adenosine mechanism in SVT 57
52 Components of structured abstract 58
53 Study designs 58
54 Ethical principles in human research 60
55 Biological changes during adolescence 61
56 Characteristics of a good research question 62
57 Need and methods of blinding for research 63
58 Testing for single gene disorders 64
59 Principles of rational antibiotic treatment 65
60 Classify headache. 66
61 Common movement disorders in children 67
62 Common insulin regimens in DM1 68
63 Epilepsy syndromes with focal seizures 69
64 Complications of Obesity 70
65 Indications of growth hormone 71
66 Autism treatment 72
67 Pain pathway. Treatment. 73
68 Aerosol therapy Drugs used in aerosol therapy 75
69 Approach to psychological problems in adolescence 77
70 Zinc. Role in immunity 78
71 Assessing validity of a diagnostic test 89
72 Meta analysis 80
73 Mechanism of antibiotic resistance 81
74 Tools used for developmental screening 82
75 Transfusion associated hepatitis 83
76 Newer anti epileptic drugs in INDIA 85

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September 2020
1. Role of EEG in children.
An electroencephalogram (EEG) is a test that measures the electrical activity in the brain (brain
waves). Small, round discs with wires (electrodes) are placed on the scalp during the test.
EEG has a wide range of applications in pediatrics as for
1. Epilepsy diagnosis and follow up.
2. Neonatal seizures.
3. Seizure like activity work up.
4. Sleep disorders.
5. Behavioural problems.
6. Status epilepticus monitoring.
7. Brain infections.
8. Intra cranial space occupying lesions.
9. Severe Traumatic brain injury .
10. Pre liver transplant and major cardiac surgery.
11. Post ECMO support or CPR.
12. Diagnosing brain death.

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2. Cytokine storm.
Cytokine storm and cytokine release syndrome are life-threatening systemic inflammatory
syndromes involving elevated levels of circulating cytokines and immune-cell hyperactivation
that can be triggered by various therapies, pathogens, cancers, autoimmune conditions, and
monogenic disorders.
Nearly all patients with cytokine storm are febrile, and the fever may be high grade in severe
cases. In addition, patients may have fatigue, anorexia, headache, rash, diarrhea, arthralgia,
myalgia, and neuropsychiatric findings.
Cases can progress rapidly to disseminated intravascular coagulation with either vascular
occlusion or catastrophic hemorrhages, dyspnea, hypoxemia, hypotension, hemostatic imbalance,
vasodilatory shock, and death.
cases can progress to acute respiratory distress syndrome (ARDS), severe cases of cytokine
storm, renal failure, acute liver injury or cholestasis, and a stress-related or takotsubo-like
cardiomyopathy can also develop. The combination of renal dysfunction, endothelial-cell death,
and acute-phase hypoalbuminemia can lead to capillary leak syndrome and anasarca.
Nonspecific markers of inflammation such as C-reactive protein (CRP) are universally elevated
and correlate with severity. Many patients have hypertriglyceridemia and various blood-count
abnormalities, such as leukocytosis, leukopenia, anemia, thrombocytopenia, and elevated ferritin
and d-dimer levels. Prominent elevations in serum inflammatory cytokine levels, such as
interferon-Î³ , interleukin-6, interleukin-10, and soluble interleukin-2 receptor alpha, a
marker of T-cell activation, are usually present.
The general treatment strategy for cytokine storm involves supportive care to maintain critical
organ function, control of the underlying disease and elimination of triggers for abnormal
immune system activation, and targeted immunomodulation or nonspecific immunosuppression
to limit the collateral damage of the activated immune system.
Antiâ€―interleukin-6, anti-TNF, antiâ€―interferon-Î³, or antiâ€―interleukin-1Î² antibody have
shown some promising results but will not always be effective.

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3. Cochrane review.
A Cochrane Review is a systematic review of research in health care and health policy that is
published in the Cochrane Database of Systematic Reviews.
Types of Cochrane Review
Intervention reviews assess the benefits and harms of interventions used in healthcare and
health policy.
Diagnostic test accuracy reviews assess how well a diagnostic test performs in diagnosing and
detecting a particular disease.
Methodology reviews address issues relevant to how systematic reviews and clinical trials are
conducted and reported.
Qualitative reviews synthesize qualitative evidence to address questions on aspects of
interventions other than effectiveness.
Prognosis reviews address the probable course or future outcome(s) of people with a health
problem.
Cochrane Reviews base their findings on the results of studies that meet certain quality criteria,
since the most reliable studies will provide the best evidence for making decisions about health
care.
Cochrane Reviews are updated to reflect the findings of new evidence when it becomes available
because the results of new studies can change the conclusions of a review. Cochrane Reviews are
therefore valuable sources of information for those receiving and providing care, as well as for
decision-makers and researchers.
Ref: pubmed. Cochrane review.

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4. Nutritional management in critically Ill children.
Critically ill pediatric patients have complex nutritional needs and require intensive nutritional
support. As part of the metabolic response to injury, resting energy expenditure may be raised,
leading to extensive catabolism, hyperglycemia, progressive lean body mass loss, changes in
serum trace element levels, fluid retention, and reduced synthesis of visceral proteins such as
albumin. Contributing to poorer outcome is the high prevalence of malnutrition (40%) in
pediatric ICU patients.
Nutrition management includes both EN and PN. For critically ill children with a functioning GI
tract, the enteral route is preferable to PN. EN is physiologic and has been shown to be more cost
effective without the added risk of nosocomial infection inherent with PN . Critically ill children
receiving early feeding (<24 h after PICU admission) reported better tolerance than children
feeding late (after 24 h) postpyloric feeds.
As per ASPEN clinical guidelines.
Provide nutritional screening in a timely manner (within 24-48 hours of admission) to identify
those patients with preexisting malnutrition or those nutritionally at risk.
Complete a comprehensive nutritional assessment with the development of a nutrition care plan
within 24 to 72 hours of admission to the PICU, using the Nutrition Care Process to include
nutrition assessment, nutrition related diagnosis, nutrition intervention, and a monitoring and
evaluation plan.
Complete an assessment of energy and protein needs to prevent or manage preexisting protein-
energy malnutrition by providing an adequate and balanced amount of calories and protein in a
timely manner during the catabolic state to prevent both underfeeding and overfeeding.
Provide nutrition support, preferably using the enteral route, in a timely manner: (a) within 24 to
48 hours in children less than 2 years of age and for children with preexisting malnutrition or
at nutritional risk and (b) within 48 to 96 hours in children greater than 2 years of age, those
previously well nourished, or those not at nutritional risk.
Manage specific disease deficiencies and provide appropriate medical nutrition therapy based on
the childs underlying diagnosis, with the goal of improving the patients baseline nutrition status.
Following the acute phase, promote catch-up growth, thereby helping to reverse the effects of
growth failure in children with underlying malnutrition and chronic nutrition conditions.

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GI symptoms are the most common complication of EN including aspiration, diarrhea,
constipation, vomiting, and abdominal distention. These may be minimized by selection of the
appropriate enteral formula and mode of delivery, gradual introduction of the feed with
monitoring of residual gastric volumes.
Nasogastric feeding should begin within 24 h, but if intolerance develops, promotility drugs
(erythromycin or metoclopramide) or small bowel feeding should be attempted before
resorting to supplementary parenteral nutrition.
There is no significant difference in the efficacy of jejunal versus gastric feeding. Reassess and
reduce to minimal effective dose of narcotic agents. Correct hypokalemia. Keep proper 45
degrees up position. Whole protein formulae are appropriate in most patients because no clinical
advantage of peptide based formulae could be found.
About total PN is provision of nutrition for metabolic requirements and growth through the
parenteral route. If the GI tract cannot be used as a route of administration for nutrition,
parenteral nutrition may be indicated. Catheter-related sepsis is one of the most serious
complications. Incidence of catheter-related sepsis is ~5%, and it is documented that any fever in
the absence of an obvious focus of infection must be attributed to catheter-related sepsis until
proved otherwise. Other effects like lipid intolerance, increased free bilirubin concentrations,
impaired pul monary function, or increased risk for developing chronic lung disease and
interference with immune and platelet function. The most serious and significant life-threatening
complication is parenteral nutrition-associated cholestasis.
During total parental nutrition infusion, a minimal amount of enteral feeds should be given to
patients whenever possible and increased gradually while decreasing total PN. Parental nutrition
may be stopped when the infant is tolerating at least 100 cm 3/kg/day of enteral feedings or is
receiving up to 25 cm 3/kg/day of total parental nutrition.
Reference: ASPEN, IAP guidelines in critical ill children. 2016.

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5. Magnitude of suicide. Approach to suspect and prevent self harm.
Epidemiological data suggests suicide is uncommon in childhood but becomes an extremely
serious issue among adolescents.
Several risk factors have been identified and include the presence of psychiatric illness, a
previous suicide attempt, family factors, substance abuse, sexual and physical abuse, disorders in
gender identity or bullying. Pediatricians have a primary role in searching for these risk factors,
recognizing them and acting synergistically with other specialists to prevent and treat suicidal
behavior.
Mean rate of suicide in children and young adolescents up to 14 years of age of approximately
0.6/100.00 worldwide, with a male-female ratio of 2:1. Childhood affective and disruptive
disorders and abuse were the most often reported psychiatric risk factors.
Suspect when.
Talking about suicide as "I'm going to kill myself," "I wish I were dead" or "I wish I hadn't been
born"
Getting the means to take own life, such as buying a gun or stockpiling pills.
Withdrawing from social contact and wanting to be left alone.
Having mood swings, such as being emotionally high one day and deeply discouraged the next.
Being preoccupied with death, dying or violence.
Feeling trapped or hopeless about a situation.
Increasing use of alcohol or drugs.
Changing normal routine, including eating or sleeping patterns.
Doing risky or self-destructive things, such as using drugs.
Saying goodbye to people as if they won't be seen again
Developing personality changes or being severely anxious or agitated.

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Preventive strategies.
1. School-based suicide prevention programs .
2. mentalization based therapy (MBT-A)
3. dialectical behaviour therapy (DBT-A)
4. cognitive behaviour therapy (CBT)
5. home-based family intervention .

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6. Management of suspected sexual abuse.
Child Sexual Abuse is an alarming reality and is being increasingly reportedin India as well as
globally. Pediatricians and allied medical professionals are often the first point of contact with
abused children and their families. They have a key role in detecting Child Sexual Abuse,
providing immediate and long-term care and support to the victims and their families.
India has adopted the Protection of Children from Sexual Offences Act (POCSO) in 2012. It is a
comprehensive law on sexual abuse, which expands the scope and range of forms of sexual
offences, makes reporting of abuse mandatory and defines guidelines for the examination of
victims.
Sexual violence takes place in all settings: at home, schools, child care institutions, places of
work and in the community.
Initial management of child sexual abuse
Every case of sexual assault is a medical emergency for which free treatment is mandatory at
government or private medical facilities, and no document or precondition is necessary for
providing emergency medical care.
An informed consent must be obtained, which is required for examination, collection of samples
for forensic examination, treatment and police intimation. The diagnosis of CSA is most often
based on the history, as opposed to physical findings; and thus obtaining a meticulous history of
the child‘s experience is crucial.
The interview should be conducted in a facilitative, nonjudgmental and empathetic manner and
should not have an investigative tone. Leading and suggestive questions are avoided and
expression of strong emotional responses such as shock or disbelief is resisted.
A review of systems is done focusing on any anal and genital complaints such as bleeding,
discharge, pain. Doctors are legally bound to examine and provide treatment to survivors of
sexual violence. Timely reporting, documentation and collection of forensic evidence are
important toward investigation of the crime.
Physical examination in CSA is very likely to be within normal limits in most cases. sexual
abuse may be nonpenetrating contact and may involve fondling, oralgenital, genital or anal
contact, as well as genital-genital contact without penetration.
The following investigations are routinely carried out:
• Gram stain of vaginal or anal discharge

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• Genital, anal, and pharyngeal culture for Gonorrhea
• Genital and anal culture for Chlamydia.
• Serology for syphilis
• Wet preparation of vaginal discharge for Trichomonas vaginalis
• Culture of lesions for herpes virus
• Serology for HIV (based on suspected risk).
The management of CSA includes the following:
• Treatment of sexually transmitted diseases (STDs) is carried out with appropriate medications.
• In post-menarchal girls, the likelihood of pregnancy and the need for emergency contraception
is considered. • Emotional support is provided. • CSA, whether confirmed or strongly suspected,
must be reported to the appropriate authorities.
• Detailed, well-documented medical records must be kept, since these are crucial in legal
proceedings, which may take place after a lapse of long periods.
• Referral to a mental health specialist should be made in all cases, which is required for
evaluation and treatment of acute stress reaction, and subsequently posttraumatic stress disorder
(PTSD). Referral to other specialists should be made as required.
The POCSO Act envisages a multidisciplinary approach that will be conducive to medical care
and justice delivery for a sexually abused child.
Refrence: POCSO. 2012.act.

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7. Digital media. Ill effects and prevention.
Radio, television (TV), movies, video games, cell phones, and computer networks have assumed
central roles in our children‘s daily lives. The media has demonstrated potentially profound
effects, both positive and negative, on children‘s cognitive, social, and behavioral development.
Very young children who developmentally think concretely and are unable to distinguish fantasy
from reality. Furthermore, time spent with media decreases the amount of time available for
pursuing other more healthy activities such as sports, physical activity, community service,
cultural pursuits, and family time.
Exposure to media violence has been positively related to subsequent aggressive behavior, ideas,
arousal, and anger. Association between TV viewing and suicidal behavior has also been
reported.
Viewing television causes poor peer relationships and thereby increases the risk for social
isolation, anxiety disorder, agoraphobia, and antisocial behavior, including aggression and gang
involvement.
Playing of video games is used as a substitute for regular physical activity with nearly a 2-fold
increased risk of obesity for every hour spent playing electronic games daily.
The frequency of reading fashion magazines was positively associated with the prevalence of
having dieted and exercised to lose weight and to improve body shape.
More than half of adolescent smoking initiation has been linked to watching smoking in movies.
There are reports of messaging of sexual contents through mobiles among schoolgoing
adolescents. Exposure to alcohol advertising and TV programming is associated with positive
beliefs about alcohol consumption.
Prevention
Media needs to be recognized as a major public health issue rather than as a series of commercial
endeavors in need of regulation, as they are among the most profound influences on children.
We need to find ways to optimize the role of media in our society, taking advantage of their
positive attributes and minimizing their negative ones.
Media should deliver positive messages e.g. program to address childhood obesity, to encourage
parents to talk to their pre-adolescent and adolescent children ―early and often‖ about delaying
the onset of sexual activity, anti tobacco message etc. Parents need to be educated about the
negative effects of media.

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American Academy of Pediatrics (AAP) has recommended guidelines for use of media in
children:
1) not allowing the bedroom to be a media center with TV, video games, and Internet access;
2) limiting media time to 1 to 2 hours of quality programming;
3) discouraging TV viewing for children younger than 2 years ;
4) viewing and discussing content together;
5) turning off the TV when no one is watching and during meals; and
6) being a good media role model.
Reference: IAP guidilines: 2018.digital media ill effects in children.

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8. Antibiotic stewardship in inpatient and outpatient.
Antibiotics are among the most commonly used medications in pediatric inpatient and outpatient
settings, with a significant proportion of antibiotic use considered unnecessary. Antibiotic
stewardship is dedicated to using antibiotics only when necessary, and using the appropriate
spectrum of activity, dose, route and duration of therapy to optimize clinical outcomes while
minimizing harm.
Outpatient programs
The vast majority of antibiotic prescribing occurs in the outpatient setting, and at least half of
these prescriptions are considered inappropriate. Although most outpatient pediatric antibiotic
prescriptions come from primary care encounters, subspecialty practices, emergency departments
(EDs), urgent care clinics, retail clinics and dentists' offices also are important settings for
outpatient antibiotic stewardship.
Strategies for conducting antibiotic stewardship in the outpatient setting include reducing
unnecessary prescribing, judicious diagnosis, and optimizing antibiotic choice, duration and
route of therapy.
Outpatient primary care practices, urgent care clinics and EDs could establish standardized
approaches for antibiotic prescribing, including clinical guidelines and/or decision support.
Outpatient stewardship can focus on judicious use of antibiotics for acute respiratory tract
infections, including avoidance of antibiotic prescribing for undifferentiated upper respiratory
tract infection, bronchiolitis, acute bronchitis and nonstreptococcal pharyngitis; refraining from
prescribing antibiotics for urinary tract infections in the absence of a urinalysis and urine culture;
and judicious diagnosis of acute otitis media, acute sinusitis and group A streptococcal
pharyngitis.
Outpatient efforts can emphasize use of the narrowest-spectrum antibiotics for the shortest
duration of therapy that will treat bacterial infections adequately.

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Inpatient programs
Strategies for conducting antibiotic stewardship in the inpatient setting include local guidelines,
prior approval, post-prescription review with feedback, syndrome-specific stewardship and use
of rapid diagnostic tests. Those governing antibiotic use for children should include specialists
with pediatric expertise.
Inpatient ASPs ideally are comprised of a medical director and a clinical pharmacist(s), both
with expertise in pediatric infectious diseases and/or antibiotic stewardship. They can utilize
clinical guidelines, prior approval and post-prescription review and feedback as core
interventions.
Inpatient ASPs can include pharmacy-driven interventions such as dose optimization,
therapeutic drug monitoring, automatic conversion of intravenous to oral antibiotic therapy or
dose adjustments in cases of organ dysfunction.
These programs can consider auditing, analyzing and reporting local unitspecific antibiotic
prescribing data periodically to stakeholders.

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9. Telemedicine. Advantage and disadvantages.
Advantage.
1. It helps hospitals provide better treatment for remote patients.
2. It improves communication between patients and specialists .
3. It gives time back to both patients and doctors.
4. It limits the exposure patients have with other sick people.
5. It helps doctors quickly handle straightforward medical problems.
6. It reduces no-show costs.
7. It expands your medical practice‘s client base.
8. It provides a competitive advantage over other practices.
9. It enables working from home.
Disadvantages.
1. It may require new equipment.
2. It may be harder to create a personal connection.
3. Not all illnesses can be diagnosed remotely.
4. Technology can fail. No matter how good your technology is, it‘s not immune to internet
outages, overloaded servers, and incompatible client hardware.
5. There are regulatory hurdles. There could be a lack of interoperability with EHR systems.
6. It requires additional training.There may be a lack of adoption. Patients might not use
telemedicine because they have a hard time with new technology, aren‘t aware of their
options, or simply because of miscommunication.

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10. Umbilical Cord banking. Pros and cons.
Pros.
1. Umbilical cord blood is a rich source of hematopoietic stem cells, which have been
successfully used for curingvarious conditions including malignancies, hematological conditions,
primary immunodeficiency and few selectedinherited metabolic disorders.
2. Umbilical cord blood can be safely collected from the placenta without any risks to the baby
and the motherin an otherwise uncomplicated delivery.
3. Public cord blood banking serves the actual purpose of preservation, which provides cord
blood stem cells forthe patients lacking matched sibling donor or matched unrelated donors, in
need of hematopoietic stem celltransplant.
4. Public cord blood banking should be promoted, which expands treatment options for patients
suffering fromcertain serious illnesses.
5. India, with high birth rate and diverse genetic pool, has a bright prospect in public cord blood
banking to increasethe chances of finding HLA-matched hematopoietic stem cells for transplant.
cons.
1. Cord blood collection is not advisable in complicated deliveries.
2. Autologous cord blood stored privately cannot be used for treating one’s own genetic
conditions in future (includinghemoglobinopathies, storage disorders, hemophagocytic
lymphohistiocytosis, immunodeficiencies, etc.) as thecord stem cells harbor the genetic
abnormality leading to the disease.
3. Autologous cord blood is not preferred in treating various hematological malignancies,
due to proven therapeuticeffect of graft-versus-leukemia reaction seen only in allogenic stem cell
transplantation.
4. Cord blood storage is not indicated for autologous stem cell transplantation.
5. Private cord blood banking is not a ‘biological insurance’ and its role in regenerative
medicine is still hypothetical.
6. Private cord blood banking is recommended only if there is an existing family member
(siblings or biologicalparents only), who is currently suffering from diseases approved to be
benefitted by allogenic stem celltransplantation.

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It is imperative to spread awareness about myths and facts about cord blood banking (public and
private) amongthe public (by mass campaigning) and among the health workers (by including
this subject in under graduateacademic curriculum).
7. Advertisements for private cord blood banking by companies (e.g., by using celebrities) are
often misleadingand exploit parents’ emotions for profit, at the vulnerable period of
pregnancy and is a costly process too.
Reference: IAP guidelines: cord banking. 2020.

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11. Recent advances in diagnosis and treatment of hypertension.
Classification <13 years <13 years Recommendations
Normal
blood
pressure
<90th percentile <120/80 mm
Hg
If normal or repeated measurements
are normal, it is recommended that it
should be measured at the well child
follow-up visit one year later
Increased
blood
pressure.
Between
120/80 and
129/80 mm
Hg
Between ≥90th
percentile and
<95th percentile
or between
120/80 mm Hg
and <95th
percentile
(whichever is
lower)
Between
120/80 and
129/80 mm
Hg
1st step: Lifestyle modifications
(healthy diet, sleep and physical
activity) should be recommended. The
patient should be asked to attend a
follow-up visit six months later. If
necessary, the patient may be
referred to the unit related to nutrition
and/or body weight.
2nd step: If increased blood pressure
still persists in the end of follow-up
visits performed with 6 month intervals
at the first year after presentation,
ABPM and diagnostic tests should be
performed, and the child should be
referred to pediatric nephrology.
Stage 1
hypertension
Between ≥95th
percentile and
<95th
percentile+12
mm Hg or
between 130/80
and 139/89 mm
Hg (whichever is
lower)
Between
130/80 and
139/89 mm Hg
1st step: If blood pressure is found at
a level of stage 1 hypertension and is
asymptomatic, the patient is asked to
attend follow-up visits with 1–2 week
intervals.
2nd step: blood pressure is measured
in the right arm, left arm and single
leg (right or left). Recommendations
related to nutrition and body weight
control are given. 3rd step: If still
increased after three follow-up visits,
ABPM and investigations should be
performed. The child should be
referred to pediatric nephrology or
pediatric cardiology.
stage 2.
Between
120/80 and
≥95th p+12 mm
Hg or ≥140/90
≥140/90 mm
Hg
1st step: If blood pressure
measurement indicates stage 2
hypertension and the patient is

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129/80 mm
Hg
mm Hg asymptomatic, blood pressure is
measured in the right arm, left arm
and single leg. Lifestyle
recommendations are given.
2nd step: If still increased in one
week, the patient is referred to
relevant center. ABPM is
recommended.
Doppler renal ultrasonography (USG) may be used with with normal weight who are
considered to have renal artery stenosis (RAS). In the diagnosis of RAS, conventional
arteriography is the gold standard. Magnetic resonance (MR) or computed tomography (CT)
are acceptable noninvasive imaging methods. Nuclear renography should not be used in children.
AAP recommends that cardiac imaging should include left ventricular ejection fraction, mass,
and wall thickness. Microalbuminuria may be observed in conditions such as chronic renal
failure, obesity, insulin resistance, dyslipidemia, and intense physical activity in children.
The objective in treatment is to prevent end-organ damage and to reduce the risk of
hypertension and cardiovascular disease in adulthood. The target blood pressure is
<130/80 mm Hg or a SBP and DBP values below the 90th percentile (whichever is
lower). The mean arterial pressure should be kept below the 50th percentile in patients
with chronic renal disease.
AAP recommends angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor
blockers (ARB), long-acting calcium channel blockers or thiazide diuretics as initial
treatment. Beta-blocker drugs should not be used as first-line therapy in children in terms
of safety. Extended release drugs should be preferred and the highest dose that will not
lead to adverse effects should be used.
Treatment-resistant hypertension is defined as persistence of hypertension despite intake of
three or more antihypertensive drugs at the highest doses . Renovascular hypertension
should be considered primarily in the differential diagnosis.
Increase physical activity and initiate a DASH-type diet (e.g. rich in vegetables and fruit,
foods containing whole grain and low-fat meat and milk products, diet poor in saturated
fat and sugar). Walking for 60 minutes daily is important in controlling blood pressure.
Sleep hours should be regulated and avoidance of smoking should be supported. Daily
salt intake should be restricted to less than 3 g. These preventive strategies should
constitute the primary step in fighting childhood and adolescence hypertension.

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12. Iap guidelines on junk food.
1. Guidelines for Children and Family.
1. Avoid consumption of the JUNCS foods and beverages by all children and adolescents, as far
as possible. Alternatively, limit consumption of the JUNCS foods at home/outside and suggest to
have not more than one serving per week; serving not exceeding 50% of total daily energy intake
for that age.
2. Do not consume foods while watching television/ screen. WHO guidelines to eliminate trans-
fat and reduce free sugars to <5% of total energy intake.
3. Freshly cooked home foods with minimal addition of sugar and no trans-fats should be
preferred over restaurant/packaged foods.
4. Traditional and acceptable home-made snacks with long shelf-line can be offered to children
as alternative to the JUNCS foods. Lunch boxes packed only with healthy food should be carried
to school if school does not have provision of providing healthy mid-day meal.
5. The JUNCS food should not be offered as reward/gift to any child as this gives undue
promotion to unhealthy foods.
2. Policy Recommendations for Schools, Labelling, Advertising, and Marketing.
1. Efforts to regulate availability of the JUNCS foods in schools must be coupled with ensuring
availability and affordability of a variety of healthy snacks and foods in mid-day meals or school
canteens .
2. Advertisement of the JUNCS foods may lead to unhealthy food choices and is likely to be
associated with increasing obesity.
3. Differential taxation on the JUNCS and healthy foods/ beverages should be considered to
promote healthy eating.
3. Behavioral Change and Communication.
1. Nutrition education initiatives should be taken to increase awareness among school children.
Schools should be motivated to organize poster-easycompetitions, debates, etc on adverse effects
of the JUNCS foods, besides teaching about healthy and balanced diet.
2. Children, parents and general public should be advocated about the associated ill health effects
of the JUNCS foods in various forms such as observing obesity prevention day, distribution and
display of charts/posters in pediatricians‘ clinics.

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2019. December
13. Hidden Hunger.
The The word hidden hunger refers to a more insidious types of deficiency caused by eating food
that is cheap and filling but deficient in essential vitamins and minerals and micronutrients.
Though the consequence of deficiency of micronutrients are understood they often go unnoticed
within community. Hence it is called as hidden hunger.
Hidden Hunger can occur even in community where food is available plenty for carbohydrates.
When people cannot diversify their diet with vegetables, fruits and animal source food,
micronutrients deficiency is inevitable.
Micronutrients are the essential vitamins and minerals required by human beings to stimulate
cellular growth and metabolism. Deficiency of iron, iodine and vitamin A are the most
widespread forms of micronutrients malnutrition with public consequences in community.
Diagnosis in the community. The external visible effects of hidden hunger are anemia, goitres,
etc.
Subclinical indicators are measured to determine and monitor the extent of problem.
In India, more than 50% children below 5 years are found to be anemic and is found even in kids
born for parents with higher education and household wealth.
Adequate interventions and education regarding nutrition can prevent the hidden hunger.
Reference: www.WHO.int.

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14. District early intervention centre.
District early intervention centres are being established at district hospital level across the
country for the purpose of evaluating and management all children below 6 years of age.
Children above 6 years are also classified as team 2 in DEIC and are not mixed with those of
below 6 years and the DEIC manager coordinates the OPD services separately and links those
below 6 years age with those NICU and SNCU graduates who had prolonged hospital stay after
birth.
Core therapies under DEIC are as follows.
It provides medical, dental, nutritional, vision, hearing therapies.
It provides occupational therapy, physiotherapy, psychosocial services.
It serves Pediatric orthopedic services and refering support for surgical procedures.
Its an integral part of RBSK project. Each DEIC is managed by a team of pediatrician, medical
officer, dentist, staff nurse, paramedics.
DEIC aimd at early detection of disabilities and development delays.
Thus the DIEC is the hub of all management activities, post identification, acts as clearing house
and referral linkage and intervention with fundings from NHM and RBSK.
Reference: nhm.gov.in.

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15. INAP
India new born action plan, developed tin response to the global every New born action plan
launched at world health assembly outlines a targeted therapy strategy for reduction of still births
and neonatal mortality rate in the country.
Insp defines the latest evidence on effective interventions.
With clearly marked timeline for implementing and evaluating and monitoring it aims at
achieving the goal of single digit NMR by 2030 in the country.
INAP will be implemented with the existing RMNCH frame work.
Its principles are integration, equity, quality of care, accountability and partnership.
The most important aspect of INAP Is care beyond survival. India has taken a vital step towards
improving the quality of life beyond survival for those New born with birth defects and
disabilities and for those with neurodevelopmental delays.
A systematic plan for monitoring and evaluation has been frameworked with a list of dashboard
indicators.
INAP is Indian commitment for ending preventable still births and neonatal deaths.
Reference: nhm.gov.in

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16. Foetal onset of adult disease.
The core of theory of fetal origin of noncommunicable adult disease like coronary heart disease
and type2 diabetes and hypertension is that they originated as a response to undernutrition while
as a fetus.
The nutritional deprivation of fetus during critical period of development force's the baby to
restore to adaptive strategies for survival which entail a resetting of metabolic development.
These adaptations become maladaptive if the organisation encounter contrast nutritional
circumstances in post natal life.
Thus maternal malnutrition leads to fetal malnutrition which leads to fetal liver malfunction and
insulin resistance and abnormal vascular development which when exposed to contrasting
circumstances post birth lead to development of hypertension and diabetes and hyperlipidemia.
The concept of fetal programming during development has been proposed to explain the findings.
Fetal undernutrition especially during 2nd trimester raises the risk of wrong programming for
blood pressure and cholesterol and hormonal metabolism.
The thinness of Indian babies was advantageous for circumstances for for survival in past, but in
current context of available of plenty food source and very6limited physical activity is causing
the consequences of maldevrlopment of programming.
Thus the genotype called as thrifty genotype responsible for surviving small baby in the past is
now reason for current paradox due to cganged post natal circumstances.
Thus it is traceable that im developing countries like India most of the adults who succumbing
for hypertension and diabetes are found to be low birth weight and had a drastic catchup later in
life.
Thus it is always better to prevent low birth weight babies by appropriate interventions to
prevent maternal malnutrition and fetal undernutrition rather than to over feed the baby after
birth.
Thus we can aim at reducing the incidence of noncommunicable adult diseass.

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17. Anemia mukth Bharat.
To achieve the target of world health assembly of 50 percent reduction of anemia in women and
children AMB has been designed and launched by shri Narendra Modi. Prime minister of India.
It has been built upon existing framework of NIPI with special focus on behaviour change
communication, vulnerable geography, supply chain management.
The benificiery are children, adolescent and women of reproductive age group.
The key interventions are IFA supplementation, deworming, creating nutritional awareness,
appropriate IYCF practices, screening and treatment of malaria, delayed cord clamping.
The components are iron and folic acid tablets and syrups and albendalzole syrups dosed
according to the age a6 requirements.
National anemia mukth Bharat steering committee will be merged into existing RBSK committee
and ministry of women and child development.
All the technical assistance is provided from AIIMS, new Delhi as the nodal center.
Anemia mukth Bharat has to work in the direction felt by the need of community to reduce the
invisibility of anemia.
Reference: nhm.gov.in, vikaspedia.in

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18. Neonatal mortality Severity scoring
A variety of risk adjustment scores have been derived and advocated for use in assessing
neonatal mortality.
Few of them are.
CRIB. Clinical Risk index of babies. Birth weight and fio2 requirements and malformations are
considered.
Berlin score. Grade of RDS, weight, base excess and apgar at 5 min.
NMPI score. Neonatal mortality prognosis index. Gestational age, birth weight, pao2/fio2 ratio,
congenital malformations, sepsis are components.
SNAP score. Score for neonatal acute physiology. Multiple bitsl parameters and laboratory
parameters are invluded.
NTSS score. National therapeutic intervention scoring system. Based on treatment recieved by
infant rather than pathophysiology factors.
These scores are even used for assessing neurological morbidity.
Illness severity scores are now well accepted essential tools comparing health care providers.
Even the best scoring system is never accurate. No mathematics formula can completely capture
the complex clinical process of a neonate.
The usage of these scoring system are associated with ethical and legal concerns causing a
restricted usage.
Further research work is needed for comfortable usage of scoring system for clinical applications.

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June 2019.
19. Simulation. Newer medical teaching training technology.
The traditional ‗apprentice‘ learning model in medical education is undergoing a pedagogical
shift to a simulation-based learning model – ‗see one, do one, teach one‘ now becomes ‗see one,
practice many, do one.
‗First, do no harm‘: Patient safety has become a major focus of individual hospitals, academic
institutions, and healthy care regions/countries over the last 15 years.
The pediatric and neonatal intensive care settings are highly dynamic and stressful workplaces
where medical errors have significant consequences. In general, the ethical imperative for SBME
may be stronger in pediatrics, since children are not capable of providing informed consent on
their own, unlike other fields of health care.
SBME creates a safe learning environment where mistakes made are not harmful or dangerous to
patients but, rather a powerful learning experience for students and professionals.
Health care workers are allowed to practice and commit mistakes in a controlled environment
that provides them an opportunity to learn from the mistakes made and with constructive
feedback.
Worldwide, SBME has been widely accepted in many neonatal, pediatric and adult life-support
courses, like neonatal resuscitation program (NRP), Acute care of at- risk newborn (ACoRN),
STABLE program, and Pediatric advanced life support (PALS) courses.
Effective simulation is not dependent on the use of highly complex and expensive patient
simulators; instead it is dependent on carefully designed scenarios that align closely with the
needs of the learners and skillfully-led debriefings.
Simulation has been used as an evaluation tool to assess knowledge e.g., OSCE stations of
medical licensing exams.
Although SBME cannot replace clinical exposure, it does provide an opportunity for repetitive
practice in a low-risk environment.
Reference.
Indian pediatrics. VOLUME 52__JANUARY 15, 2015

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20. Indications of platelet transfusion.
CHILDREN AND ADOLESCENTS
1. Maintain PLT count >50 × 109/L with bleeding
2. Maintain PLT count >50 × 109/L with major invasive procedure; >25 × 109/L with
minor
3. Maintain PLT count >20 × 109/L and marrow failure WITH hemorrhagic risk
factors
4. Maintain PLT count >10 × 109/L and marrow failure WITHOUT hemorrhagic risk
factors
5. Maintain PLT count at any level with PLT dysfunction PLUS bleeding or invasive
procedure
INFANTS ≤4 MO OLD
1. Maintain PLT count >100 × 109/L with bleeding or during extracorporeal
membrane oxygenation
2. Maintain PLT count >50 × 109/L and an invasive procedure
3. Maintain PLT count >20 × 109/L and clinically stable
4. Maintain PLT count >50 × 109/L and clinically unstable and/or bleeding or not when
on indomethacin, nitric oxide, antibiotics, etc. affecting PLT function
5. Maintain PLT count at any level with PLT dysfunction PLUS bleeding invasive
procedure.
Reference. Nelson 20 edtn. Pg. 2374.

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21. Selective hypothermia for HIE.
Whole body (systemic) or selective cerebral therapeutic hypothermia reduces mortality or
major neurodevelopmental impairment in term and near-term infants with HIE.
Isolated cerebral cooling to a core (rectal) temperature of 33.5°C (92.3°F) within the 1st 6
hr after birth (duration 72 hr) reduces mortality and major neurodevelopmental impairment
at 18 mo of age.
Complications of induced hypothermia include thrombocytopenia (usually without bleeding),
reduced heart rate, and subcutaneous fat necrosis (associated with hypercalcemia in some)
and the potential for overcooling and the cold injury syndrome.
Indications.
1. Postmenstrual age (PMA) ≥36 weeks, BW ≥2,000 g
2. Evidence of fetal distress or neonatal distress as evidenced by clinical examination or
ABG analysis.
3. Evidence of moderate to severe neonatal encephalopathy by exam and/or aEEG.
Systemic hypothermia may result in more uniform cooling of the brain and deeper CNS
structures. Infants treated with systemic hypothermia have a lower incidence of cortical
neuronal injury on MRI.
Reference Nelson. 20 edtn. Pg 840. Cloherty 8 edtn. Pg 804.

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22. Immunomodulatory therapy in Nephrotic syndrome.
Steroid-dependent patients, frequent relapsers, and steroid-resistant patients are candi-dates for
alternative therapies, particularly if they have severe cortico-steroid toxicity features.
The agents used are.
1. Cyclophosphamide prolongs the duration of remis-sion and reduces the number of relapses in
children with frequently relapsing and steroid-dependent nephrotic syndrome. 2mg/kg for 12
weeks.
Side effects. neutropenia, disseminated varicella, hemor-rhagic cystitis, alopecia, sterility,
increased risk of future malignancy.
2. Calcineurin inhibitors (cyclosporine or tacrolimus) are recom-mended as initial therapy for
children with steroid-resistant nephrotic syndrome. 5mg/kg for 12 months.
side effects. hypertension, nephrotoxicity, hirsutism, and gingival hyperplasia.
3. Mycophenolate . Mycophenolate can maintain remission in children with steroid-dependent
or frequently relapsing nephrotic syndrome. 800mg/m2 for 12 months.
4. Levamisole, an antihelmintic agent with immunomodulating effects that has been shown to
reduce the risk of relapse .2mg/kg for 12 months
5. Rituximab, the chimeric monoclonal antibody against CD20, in children with steroid-
dependent and/or steroid-resistant nephrotic syndrome achieves prolonged remissions.
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers may be helpful as
adjunct therapy to reduce proteinuria in steroid-resistant patients.
Scotts pediatrics. 3rd edtn. Pg. 205.

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23. Combined vaccines.
As more effective vaccines are being developed, the question of the number of needle pricks to
which the young infants are subjected to becomes important.
More vaccines may also lead to more visits to physicians. Combination vaccines represent one
solution to the issue of increased number of injections during a single visit.
The combination has facilitated the introduction of these vaccines into recommended
immunization schedules by reducing the number of injections required and has therefore
increased immunization compliance.
Reducing injections by combining vaccines reduces trauma to the infant and has been found to
lead to higher rates of compliance with complex vaccination schedules.
Immunological, physical, and/or chemical interactions between the combined components have
the potential to alter the immune response to specific components. Furthermore, if the vaccines
to be combined have differing immunization schedules, consolidation of these should also not
negatively affect immunogenicity, efficacy, or safety.
1. DPT. Among the traditional vaccines, DPT combination was a standard for a long time
covering diphtheria, pertussis, and tetanus. Given as intramuscular
Logical additions to (DPT) were Haemophilus influenzae type B (Hib), injectable polio, and
hepatitis B.
2. Quadravac. DPT plus H. Influenza type B. 0.5ml IM
3. Pentaxim. DPT Hib. Plus inactivated polio .0.5 ml IM
4. Hexaxim. DPT, Hib, inPolio, Hepatitis B. 0.5 mo IM.
5. MMR. Measles mumps rubella vaccine covering 3 viruses given as subcutaneous dose o.5 ml
6. MMMRV. Additional varicella component added. 0.5 ml subcutaneous.
The preservation of efficacy will need to be continually seen by trials and monitored by
surveillance as more such combinations are on the horizon.
Reference. IAP immunization guidelines. 2019.

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24. Newer treatment modalities in Hemophilia.
RICE therapy. Rest, Ice, Immobilisation, Compression, Elevation.
Factor replacement therapy. WtX100 for B, wt x100/2 for Hemophilia A.
DDVAP nasal spray 150ug metered dose or 0.3ug/kg iV dose.
Gene therapy using adeno associated virus AAV. vector.
Recombinant humanised factor replacement.
Factor 8 inhibitor bypassing acent. FEIBA. used in cases refractory to conventional therapy.
Reference. Piyush gupta. Textbook. Hemophilia.

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25. Prebiotics and probiotics.
Probiotics are gut friendly bacterial agents used in acute diarrhoea.
Have limited role but promising utility in persistent diarrhea.
Probiotics are living microorganisms which act as surrogate of normal flora.
Sacharomyces baulardi, lactobacillus rhamnosus GG, Etc.
One specific strain to be used. Mixing up may cause ineffictiveness or fungal sepsis.
Efficacy of one agent cannot be compared with those to another hence more extensive research
study is needed for finding out probiotics of choice.
Prebiotics. Prebiotics are a group of nutrients that are degraded by gut microbiota.
Their degradation products are short-chain fatty acids that are released into blood circulation,
consequently, affecting not only the gastrointestinal tracts but also other distant organs.
Fructo-oligosaccharides and galacto-oligosaccharides are the two important groups of
prebiotics with beneficial effects on human health.
Reference. Piyush gupta textbook. Diarrhoeal disorders.
doi: 10.3390/foods8030092 prebiotic Foods. 2019 Mar; 8(3): 92.

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26. Indications for liver transplantation.
T he diseases for which liver transplantation is indicated can be categorized into the
following groups:
◆Obstructive biliary tract disease: biliary atresia, sclerosing cholangitis, traumatic or
postsurgical injury
◆Metabolic disorders: α1-antitrypsin deficiency, tyrosinemia type I, glycogen storage
disease type IV, Wilson disease, neonatal hemochromatosis, Crigler-Najjar type I, familial
hypercholesterolemia, primary oxalosis, organic academia, urea cycle defects
◆Acute hepatitis: fulminant hepatic failure, viral, toxin, or drug induced
◆Chronic hepatitis with cirrhosis: hepatitis B or C, autoimmune
◆Intrahepatic cholestasis: idiopathic neonatal hepatitis, Alagille syndrome, progressive
familial intrahepatic cholestasis
◆Miscellaneous: cryptogenic cirrhosis, congenital hepatic fibrosis, Caroli disease, cystic
fibrosis, polycystic kidney and liver disease, cirrhosis induced by total parenteral nutrition
◆Primary liver tumors: benign tumors (hamartomas, hemangioendothelioma), unresectable
hepatoblastoma, and hepatocellular carcinoma
◆Emerging indications: graft-versus-host-disease (a complication of bone marrow
transplantation), hemophilia, and portosystemic shunts
Biliary atresia is the most common indication for liver transplantation in children,
followed by metabolic and inborn disorders, autoimmune and familial cholestatic disorders,
and acute hepatic necrosis.

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27. Intra uterine foetal therapy.
Many genetic disorders can now be easily diagnosed using invasive and non invasive techniques.
Treatments for such conditions can be initiated intra uterine phase only.
1. Effective treatments for foetal tachycardias.
2. Corticosteroids treatment for CAH.
3. interventions for obstructive hydrocephalus.
4. Interventions for obstructive uropathy.
5. Open surgeries for meningomyelocele at 25 week GA.
6. Catheterization ballon dilations for congenital aortic stenosis.
7. Stem cell therapy for foetuses with thalassemia and immunodeficiency disorders.
Invasive nature of these therapies posses risk to both mother and the baby.
Reference. Piyush gupta textbook.

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28. Human milk bank. Indications.
WHO and UNICEF state that the use of human milk from other sources should be the first
alternative when it is not possible for the mother to breastfeed. Human milk banks should be
made available in appropriate situations. The IYCF Chapter is actively concerned about the
compelling use of formula feeds in the infants because of the non availability of human breast
milk banks.
Human milk banks are primarily focused to provide donor milk to high risk newborns admitted
in the neonatal unit.
If mother‘s own milk is unavailable or insufficient, the next best option is to use pasteurized
donor human milk (PDHM). India faces its own unique challenges, having the highest number of
low birth weight babies, and significant mortality and morbidity in very low birth weight
(VLBW) population.
If PDHM supplies are sufficient donor milk may be supplied for:
1• Absent or insufficient lactation: Mothers with multiple births, who can not secrete adequate
breastmilk for their neonates initially.
2• For babies of non-lactating mothers, who adopt neonates and if induced lactation is not
possible.
3• Abandoned neonates and sick neonates.
4• Temporary interruption of breastfeeding.
5• Infant at health risk from breastmilk of the biological mother.
6• Babies whose mother died in the immediate postpartum period.
Reference. HUMAN MILK BANKING GUIDELINES. Indian pediatrics. VOLUME 51__JUNE
15, 2014

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29. Indications of High flow nasal cannula oxygen in neonates.
Current practice in neonatology is directed toward the preference of noninvasive ventilation and
limitation of oxygen exposure.
High-flow nasal cannula (HFNC) was introduced through the last decade in adult, pediatric, and
perinatal care as an alternative to other noninvasive ventilatory interfaces.
The major indications for HFNC in neonates are thus the same as for nasal CPAP:
1. respiratory distress syndrome,
2. postextubation, and
3. apnea of prematurity.
It is as efficacious as nasal CPAP with even fewer adverse effects, especially trauma to the nasal
septum.
In neonates, it particularly reduces total ventilator days, occurrence of bronchopulmonary
dysplasia, re-intubation, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy
of prematurity.
Reference. High-Flow Nasal Cannula in Neonates
Ola G El-Farghali, Respiratory Care May 2017, 62 (5) 641-642; DOI: 10.4187/respcare.05566.

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December 2018
30. Indications of splenectomy in thalasemia.
1. Packed cellrrequirements more than 200ml/kg/yrs
2. Annual transfusionmore than 1.5 times basal requirements.
3. Difficulty to maintain pre transfusion level of 10g/dL
4. Massiv spleen size with abdominal discomfort
5. Presence of leukopenia and thrombocytopenia.
reference. Piyush gupta tb1. Pg 1556.
31. Role of immunophenotyping in leukemia.
1. Immunophenotyping of leukemic lymphoblasts and myeloblasts aids in the diagnosis.
2. It helps to find out the minimal residual disease.
3. Performed by using flow cytometry.
4. CD19,CD 22, CD10 are used to classify ALL as preB cell, B cell, T cell ALL.
5. CMPO, CD 33,CD34, CD13 are used to classify AML.
6. It doesn't aid in prognostic risk stratification.
reference. Piyush gupta tb1. pg 2420.

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32. Anti cytokine drugs. Indications
1. Anti TNF alfa. Etanercept, Infliximab, Adalimumab.
Used for Juvenile idiopathic arthritis, crohns disease, psoriasis, tuberculosis
2. Anti IL1. anakinra, rionacept.
Used for Auto inflammatory imunodeficent syndromes like CAPS, NOMID, FMF, TRAPS,
HIDS.
3. Anti IL6. Toclizumab.
Used for SOJIA, MAS, and malignanices like MDS.
33. Hematopoietic growth factors.
1. IL2 TCell growth factor.
2. IL5, eosinophils growth factor.
3. IL6, Bcell growth factor.
4.IL15, NK cell growth factor.
5. GMCSF, stimuluates granulocyte and activates macrophages and are produced from liver.
6. TPO, Synthesized in liver and activates megakaryocytic precursors.
7. EPO. Produced from kidney and liver and activates JAK2 kinase and stimulate synthroid
progenitors.
reference. piyush gupta tb1. pg 150

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34. Spinal muscular atrophy therapies.
1. Family education and counseling.
2. Genetic counseling. prenatal counseling for future pregnancies.
3. Pulmonary care. Airway clearance, respiratory support.
4. Nutritional care. GER prevention, PPI, prokinetics.
5. Speech therapy and Orthopedic andM rehabilitative care.
6. Gene therapy SMN1 recently approved by FDA, ZOLGENSMA.
7. And stem cell therapy.
reference. Piyush gupta tb1. Pg2246.
35. Diagnostic approach precocious puberty in girls.
1. Before 8 yrs in girls.
2. Clinical evaluation, CNS symptoms, eye symptoms
3. Family history, constitutional and familial.
4. tanners staging, anthropometry.
5. Hormonal evaluation. LH, FSH, Estradiol. High LH, FSH occur in central PP, whereas high
estradiol occurs in ovarian tumors.
6. Gonodotroipn stimulation test to differentiate between central and peripheral precocious
puberty.
6. 17OH Progesterone to rule out CAH.
7. Left wrist xray for bone age. Increased bone age compared to chronological age goes in
favour of central PP.
8. CT brain, MRI adrenals for tumours.
9. Pelvic USG for evaluation of peripheral PP.
Reference. piyush gupta tb1. Pg 2332.

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36. Renal nuclear scans.
1.DTPA. Diethylenetriamine pentaacetate. Glomerular filtering agent used intravenously Tc
labelled drug with perfusion phase, parenchymal phase and excretory phase.
Differential functioning capacity of each kidney can be determined.
2. Furosemide renography used for evaluation of obstruction.
3. Captopril renography used in evaluation of renovascular hypertension.
4. MAG scan. Mercaptoacetyl triglycine is used more in pediatrics bcz extraction fraction is
more for MAG than DTPA.
5. DMSA scan. Dimercapto succincic acid concentrated in renal tubules giving excellent image
of cortex. DefinesDDefined areas of inflammation and is used for identifying scarring.
Reference. piyush gupta tb1. Pg1974.
37. Serological tests for celiac disease.
1. In symptomatic cases serology values more than 10 times can omit the need for biopsy.
2. If less than 2 yrs continue further testing even if serology is negative.
3. In asymptomatic group at risk with positive HLADQ2, serology values more than 3 times
need biopsy.
4. tTGA. Tissue transglutaminase is th first screening test.
5. Anti endomysial antibodies.EMA are used if TGA results are equivocal.
6. Check for IGA deficiency if both are negative.
Reference. piyush gupta tb 1. Pg. 1370.

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38. Causes and pathophysiology of pancreatic exocrine deficiency.
1.cystic fibrosis . Fibrosis of the tissue with recurrent pancreatitis causes insufficiency. Large
volume foul smelling greasy stool, meconium ileus, distal obstruction.
2. Schwaback diamond syndrome. SBDS gene mutation causing ribosomal dysfunction in
secretion of pancreatic enzymes along with neutropenia.
3. Pearson syndrome. mitochondrial gene depletion causing bone marrow failure and pancreatic
disease.
4. Johnson blizzard syndrome. ubiquitin protein gene defect causing multiple endocrine and
exocrine deficiencies and congenital anomalies like urogenital anomalies and hypothyroidism
and deafness and short stature.
5. Isolated enzyme deficiencie of trypsinogen, enterokoinase, lipase.
6. Congenita rubella, duodenal artesia, celiac disease, chronic pancreatitis.
reference. Nelson 21. Ch.376.

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39. Childhood vertigo investigations and treatment.
1. Vertigo is positional dizziness. caused due to vestibular neuritis, labyrynthitis, migraine,
tumours, head trauma, meniers disease and benign positional.
2. Detailed history. Medication induced, orthostatic, travel associated, psychogenic.
3. Triggered exposure. trauma, migraine, BPPV.
4. Stroke, tumours, vestibular neuritis.
5. Perform dix hallpike maneuver. quickly making child supine rotated position from sitting
position. Checking for nystagmus.
6. Record blood pressure.
7. Epleys maneuver used to treat BPPV. it is quickly making child sit from prone rotated
position.
8. Suppurative labyrynthitis and compressing SOL needs surgical management.
9. Betahhistine used for meniere disease.
10. Lifestyle changes and physiotherapy
Reference. Nelson 21st. Ch.660.

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June 2018.
40. Diagnostic tests for dengue fever.
1. Virus isolation in culture in 1to 5 days.
2. Genome detection PCR in 1 to 5 days.
3. Antigen detection NS1. 1 to 5 days.
4. Antibody detection IGM. after 5 days.
5. Paired sera IGG. convalescent infections.
6. Raised hematocrit, thrombocytopenia, hyponatremia, metabolic acidosis, elevated liver
enzymes.
Reference. piyush gupta tb1. Pg 1206.
41. Diagnosis and treatment of scrub typhus.
1. History of travel to endemic area, presence of thrombocytopenia and eschar.
2. High tire of OXK in weilfelix test.
3. ELISA for outer membrane antigen is highly sensitive.
4. Indirect fluorescent assay and PCR are gold standard but costly.
5. Doxycycline 4mg/kg/day PO BD 7 days.
6. Azithromycin 10mg/kg/day on day 1 and 5mg/kg/day for 5 days PO OD.
Reference. piyush gupta tb1. Pg no. 1314.

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42. Investigations for diagnosis of tubercular meningitis.
1. Laboratory diagnosis.
A.CSF Microscopy ZN staining for AFB.
B. Low sugar high to near normal protein.
C. Aerobic culture of CSF.
D. CBNAAT of CSF.
E. CSF ADA levels and imunocytochemical staining ISMA.
2. MRI/ CT brain and spine.
3. Evidence of TB elsewhere.
A. Chest xray.
B. Montoux.
C. Sputum/gastric savage for AFB.
D. CBNAAT Of extra neural specimen.
reference. piyush gupta tb1. Pg no 2146.

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43. Cutaneous manifestations of SLE.
1. Malar rash. Butterfly shaped rash on face. Spares nasolabial folds,fixed erythema.
2. Discoid rash. Raised patches with scaling. Occurring on limbs, tunk and face.
3. Vasculitic rash. Which present as palmar erythema and tender nodules on skin.
4. Reynaud phenomenon showing coloured changes. Cyanotic appearance.
5. Alopecia. Cicatrial variant leading to hair loss.
6. Photosensitivity over sun exposed skin developing erythematous rash.
Referenc. piyush gupta tb1. Pg no 2552.

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44.Treatmen of JIA.
1. Multidisciplinary approach with physiotherapy, opthalmic, orthopedic, psychological and
pharmacological.
2. Oligo JIA.: NSAIDS and intraarticular steroids.
3. Polyarticular JIA.
Hydroxychloroquine 5mg/kg/day.
methotrexate weekly 10mg/m2.
Etanercept, Infliximab. TNF alfa antagonist.
4. Systemic onset JIA.
IV Methyl prednisolone 30mg/kg/day for 3 days.
Methotrexate weekly 20mg/m2.
Cyclosporine 5mg/kg/day BD .
5. Rituximab and abatacept are used in refractory cases.
Reference. Piyush gupta tb1. Pg 2533.

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45. Mamanagement of corrosive Ingestion in children.
1. They are acid, alkali,oxidants and heavy metals.
2. Immediate response is rinse with water, no neutralizing substance to be used.
3. Stabilization of airway.
4. Decontamination via lavage or charcoal are contraindicated.
5. Diagnostic upper GI scope with grading of injury.
6. Steroids to be given only in grade2 injury but not in grade 1 and 3.
7. PPI and H2 blockers and prophylactic Antibiotics.
8. Surgical referral and managemen accordingly if any perforation.
9. Long term management is stenosis which needs endoscopic dilatation and stent placements.
10. NG tube placed endoscopically after injury acts as temporary stent to keep patency.
Reference. Piyush gupta tb1. Pg no. 304.

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46. Hyper IGE syndromes.
Two different spectrum of disease variants are found.
1. Autosomal recessive.
DOCK8 mutations are found.
IgE >200IU/MLS. More of viral infections.
History of allergy, atopy and asthma is present.
There is an association of increased d risk of lymphoma.
Associated with poor prognosis.
2. Autosomal Dominant. Job syndrome, Buckley syndrome.
Occurs due to STAT3 mutation. Presents with recurrent bacterial infections.
Predominantly staphylococcus aureus infections occur.
Extra immune manifestation include craniosynostosis, scoliosis, hyperextensible joints.
Reference. Nelson 21ed. Pg 1118.

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47. Plasmapheresis
1.Plasmapheresis divided into membrane and centrifugal plasmapheresis.
Membrane plasmapheresis: Membrane plasmapheresis is therapeutic and it is done in the
dialysis centers.
Centrifugal plasmapheresis: Centrifugal plasmapheresis is done on transfusion department for
separation of individual components from donor blood.
2. Therapeutic plasma exchange (TPE) is an extracorporeal procedure where plasma is separated
from the cellular component of patient's blood, which is retained. Then, plasma is discarded and
replaced with either fresh frozen plasma (FFP) or albumin.
3.Mechanism of action . TPE or plasmapheresis efficiently removes pathogenic antibodies,
immune complexes, plasma proteins, cytokines, lipoproteins, protein-bound drugs, and metabolic
toxins from the plasma. Consequently, TPE has been used to treat a variety of diseases in both
children and adults.
1) By rapid depletion of pathologic antibody or immune complexes
2) Immune modulation by reducing immunomodulation by reducing T helper type-1/T helper
type-2 (Th1/Th2) cytokine ratio.
4. Uses in clinical practice are
1. Category 1. 1st line of treatment . GBS, Atypical HUS, TTP, MG, Wilson disease.
2. Category 2. 2nd line of therapy. ADEM, MS, SLE, Lambert Eaton syndrome.
3. Category3. No proven role. AIHA, Pancreatitis.
4. Category 4. Proven to be effective. ITP, D+HUS, Sepsis with multiorgan dysfunction
5. Single volume plasma exchange : 40ml/kg. Albumin, FFP, Starch can be used.
6. Contra indications. No central line, unstable hermodynamics, allergy and hypercalcemia.
7. Complications. Hypotension, Hypocalcemia , Allergic reaction, Catheter related infection ,
Iron deficiency anemia.
Reference. padmanabhan etal, guidelines on use of therapeutic plasmapheresis. Journal of
clinical apher.2019.jun.34.(3).

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48. Safe injection practices.
A. Safe injection practices. WHO defines a safe injection as one that does no harm to recipients;
does not expose the health care worker to any risk; and does not result in waste that is dangerous
for the community.
Safe injection practice at level three include
1) Through hand washing with soap and water for 2 minutes through 6 steps before each
injection. Hand cleaning with alcohol based antiseptic rub is alternative.
2) Routine use of hand gloves not recommended and is needed only if healthcare worker is
likely to have contact with potentially infectious body fluids or has open lesion on hand.
3) Skin preparation at injection site with 70% isopropyl alcohol or other disinfectant.
4) Needles and syringes should be sterile.
5) Separate needle and syringes for each patient.
6) Multidose vial‘s septum should be cleaned with alcohol swab prior to each withdrawal
and needle should not be left in the vial.
7) Needles should be discarded in puncture proof container to avoid injuries.
8) Recapping of the needle should be avoided.
9) Use of auto disabled syringes to prevent reuse.
10) Use of jet injectors which are needle free devices if available .
Reference. IAP Workshop on Safe Injection Practices: Recommendations and IAP Plan of
Action INDIAN PEDIATRICS VOLUME 42. 2005. 155_161.

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49. Management of a needle stick injury to a health care provider.
1: Immediate measures if the skin is broken after a needle-stick or sharp instrument:
Immediately wash the wound and surrounding skin with water and soap, and rinse. Do not scrub,
Do not use antiseptics or skin washes (bleach, chlorine, alcohol, betadine), Do not panic , Do not
put pricked finger in mouth, Do not squeeze wound to bleed it, Do not use bleach, chlorine,
alcohol, betadine any antiseptic or detergent.
II: Prompt reporting: All needle-stick/sharp injuries should be reported to the immediate
supervisor, and then to the Casualty Medical Officer.
III: Post exposure treatment: A baseline rapid HIV testing of exposed and source person must
be done for PEP. However, initiation of PEP should not be delayed while waiting for the results
of HIV testing of the source of exposure. First PEP dose within 72 hours ideally within 2
hours and not recommended after 72 hours.
Whenever PEP is required recommended regimen is Tenofovir+ Emtricitabine+ Raltegravir once
daily for 28 days.
If Hepatitis B exposure: Send blood of source person for HBsAg status. Inquire immunization
status of exposed health care person.
Action. No prophylaxis is needed if source blood is HBsAg negative. No prophylaxis is needed
if exposed person is immunized even if source person is HBsAg positive. Administer HBIG
(0.06 ml/kg/body wt) and initiate Hepatitis B vaccine series if exposed person is unimmunized
and source person is HBsAg positive.
IV: Counselling for PEP. Exposed persons should receive appropriate information about what
PEP is about and the risk and benefits of PEP in order to provide informed consent for taking
PEP.
V: Psychological support . Every exposed person needs to be informed about the risks, and the
measures that can be taken. This will help to relieve part of the anxiety.

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VI: Documentation of exposure. Documentation of exposure is essential. Special leave from
work should be considered initially for a period of two weeks. Subsequently, it can be extended
based on the assessment of the exposed person‘s mental state, side effects and requirements.
Seek expert opinion in case of Delay in reporting exposure (> 72 hours), Unknown source,
Known or suspected pregnancy, Breastfeeding mothers, Source patient is on ART, Major
toxicity of PEP regimen.
VII: Follow-up of an exposed person . Whether or not post-exposure prophylaxis is started, a
follow up is needed to monitor for the eventual appearance of signs indicating an HIV
seroconversion. Exposed persons should have post-PEP HIV tests. HIV-test at 3 months and
again at 6 months is recommended. If the test at 6 months is negative, no further testing is
recommended.
Reference. IAP Workshop on Safe Injection Practices: Recommendations and IAP Plan of
Action INDIAN PEDIATRICS VOLUME 42. 2005. 155_161.

P a g e | 56
June 18.
50. Valproate mechanism as anti epileptic.
Although mechanism of action of sodium valproate is not fully understood it has been used as
anti epileptic from a quiet pretty long duration of time.
Predominantly it's mechanism as Anti epileptic is seen to be due to
1. Blockade of voltage gated sodium channels.
2. Increased brain levels of GABA.
3. Calcium channel blockade.
4. Inhibition of histone deacetylase.
5. Reduction of PIP3. Phosphatidyl inositol phosphorylase 3.
Reference. KDT. pharmacology. Antiepileptic drugs.

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51. Mechanism of SVT and mode of action of Adenosine.
1. Reentry accounts for most cases and has been localized to the A-V node and less frequently to
the sinus node, the atria themselves, and A-V nodal bypass tracts (Wolff-Parkinson-White
syndrome).
These forms of supraventricular tachycardia are initiated by premature beats that dissociate
conduction between two pathways and permit the establishment of circulating electrical activity
that spreads to atrial and ventricular myocardium.
Paroxysms cease when the conducting properties of the reentrant circuits are disturbed by
changes in autonomic tone or the application of certain drugs, pacing, or cardioversion.
Supraventricular tachycardia may also result from abnormal automaticity in atrial tissues.
Mechanism of Adenosine.
1. Interrupts the reentry pathway.
2. Slows conduction time through AV node.
3. Restores normal sinus rhythm.
Reference. KDT. Pharmacology textbook. Anti arrhythmic drugs.

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52. Components of a structured abstract.
1. A structured abstract is an abstract with distinct, labeled sections (e.g., Introduction, Methods,
Results, Discussion) for rapid comprehension.
2. Standardized formats for structured abstracts have been defined for original research studies,
review articles and clinical practice guidelines.
3. The IMRAD format (INTRODUCTION, METHODS, RESULTS, and DISCUSSION), a
defacto standard that reflects the process of scientific discovery is commonly used as a structure
for journal abstracts.
Reference. pubmed NIH guidelines.
53. Study designs.
Various study designs are available for research methodology.
1. Meta-Analysis
A way of combining data from many different research studies. A meta-analysis is a statistical
process that combines the findings from individual studies.
2. Systematic Review
A summary of the clinical literature. A systematic review is a critical assessment and evaluation
of all research studies that address a particular clinical issue. The researchers use an organized
method of locating, assembling, and evaluating a body of literature on a particular topic using a
set of specific criteria. A systematic review typically includes a description of the findings of the
collection of research studies. The systematic review may also include a quantitative pooling of
data, called a meta-analysis.
3. Randomized Controlled Trial
A controlled clinical trial that randomly (by chance) assigns participants to two or more groups.
There are various methods to randomize study participants to their groups.

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4. Cohort Study (Prospective Observational Study)
A clinical research study in which people who presently have a certain condition or receive a
particular treatment are followed over time and compared with another group of people who are
not affected by the condition.
5. Case-control Study
Case-control studies begin with the outcomes and do not follow people over time. Researchers
choose people with a particular result (the cases) and interview the groups or check their records
to ascertain what different experiences they had. They compare the odds of having an experience
with the outcome to the odds of having an experience without the outcome.
6. Cross-sectional study
The observation of a defined population at a single point in time or time interval. Exposure and
outcome are determined simultaneously.
7. Case Reports and Series
A report on a series of patients with an outcome of interest. No control group is involved.
8. Ideas, Editorials, Opinions
Put forth by experts in the field.
reference. http://www.nlm.nih.gov/nichsr/ihcm/06studies/studies03.html.

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54. Ethical principles in research on humans.
1. The principles given below are intended to apply to research with human participants.
Principles of conduct in professional practice are to be found in the Society's Code of Conduct
and in the advisory documents prepared by the Divisions, Sections and Special Groups of the
Society. Participants in psychological research should have confidence in the investigators.
2. The essential principle is that the investigation should be considered from the standpoint of all
participants; foreseeable threats to their psychological wellbeing, health, values or dignity
should be eliminated.
3. The investigator should inform the participants of all aspects of the research or intervention
that might reasonably be expected to influence willingness to participate. In addition, where
research involves any persons under sixteen years of age, consent should be obtained from
parents or from those in loco parentis.
4. Intentional deception of the participants over the purpose and general nature of the
investigation should be avoided whenever possible. Participants should never be deliberately
misled without extremely strong scientific or medical justification.
5. The investigator should discuss with the participants their experience of the research in order
to monitor any unforeseen negative effects or misconceptions. Debriefing does not provide a
justification for unethical aspects of an investigation.
6. The participant has the right to withdraw retrospectively any consent given, and to require
that their own data, including recordings, be destroyed.
7. Subject to the requirements of legislation, including the Data Protection Act, information
obtained about a participant during an investigation is confidential unless otherwise agreed in
advance. Investigators have a primary responsibility to protect participants from physical and
mental harm during the investigation.
8. During research, an investigator may obtain evidence of psychological or physical problems
of which a participant is, apparently, unaware.
Reference. Ethical Priciples for Research with Human Participants. http://www.bps.org.uk/.

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December 2017.
55. Biological changes during adolescence.
1. This period of development comprises adolescence, which is divided into 3 phases—early,
middle, and late adolescence—each marked by a characteristic set of biologic, cognitive,
and psychosocial milestones.
2. Puberty is the biologic transition from childhood to adulthood. Pubertal changes include the
appearance of the secondary sexual characteristics, increase in height, change in body
composition, and development of reproductive capacity.
3. Maturation of the gonadotropin-releasing hormone (GnRH) pulse generator is among the
earliest neuroendocrine changes associated with the onset of puberty.
4. T he progression of the development of the secondary sex characteristics may be
described using the sexual maturity rating (SMR) scale (ranging from 1, preadolescence, to 5,
sexual maturity), or Tanner stages.
5. Early adolescence. 10 to 13 yrs, SMR of 1to 2.
Males. start of genital growth, Females. Start of secondary sexual characters.
6. Mid adolescence. 14 to 17 years, SMR of 3 to 5.
Males. Growth spurt, secondary sexual characters appear. Females. Menarche, peak growth
velocity.
7. Late adolescence. 18 to 21 yrs. SMR of 5.
Males. Increased lean muscle mass. Females. Increased fat deposition.
Reference. Nelson TB,21ed. Pg 1016.

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56. Characteristics of a good research question.
The characteristics of a good research question are described as. FINER.
1. F. Feasible. Adequate num ber of subjects, technical expertise, time and money.
2. I. Interesting. Getting the answer intrigues the investigator and her friends.
3. N. Novel. confirms, refutes or extends previous findings.
4. E. Ethical. Amenable to a study that institutional review board will approve.
5. R. Relevant. To scientific knowledge, clinical health policy and future research.
Reference. Hulley, charecteristics of a good research question. Designing of clinical research.
2007. 3rd edition.

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57. Need and methods of blinding for research.
1. Blinding refers to the concealment of group allocation from one or more individuals involved
in a clinical research study, most commonly a randomized controlled trial (RCT).
2. Rigorous, well-conducted RCTs provide the best estimates of the impact of surgical
interventions. However, if RCTs are difficult to conduct rigorously in an area, the methodology
is more likely to be faulty, and the results may be misleading.
3. Rather than performing a critical appraisal of the available literature, clinicians’ decisions
may be influenced by the fact that an RCT design was used, and erroneous conclusions may
guide clinical practice.
4. The term blinding refers to keeping trial participants, investigator unaware of assigned
intervention thereby preventing bias at several stages of trial.
5. Single blinding. Usually when the participants are unaware of intervention.
6. Double blinding. Here both the participants and investigator are unaware of the intervention.
7. Triple blinding. Here all the participants, investigators and the assessors of the analysis of
the data are unaware of the the intervention.
Reference. Vivek Jain. Statistic and PSM notes.

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58. Testing for single gene disorders.
1. The resolution of routine cytogenetic testing is 5Mb. Deletions or duplications less than that
size needs more precise methods of detection.
2. Single gene disorders are diagnosed using FISH and ACGH.
3. FISH. Fluorescent insitu hybridization. DNA probes complimentary to mutated sequences
are prepared and labelled with floursence dye.
4. ACGH. Array comparative genomic hybridization. Whole genome is labelled with flouro
probes that are hybridized into nucleic acids targeted on a micro array.
5. SNP arrays. Single nucleotide polymorphisms array sequencing analysis are used for
certain disorders.
Reference. Nelson 21ed. pg 684. Piyush gupta tb1. pg 45.

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59. Principles of rational antibiotic treatment.
1. Aspects of rationale antibiotic therapy can be best described by mnemonic RATIONALE.
R-Reasoning for prescription, Right dose, route, duration;
A-Academically updated decisions; The pediatrician must be aware of the IAP guidelines for
the management of infectious diseases.
T-Training of mind, residents, parents, pharmacists; Training of mind about 3 ‗O‘s; the Organ
involved, the causative Organism and the available therapeutic Option.
I -Instructions to parents; It is expected that a pediatrician gives time and speaks up about
irrationality of antibiotics in viral infections.
O-Organism search; Efforts to search the Organism, by developing a culture of sending
cultures. One should remember that in vitro sensitivities do not always result in clinical cure.
N-Noting down the diagnosis; Clinical differentiation between bacterial and viral infection,
although difficult is possible with reasonable certainty most of the times .
A-Antibiotic Policy; Choose the antibiotic from the antibiotic policy after checking for allergy
risks. Some antibiotics should be prescribed after getting an infectious disease consult like
carbapenems, colistin, linezolid, vancomycin, amphotericin B. Follow the clinical response and
de-escalate antibiotics. Infection control team should fill antibiotic audit form and conduct
regular department-wise audits.
L-Local sensitivity pattern; knowledge of Local sensitivity pattern through ongoing research.
The research need not be in the institutes alone; it could be a part of Pediatric Research in office
setting.
E-Ethical considerations, Economic condition of the patient.
Reference. Rationale of antibiotic treatment. Indian pediatrics. Sep 2016. Vol. 53.

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60. Classify headache in children. Diagnosis Of pseudo tumour cerebri.
1. Headache is an extremely frequent occurance in childhood and a common reason for
neurological consultation. Headache may be primary or secondary due to underlying conditions.
2. Primary. Migraine, tension, trigeminal autonomic cephalalgia.
3. Secondary. Trauma, infection, vascular, space occupying lesion, facial, para nasal sinuses.
4. Neuropathy, psychiatric disorder pain.
5. Pseudo tumour cerebri. Benign intra cranial hypertension. a clinical syndrome with raised
intra cranial pressure in absence of any space occupying lesion or obstruction to a marked level
of more than 200mmH2O in Infants and 250mmH2O in children. The diagnosis is of
exclusion. Bilateral Papilloedema is the hallmark diagnosis of this disease. Modified Dandy
criteria are used.
6. Investigations needed are CBC, ANA, CSF analysis, MRI Brain, MR venogram.
Reference. piyush gupta tb1. pg 2177, 2215.

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61. Common movement disorders in children.
1. Movement disorders comprise a group of heterogeneous conditions in which primary
symptom of presentation is an involuntary movement.
2. Primary. Idiopathic or genetic.
3. Secondary. Structural lesions in CNS.
4. Hypokinetic. Parkinsons disease.
5. Hyperkinetic. Myoclonus, chorea, athetosis, dystonia, Tics.
6. Disorders with involuntary movements are.
A. Developmental related. Benign infantile physiological myoclonus, chores.
B. Exrtapyrimadal disorders. Wilson's chorea, ataxia.
C. Static encephalopathy. Dystonia of cerebral palsy.
7. A. Dystonia. Forceful intermittent or sustained muscle contraction posturing of the body
either focal, segmental or generalized. Due to congenital, toxin, infectious, degenerative
conditions.
B. Myoclonus. Sudden shock like contraction of a muscle due to pathology from cortex or spinal
cord. Due to benign sleep, epileptic, toxic, vascular, endocrine, infective conditions.
C. Chorea. Irregular brief, jerky semi purposive movements. manifests as pronator sign, milk
maid grip, Jack in box tongue, hung up ankle reflexes. Due to Wilsons disease, friedrichs ataxia,
SLE, Rhematic fever.
D. Tremors. Regular rhythmic oscillatory movements. due to benign infantile, hyperthyroidism,
Parkinson's, cerebellar disorders.
E. Tics. Brief sterotyped jerky movements. Eye, vocal, finger, simple or complex tics.
Reference. piyush gupta tb1. pg 2182.

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62. Commonly used insulin regimens for long term treatment of DM1.
1. Life long insulin therapy is essential for survival of children with diabetes. Recombinan
human insulins (regular and NPH) are available in market.
2. Insulin analogs modified insulins are available as rapid acting (aspart, lispro) and long
acting (glargine) formulas.
3. There are two types of insulin regimens. The split mix regimen and basal bolus regimen.
4. In split mix regimen child gets limited number of pricks. Insulin is injected as a mixture of
short acting regular and NPH twice a day. The principle is short acting serves for the immediate
post prandial duration and NPH serves for inter meal duration.
5. The basal bolus regimen mimics the physiological pattern of secretion but needs more
number of injections per day. A single dose of long acting insulin given regulates hepatic
glucose release and 3 to 4 intermittent injections of short acting insulins taken before meals to
take care of post meal glycemic. It can be given using regular and NPH or using Aspart and
Glargine.
6. More Advanced regimen is a continuous infusion of short acting insulin via an infusion pump
subcutaneously.
7. All of these regimens need therapeutic self blood glucose monitoring.
Reference. piyush gupta tb1. pg. 2381.

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63. Epilepsy syndromes with focal seizures.
Epileps syndromes with focal seizures may be of benign or severe type.
A. Benign.
1. BECTS. Centrotemporal spikes. Around 5 yrs during nights.
2. Atypical BECTS. Younger age group and multiple drop attacks.
3. Benign epilepsy with occipital spikes.
4. Nocturnal autosomal dominant frontal lobe epilepsy.
B. Severe. Structural or metabolic disorder.
1. Epilepsy of infancy with migrating focal seizures. Associated with structural abnormalities.
2. Pseudo lennaux gestsut.
3. Mesial temporal sclerosis. Surgically remideable cortical dysplasia.
4. Landu kleffner syndrome. Associated aphasia.
5. Rasmussen encephalitis. associated progressive hemiparesis.
Reference. Nelson 21. Pg. 3097.

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June 2017.
64. Complications of pediatric obesity.
1. Complications of pediatric obesity occur during childhood and adolescence and persist into
adulthood.
2. More immediate comorbidities include type 2 diabetes, hypertension, hyperlipidemia, and
nonalcoholic fatty liver disease (NAFLD).
3. Insulin resistance increases with increasing adiposity and independently affects lipid
metabolism and CV health. The metabolic syndrome (central obesity, hypertension, glucose
intolerance, and hyperlipidemia) increases risk for CV morbidity and mortality.
4. NAFLD is now the most common chronic liver disease in children and adolescents. It can
present with advanced fibrosis or nonalcoholic steatohepatitis and may result in cirrhosis and
hepatocellular carcinoma.
5. Obesity may also be associated with chronic inflammation. Adiponectin, a peptide with
antiinflammatory properties, occurs in reduced levels in obese patients compared to insulin-
sensitive, lean persons. Low adiponectin levels correlate with elevated levels of free fatty acids
and plasma triglycerides as well as a high BMI.
6. Proinflammatory peptides such interleukin (IL)-6 and tumor necrosis factor (TNF)-α occur
in higher levels in obese patients. Specifically, IL-6 stimulates production of C-reactive protein
(CRP) in the liver. CRP is a marker of inflammation and might link obesity, coronary disease,
and subclinical inflammation.
7. Some complications of obesity are mechanical, including obstructive sleep apnea and
orthopedic complications like Blount disease and slipped femoral capital epiphysis.
8. Mental health problems can coexist with obesity, with the possibility of bidirectional effects.
There is considerable interest in the co-occurrence of eating disorders and obesity. Obese youth
are also at risk for bullying based on their appearance.
Reference. Nelson 21. Pg. 351.

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65. Indication of growth hormone in pediatrics.
1. The Food and Drug Administration (FDA) has approved 8 pediatric indications for rhGH
treatment to promote linear growth.
1. GH deficiency,
2. Turner syndrome,
3. chronic renal failure before transplantation,
4. idiopathic short stature,
5. small-for-gestational-age short stature,
6. Prader-Willi syndrome,
7. SHOX gene abnormality, and
8. Noonan syndrome.
2. The recommended initial dose of rhGH for treatment of GH deficiency is 0.16-0.24
mg/kg/wk (22 to 35 µg/kg/ day). Higher doses have been used during puberty and for non-GH
deficiency indications. RhGH is administered subcutaneously once daily.
3. Maximal response to rhGH occurs in the 1st yr of treatment. Growth velocity during
this 1st yr is typically above the 95th percentile for age. With each successive year of treatment,
the growth rate tends to decrease.
4. IGF-1 may be measured as an objective assessment of adherence. GH therapy should be
continued until near-final height is achieved. Criteria for stopping GH treatment include a
decision by the patient that he or she is tall enough, a growth rate <1 inch/yr, and a bone
age >14 yr in girls and >16 yr in boys.
Reference. Nelson 21ed. Pg. 2886.

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66. Treatment of childhood autism.
1. The primary treatment for ASD is done outside the medical setting and includes
developmental and educational programming.
2. Intensive behavioral therapies have the strongest effect. Earlier age at initiation of treatment
and higher intensity of treatment are associated with better outcomes.
3. Applied behavioral analysis (ABA) involve direct incremental teaching of skills within a
traditional behavioral framework using reinforcement of desired behavior, careful data collection,
and analysis and adjustment of the treatment program based on review of data.
4. Educational approaches such as the Treatment and Education of Autistic and Communication
Handicapped Children (TEACCH) incorporate structured teaching, visual supports, and
adjustment of the environment to the individual needs of students with ASD, such as difficulty
with communication and understanding time.
5. Speech and language therapy can help build vocabulary, comprehension, and pragmatic
skills. Augmentative communication approaches using photographs or picture icons can
improve comprehension and ability to communicate.
6. Social skills programs that include training peer mentors have higher rates of efficacy.
Occupational and physical therapy may be indicated for individuals with motor delay and
difficulty acquiring adaptive skills such as dressing and toileting.
7. Comorbidities like Seizures, GERD, irritability, sleeplessness have to be treated.
8. There are currently no medications that treat the core symptoms of ASD. Medications can be
used to target specific co-occurring conditions or symptoms.

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9. Intra nasal therapy with oxytocin may improve social functioning in children with ASD.
Stimulant medication like atomoxetine and α-agonists for ADHD in ASD. Selective serotonin
reuptake inhibitors (SSRI) can be used for anxiety, OCD, depression.
10. Clonidine, Melatonin or trazodone may be used for sleep onset and maintenance. No
medications are specifically labeled for treatment of insomnia in ASD.
Reference. 21ed. Nelson . Pg 301.
67. Pain pathway, pharmacological and non pharmacological treatment.
1.

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2. Primarily, both the CNS and PNS are involved in the mechanism and pathways of all
variations of pain perception.
3. Acute pain, chronic pain and neuropathic pain.
4. Sensation of pain is composed of transduction, transmission, modulation and perception.
5. A.beta fibres are large myelinated and fast conducting.
6. A delta fibres are small myelinated and slow conducting responding to pressure.
7. C fibres are small unmyelinated slow conducting responding to all noxious stimulus.
8. Non pharmacological approaches are psychological support, cognitive behaviour therapy,
counter irritant therapy, acupuncture, electrical therapy, hot or cold compresses, surgical
procedures like rhizotomy, sypathetectomy.
9. Analgesic drugs are
A. Opioid analgesics. Morphine, fentanyl, buprenorphine, tramadol. Acting on U receptors.
B. NSAIDS. Aspirin, diclofenac, diclofenac, etoricoxib, COX2 Inhibitors.
C. Benzodiazepine. Gaba petine, pregabalin. Acting via GABA receptors.
D. Acetaminophen. Safest analgesic in pediatric practice.
Reference. KDT pharmacology TB. Analgesics.
Ganongs physiology. image source. pain pathway.

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68. Aerosol therapies in pediatrics for respiratory diseases.
1. Inhaled medications are the mainstay of therapy for many pediatric pulmonary diseases. These
therapies are given to patients who receive different types of respiratory support.
2. This heterogeneous population includes pediatric patients with asthma, patients with
respiratory distress requiring invasive mechanical ventilation or non invasive ventilation (NIV)
support, pediatric patients requiring transnasal support in the form of highflow nasal cannula
(HFNC), and spontaneously breathing tracheostomized pediatric patients, pneumonia and
acute bronchiolitis patients.
3. Many aerosol delivery devices are available to deliver inhaled aerosols to children. Nebulizers,
pressurized metered-dose inhalers (pMDIs), soft mist inhalers, and dry powder inhalers,
Ultrasonic nebulizer and Vibrating mesh nebulizer.
4. Device selection is a complex process that is influenced by multiple variables. These
limitations are: (1) drug availability, (2) device availability, (3) ease of use, (4) acceptability by
the family, (5) cost, and (6) patient cooperation.
5. Both nebulizer and pMDI/VHC are effectivein delivering bronchodilators to children
experiencing acute bronchoconstriction.
6. Aerosol delivery through HFNC is significantly affected by gas flow rate.
7. Aerosol delivery during invasive mechanical ventilation can be enhanced by placing the
nebulizer on the dry side of the humidifier with adult circuits and before the Y-piece with
neonatal circuits.

P a g e | 76
Drugs used in aerosol therapy are
A. Beta agonists. Salbutamol, levosalbutamol.
B. Anticholinergics. Ipratropium.
C. Steroids. Budesonide, fluticasone.
D. Antibiotics. Tobramycin.
E. Fibrinolytics. Nacetyl cysteine.
Reference. Ariel Berlinski. Pediatric Aerosol Therapy. Respiratory Care Jun 2017, 62 (6) 662-
677.

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69. An approach to psychological problems in adolescents.
1. A few questions should be asked to identify the adolescent who is having
2. Difficulty with peer relationships (Do you have a best friend with whom you can share even
the most personal secret?),
3. Self-image (Is there anything you would like to change about yourself?),
4. Depression (What do you see yourself doing 5 yr from now?),
5. School (How are your grades this year compared with last year?),
6. Personal decisions (Are you feeling pressured to engage in any behavior for which you do not
feel you are ready?), and
7. Eating disorder (Do you ever feel that food controls you, rather than vice versa?).
8. The HEADS/SF/FIRST mnemonic, basic or expanded, can be useful in guiding the interview
if encounter forms are not available.
H. Home, E. Education, A. Abuse, D. Drugs, S. Safety, S. Sexual identity, F. Family, F.
Friends, I. Image, R. Recreation, S. Spirituality, T. Threats.
9. Based on the assessments, appropriate counseling or referrals are recommended for more
thorough probing or for in-depth interviewing.
10. The identification, treatment, and follow up of mental health problems in young people can
be complicated. Parents and teachers may dismiss problems as merely reflecting adolescent
turmoil.
Reference. nelson 21 ed. Pg. 1034.

Title: "DNB Exam: Past Papers and Answers - Your Comprehensive Guide"

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