Cracking code of theory: Aspiration Syndromes

Monday, December 5, 2016   at  9:35:00 PM

Aspiration Syndromes
The spectrum varies from asymptomatic condition to acute life-threatening events,
Occult aspiration of nasopharyngeal secretions into the lower respiratory tract is a normal event in healthy people, usually without apparent clinical significance.

A. Aspiration of Gastric contents:
Large volume aspiration of gastric contents usually occurs after vomiting;
It is an infrequent complication of general anesthesia, gastroenteritis, and an altered level of consciousness.
Pathophysiologic consequences depends primarily on:
o The pH
o Volume of the aspirate
o The amount of particulate material.
Increased clinical severity is noted with volumes greater than approximately 0.8 mL/kg and/or pH < 2.5.
Hypoxemia, hemorrhagic pneumonitis, atelectasis, intravascular fluid shifts, and pulmonary edema all occur rapidly after massive aspiration.
These occur earlier, become more severe, and last longer with acid aspiration.

Most clinical changes are present within minutes to 1–2 hr after the aspiration event.
In the next 24–48 hr, there is a marked increase in lung parenchymal neutrophil infiltrations, mucosal sloughing and alveolar consolidation that often correlates with increasing infiltrates on chest radiographs.

Infection after aspirations
Infection usually does not have a role in initial lung injury after aspiration of gastric contents
Aspiration impair pulmonary defenses, predisposing the patient to secondary bacterial pneumonia.
In the patient who has shown clinical improvement but then develops clinical worsening, especially with fever and leukocytes, secondary bacterial pneumonia should be suspected
  1. If a patient has had large volume or highly toxic substance aspiration it is important to perform immediate suctioning of the airway.
  2. When immediate suctioning cannot be performed, later suctioning or bronchoscopy is usually of limited therapeutic value.
  3. An exception to this is if significant particulate aspiration is suspected.
  4. Attempts at acid neutralization are not warranted because acid is rapidly neutralized by the respiratory epithelium.
Patients suspected of large volume or toxic aspiration should :
o Be observed,
o Have oxygenation measured by oximetry or blood gas analysis,
o Have a chest radiograph taken, even if asymptomatic.
If the chest radiograph and oxygen saturation are normal, and the patient remains asymptomatic, home observation, after a period of observation in the hospital or office, is adequate.

No treatment is indicated at that time, but the caregivers should be instructed to bring the child back in for medical attention should respiratory symptoms or fever develop.
  1. For those patients who present with or develop abnormal findings during observation, oxygen therapy is given to correct hypoxemia.
  2. Endotracheal intubation and mechanical ventilation are often necessary for more severe cases.
  3. Bronchodilators may be tried, although they are usually of limited benefit.
  4. corticosteroids does not appear to have any benefit, unless given nearly simultaneously with the aspiration event; their use may increase the risk of secondary infection.
  5. Prophylactic antibiotics are not indicated, although in the patient with very limited reserve, early antibiotic coverage may be appropriate.
  6. If used, antibiotics should be used that cover for anaerobic microbes.
  7. If the aspiration event occurs in a hospitalized or chronically ill patient, coverage of Pseudomonas and enteric gram-negative organisms should also be considered.
A mortality rate of ≤5% is seen if 3 or fewer lobes are involved.
Unless complications develop, such as infection or barotrauma, most patients will recover in 2–3 wk, although prolonged lung damage may persist, with scarring and bronchiolitis obliterans.

Prevention of aspiration should always be the goal when airway manipulation is necessary for intubation or other invasive procedures.
Feeding with enteral tubes passed beyond the pylorus and elevating the head of the bed in mechanically ventilated patients have been shown to reduce the incidence of aspiration complications in the intensive care unit.

B. Hydrocarbon Aspiration:

The most dangerous consequence of acute hydrocarbon ingestion is usually aspiration and resulting pneumonitis.

Hydrocarbons with lower surface tensions (gasoline, turpentine, naphthalene) have more potential for aspiration toxicity than heavier mineral or fuel oils.

Ingestion of >30 mL (approximate volume of an adult swallow) of hydrocarbon is associated with an increased risk of severe pneumonitis.

Clinical findings of chest retractions, grunting, cough, and fever may occur as soon as 30 min after aspiration, or may be delayed for several hr.


Lung radiograph changes usually occur within 2–8 hr, peaking in 48–72 hr.

Pneumatoceles and pleural effusions may occur.

Patients presenting with cough, shortness of breath, or hypoxemia are at high risk for pneumonitis.

Persistent pulmonary function abnormalities can be present many years after hydrocarbon aspiration.
Other organ systems, especially the liver, central nervous system, and heart, may suffer serious injury.

Cardiac dysrhythmias may occur and be exacerbated by hypoxia and acid-base or electrolyte disturbances.


Gastric emptying is nearly always contraindicated because the risk of aspiration is greater than any systemic toxicity.

In Case volumes >30 mL, such as might occur with intentional overdose, may benefit from gastric emptying
Treatment is generally supportive with oxygen, fluids, and ventilatory support as necessary. 
The child who has no symptoms and a normal chest radiograph should be observed for 6–8 hr to ensure safe discharge. 
Certain hydrocarbons have more inherent systemic toxicity. 
The pneumonic CHAMP refers collectively to these: camphor, halogenated carbons, aromatic hydrocarbons, and those associated with metals and pesticides. 
Cuffed endotracheal tube can be placed without inducing vomiting, this should be considered, especially in the presence of altered mental status.
Other substances that are particularly toxic and cause significant lung injury when aspirated or inhaled include baby powder, chlorine, shellac, beryllium, and mercury vapors.

Repeated exposure to low concentration of these agents à chronic lung disease, such as interstitial pneumonitis and granuloma formation. Corticosteroids may help reduce fibrosis development and improve pulmonary function, although the evidence is limited.

C. Chronic Recurrent Aspiration


The recurrent aspiration of small quantities of gastric, nasal, or oral contents can lead to several clinical presentations.

These include recurrent bronchitis or bronchiolitis, recurrent pneumonia, atelectasis, wheezing, cough, apnea, and laryngospasm.

Pathologic outcomes may include:
o Granulomatis inflammation,
o Interstitial inflammation,
o Fibrosis,
o Lipoid pneumonia,
o Bronchiolitis obliterans
Oropharyngeal incoordination is reportedly the most common underlying problem associated with recurrent pneumonias of hospitalized children.

Lipoid pneumonia may occur after the use of home/folk remedies involving oral or nasal administration of animal or vegetable oils to treat various childhood illnesses.

Conditions Predisposing to Aspiration Lung Injury in Children:
A. Anatomical and Mechanical
  1. Tracheoesophageal fistula
  2. Laryngeal cleft
  3. Vascular ring
  4. Cleft palate
  5. Micrognathia
  6. Macroglossia
  7. Achalasia
  8. Esophageal foreign body
  9. Tracheostomy
  10. Endotracheal tube
  11. Nasoenteric tube
  12. Collagen vascular disease (scleroderma, dermatomyositises)
  13. Gastroesophageal reflux disease
  14. Obesity
B. Neuromascular
  1. Altered consciousness
  2. Immaturity of swallowing/prematurity
  3. Dysautonomia
  4. Increased intracranial pressure
  5. Hydrocephalus
  6. Vocal cord paralysis
  7. Cerebral palsy
  8. Muscular dystrophy
  9. Myasthenia gravis
  10. Guillain-Barré syndrome
  11. Werdnig-Hoffmann disease
  12. Ataxia-telangiectasia
  13. Cerebral vascular accident
C. Miscellaneous
  1. Poor oral hygiene
  2. Gingivitis
  3. Prolonged hospitalization
  4. Gastric outlet or intestinal obstruction
  5. Poor feeding techniques (bottle propping, overfeeding, inappropriate foods for toddlers)
  6. Bronchopulmonary dysplasia
  7. Viral infection
causes of aspiration syndromes

Gastroesophageal reflux is also a common underlying finding that may predispose to recurrent respiratory disease, but it is less frequently associated with recurrent pneumonia.

Recurrent microaspiration has been reported in otherwise apparently normal newborns, especially premature infants.

Aspiration is also a risk in patients suffering from acute respiratory illness from other causes, especially respiratory syncytial virus infection, This emphasizes the need for a high degree of clinical suspicion of ongoing aspiration in a child with an acute respiratory illness who is being fed enterally and who deteriorates unexpectedly.


Underlying predisposing factors are frequently clinically apparent but may require specific further evaluation.

The caregiver should be asked about spitting, vomiting, arching, or epigastric discomfort in an older child; and the timing of symptoms in relation to feedings, positional changes, and nocturnal symptoms such as coughing or wheezing.

Coughing or gagging may be minimal or absent in a child with a depressed cough or gag reflex.

Observation of a feeding is an essential part of the examination when considering a diagnosis of recurrent aspiration.

Particular attention should be given to nasopharyngeal reflux, difficulty with sucking or swallowing, and associated coughing and choking.

The oral cavity should be inspected for gross abnormalities and stimulated to assess the gag reflex.

Drooling or excessive accumulation of secretions in the mouth suggests dysphagia.

Lung auscultation may reveal transient crackles or wheezes after feeding, particularly in the dependent lung segments.

Diagnosis of Recurrent microaspiration :
The diagnosis of is challenging because of the lack of highly specific and sensitive tests. 
A plain chest radiograph is the usual initial study for a child suspected of recurrent aspiration.
The classic findings CXR :
Segmental or lobar infiltrates localized to dependent areas may be apparent
Other findings:
Diffuse infiltrates,
Lobar infiltrates,
Bronchial wall thickening,
Even normal-appearing chest x-rays.
 Barium esophagram:
Useful for anatomic abnormalities such as :
  1. vascular ring, stricture,
  2. Hiatal hernia,
  3. Tracheoesophageal fistula.
  4. It also yields qualitative information about esophageal motility and, when extended, of gastric emptying.
The esophagram is insensitive and nonspecific for aspiration or gastroesophageal reflux.
Modified barium swallow with videofluoroscopy:
Generally considered the gold standard for evaluating the swallowing mechanism.

This study is preferably done with the assistance of a pediatric feeding specialist and a caregiver to try to simulate the usual feeding technique of the child.

The modified barium swallow occasionally detects aspiration without apparent respiratory abnormalitie
 Gastroesophageal “milk” scintiscan :
Offers theoretical advantages over a barium swallow in being more physiologic and providing a longer window of viewing than the barium esophagram for detecting aspiration and gastroesophageal reflux.
        This procedure has been a relatively insensitive test for detecting aspiration.
“Salivagram: useful in assessing aspiration of esophageal contents, although its sensitivity has not been well studied.
Fiberoptic endoscopic evaluation of swallowing:
Used effectively in adults, has been reported to be useful in pediatric patients.
The swallowing is observed directly, without radiation exposure.
The endoscope may alter the assessment of function, depending on level of comfort and cooperation.
CT scans (generally not indicated to establish a diagnosis of aspiration) may show infiltrates with decreased attenuation suggestive of lipoid pneumonia.
Tracheobronchial aspirates :
For patients with artificial airways, the use of an oral dye and visual examination of tracheal secretions is useful. This test should not be done on a chronic basis due to possible dye toxicity. 
It is important to use an adequate volume of dye, but even this may be relatively insensitive compared to measuring lactose or glucose in airway secretions.

Quantitation of lipid-laden alveolar macrophages from bronchial aspirates has been shown to be a sensitive test for aspiration.
     False-positive tests: seen in
Endobronchial obstruction,
Use of intravenous lipids,
Pulmonary bleeding.
Bronchial washings may also be examined for various food substances, including lactose, glucose, food fibers, and milk antigens.

Treatment should be directed towards underlying medical condition.
Milder dysphagia can be treated with:
o Alteration of feeding position,
o Limiting texture of foods to those best tolerated on modified barium esophagram (usually thicker foods), or
o Limiting quantity per feeding.
Nasogastric tube feedings can be utilized temporarily during periods of transient vocal cord dysfunction or other dysphagia.

Post-pyloric feedings may also be helpful, especially if gastroesophageal reflux is present. Several surgical procedures may be considered.

Tracheostomy, although sometimes predisposing to aspiration, may provide overall benefit from improved bronchial hygiene and the ability to suction aspirated material.

Fundoplication with gastrostomy or jejunostomy feeding tube will reduce the probability of gastroesophageal reflux–induced aspiration, but recurrent pneumonias often persist because of dysphagia and presumed aspiration of upper airway secretions.

Medical treatment :
o Anticholinergics: glycopyrrolate or scopolamine,
o Botulism toxin.
Aggressive surgical intervention with salivary gland excision, ductal ligation, laryngotracheal separation, or esophagogastric disconnection can be considered in severe, unresponsive cases.
Poor prognostic factors:
   In hydrocarbon poisoning prior lavage,
   Hypoxemia at admission,
   Need for ventilation,
   Secondary pneumonia
   Ventilator related complications were associated with poor outcome.
Aspiration syndrome
About the Author
Dr Ranjith Kumar CS  is Currently persuing DM in medic oncology from JIMER, completed DNB from Kanchi Kamakoti Child Trust Hospital with a gold medal, has great academic interests, contributed about 9 chapters  in scott pediatriks clinical methods  |  View Ranjith Kumar CS  posts

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Theory question bank update 2016: Part 1

Monday, November 14, 2016   at  11:10:00 PM

Theory question bank in three parts reorganized and updated till 2016

What new in this update
1. All questions reorgnaised.
2. Questions arranged chapterwise as per appearance in Nelson’s textbook of Pediatrics.
3. Arranged in chronological order old first and latest last.
4. Adequate space and gaps given to take side notes and jot doin points for last minute revision.


1. Questions are divided based on Chapters of Nelsons Textbook of Pediatrics
2. Questions contain two numbers at the end. Numbers within bracket indicates the year. For example (97/1)- 97 means year 1997 & 1 means June (2 means December). Thus (06/1) means June 2006
3. Number at the end of the question (not within bracket) indicates marks



1. Approach to a child with Delayed Speech (02/1)15


1. Discuss the causes and approach to a Preschool child with Developmental Regression (02/1)25
2. A 2 yr old child presents with history of regression of milestones for past 6 months and hepatosplenomegaly.Discuss the differential diagnosis and diagnostic approach 7+3(1/16)


1. Define Growth, Development, and Velocity of growth mean, median, percentiles. Enumerate causes of retarded growth. Briefly outline a schedule for investigation of such a case (92/2) 25
2. Factors affecting Development of children (92) 15
3. Gessel Developmental schedule (93/1)15
4. Describe the events of sexual development in relation to physical growth. Name the most important regulatory factors (94) 25
5. Discuss the basis for use of Growth Standards. What should be taken as a reasonable approach for India (94/2) 25
6. Sexual Maturity Rating in female adolescents (95/2) 15
7. Velocity and cross-sectional standards as applied to Human Growth (95/2) 15
8. What are the developmental disorders in preschool years? Discuss the management (97/1) 15
9. Growth Monitoring (98/1) 15
10. Growth Factors (99/1) 15
11. Principles of Growth and Development (00/1) 15
12. Importance of Bone age assessment in children 15
13. SMR (03/2)
14. What is SMR? Discuss the secular trend in Children 5+5 (05/02)
15. How would you assess sexual maturity of a female adolescent (06) 10
16. Write the height velocity curves of girls and boys from birth to adolescence, describe the principles and factors governing the growth and development in children (06)10
17. Bone age assessment and its usefulness (07/2) 10
18. Growth and development in second year of life in children (07/1) 10
19. Describe: (09/2) 5+5
a) Factors affecting child development
b) Developmental screening tests available and suitable for use in Indian children.
20. Developmental milestones in first two years of life. (10/1) 10
21. Outline the fine motor milestones along with their normal age of achievement in sequence attained between birth and 5 years of age.
22. Discuss the evolution and characteristics of WHO growth charts. Discuss their implications on the magnitude of malnutrition in Indian setting. (11/1) 3 +4+3
23. Enumerate the available methods and indications for determination of bone age in children and adolescents. Outline the differential diagnosis of a child with short stature on the basis of bone age. (11/1) 3+3+4
24. Describe Tanner’s Sexual Maturity Rating (pubertal staging) in boys based on
a) Genitalia and
b) Pubic hair development. (11/2) 5+5
25. Describe in detail the physical growth and development in all domains from birth till completion of first year. (11/2) 5+5
26. Define growth velocity. Draw a typical height velocity curve from birth to puberty for boys and girls. Discuss the utility of determining growth velocity. (12/1) 2+4+4
27. What is developmental screening? Enumerate common developmental screening test. What issues they identify in a child? (12/1) 2+4+4


1. Define Short Stature. Discuss the approach to a child with short stature and the role of GH in Short Stature (05)2+5+3
2. Approach to a child with short stature (06/1) (07/2) 10
3. Short stature – definition, differential diagnosis and management approach. (10/1) 2+3+5
4. Define short stature. Outline the approach to clinical evaluation and management of a child with short stature. (13/1) 2+8
5. A)What is short stature
b) What are the common causes of short stature?
c) Algorithmic approach to manage a 5 yr old child with short stature. 1+3+6(1/15)
6. A 12year old female child presents with short stature and delayed puberty.
a. Enumerate various possible causes
b. Approach to diagnosis and their management. 2+8(1/16)


1. What is developmental delay? Describe different tools used for screening of developmental delay. (11/2)3+7
2. Define developmental delay and developmental dissociation.Outline the screening and definitive tests for diagnosis of developmental delay. (13/1)5+5
3. What is global developmental delay? What are the common causes of global developmental delay? Discuss the algorithmic approach to evaluate a child with global developmental delay. (13/2)2+3+5
4. What is developmental delay? Describe different tools used for screening and for diagnosis of developmental delay. (15/2)2+4+4



1. Management of Conversion reactions (98/1)15
1. Encopresis (99/2)15
2. What is Vegetative Disorder (05) 5
3. What is vegetative disorder? Discuss management of a child with injuries (05) 5+5
4. Rumination (06/1) 5
5. Pica (07/1) 5


1. Habit Disorders in children (07/1)10
1. Childhood Depression (06)10
2. A) Aetiology of depression in adolescents 2 (15/1)
b) comorbidities ,clinical features and treatment of depression in adolescents 3+3+2 (15/1)
3. Management of
a.  Post traumatic stress disorder 4(1/16)
b. Tourette’s disorder 3
c.  PANDAS 3


1. Common Behavioral problems in children (97/2) 15
1. Autism (03/2)15
2. Define autism. Outline its etiology. Outline the clinical markers of autism and its prognosis. (04/2) 2+3+3+2
3. Etiology, clinical manifestations and treatment of Autistic Disorder (06/1)10
4. Autistic Disorder (07/1) 10
5. Autistic spectrum disorder (07/2) 10 Rpt Apr16 3marks
6. Describe the etiology, clinical manifestations and management of autistic spectrum disorders in children. (09/2)2+3+5
7. Discuss briefly the diagnostic features and management of Pervasive Developmental Disorders/ autistic spectrum disorders. (11/2)4+6
8. Enumerate various pervasive developmental disorders and autism spectrum disorders. Outline one core feature of each of them. (12/1) 5+5
9. Define autistic spectrum disorders. Enumerate their clinical features and discuss their managements (13/2) 2+4+4
10. What are Autistic Spectrum Disorders? Discuss the differential diagnosis and management of a child with Autism. (14/1) 3+3+4
11. Discuss the management of a child with schizophrenia (04/2)5
12. Discuss the management of a child with Schizophrenia (05)5
1. Attention Deficit Disorders (97/1)(95/2) (00/1)15
2. ADHD (03/1)15Rpt (15/2) 5marks
3. Describe clinical manifestations, diagnosis and management of ADHD (06)10
4. Define Dyslexia. Briefly discuss its management. (14/2) 5


1. Sleep Disorders in children (99/2)10
2. Pathophysiology of Sleep Apnea (03/1)15
3. Outline the basic principles of sleep hygiene for children and adolescents (09/1)10 (12/1) 5+5
4. Principles of sleep hygiene in children (13/1) 5
5. Evaluation of Obstructive sleep Apnea (14/2) 5
6. A)mention anatomical and functional factors responsible for obstructive sleep apnea in children 5
b) How do you diagnose and treat this condition 2+3(15/2)
7. Obstructive sleep apnea: diagnosis and management 5(1/16)


1. Enuresis (96/2)15
2. Define Enuresis. Discuss its manifestations and management (06)5
3. Management of nocturnal Enuresis. (07/1)5
4. What is nocturnal enuresis? Outline the causes for the same. Describe the modalities for managing a 6 year old child with enuresis.
5. Discuss evaluation and management of an 8 year old male with primary nocturnal enuresis. (10/2)4+6



1. Approach to a child with Failure To Thrive (96/1)14
2. Causes of Failure to Thrive in infancy (96/2)15
3. Define failure to thrive. Outline a diagnostic approach for a child with failure to thrive. (04/2)2+8
4. Non organic failure to thrive (07/1)10
5. Define failure to thrive. Give its etiology, classification, clinical features and management. (09/2) 1+2+2+2+3
6. Define failure to thrive and tabulate its causes. Outline the approach to manage a child with failure to thrive. (10/2) 2+3+5
7. Failure to thrive (15/1) 6


1. Role of Pediatrician in Adoption of a child (95/1)10
2. Adoption (03/2)
3. Role of pediatrician in adoption of a child (13/1)5
4. Laws of adoption in India 4(Apr 16)


1. Management of the sex abused child (95/2)15
2. Define child abuse. List the etiology of child abuse in India. Outline strategies for prevention. (04/2)
3. Discuss Child maltreatment. What are the factors related with child abuse (05)5+5
4. Define Child Abuse. Describe clinical manifestations of Child Abuse. Discuss some useful investigations in a suspected case of Child Abuse (06)10
5. Define child abuse. Describe in brief the factors responsible for child abuse. Outline management of a child who is suspected of being abused. (11/1)2+3+5
6. Define child abuse and neglect. Discuss various clinical manifestations, diagnostic work up and management of physical abuse. (11/2)2+3+2+3
7. Write short notes on : (09/2) 5+5
a. Female infanticide (14/2) 5
b.karyotyping (14/2)5
8. Write short notes on :child abuse (14/2) 5
9. a)Define child abuse and child neglect 2+2
b) Outline the steps involved in managment of suspected child of sexual abuse 6 (15/2)
10. Steps to curb female infanticide. 5 (Apr 16)
11. Munchausen syndrome by proxy 4 (01/16)


1. Various physical features that are likely to be associated with specific syndromes of mental retardation (95/2)10
2. Preventable and treatable causes of Mental retardation (96/2)10
3. Enumerate the causes of mental retardation in children. Give an outline of management of a child with mental retardation. (10/1)4+6
4. Enumerate the criteria for diagnosis of mental retardation (MR). Classify MR and describe its evaluation. (14/1)2+2+6



1. Discuss the influences of malnutrition on mental functions in relation to its onset, severity and type of functional losses with supportive advances. (93/1)25
2. Prevention of hypocalcaemia in PEM (93/1)15
3. Biochemical changes in PEM (96/2)10
4. Immunological changes that take place in PEM (98/2)10
5. Age independent Anthropometric criteria for assessment of PEM (06)5
6. Management of a 4 year old child with grade 4 PEM (07/2)10
7. Outline the initial management (in first 48 hours) of a 2 year old severely malnourished child (weight 5.5kg) who is cold to touch and has edema and poor peripheral pulses. (08/1)10
8. Discuss biochemical and metabolic derangements in a child with severe malnutrition. Discuss factors associated with high mortality in severe PEM. (08/2)10
9. Outline the 10 steps of management of severe malnutrition, as per WHO guidelines, in appropriate sequence. (10/2)10
10. Define ‘Severe Acute Malnutrition (SAM)’. Outline the tools for its diagnosis in the community and discuss their merits/ demerits.
11. Enlist the clinical and anthropometric criteria for diagnosis of Severe Acute Malnutrition (SAM). Discuss the principles of management of Sam in an 18 months old baby who also has watery diarrhea. (13/1)3+7
12. What are the different growth charts? Discuss the WHO growth chart. What is Sam (Severe Acute Malnutrition)? How do you manage a child with SAM? (14/1) 2+2+2+4
13. A) Clinical signs and symptoms of refeeding syndrome. 7
b) how will you manage such a case ? 3 (15/2)
14.a)What is Severe acute malnutrition (SAM) 2
b) What are clinical signs of SAM? 2
c) Management of SAM in an 1 year old child weighing 5 kg. 6(Apr 16)


1. Hazards and virtues of Vitamin A in pediatric practice (96/2)10
2. Vitamin A supplementation (07/1) 5
3. Enumerate functions of vitamin A in human body. Tabulate the WHO classification of vitamin A deficiency. Outline the treatment schedule for managing Xerophthalmia in children. (10/2)2+3+5
4. Describe WHO classification of eye manifestation of vitamin A deficiency. Discuss prevention & mgmt of Vit. A deficiency in children (14/2) 4+6
5. Hypervitaminosis A 4 (Apr16)Rpt 3marks (1/16)


1. Discuss the etiopathogenesis, clinical features, diagnosis and management of cobalamine deficiency. (12/1) 2+3+1+4


1. Clinical manifestations of Rickets (93/2)10
2. Vitamin D Resistant Rickets (96/2)12
3. Renal Rickets (97/2) 15
4. Functions of vitamin D (98/2) 10
5. Resistant Rickets 15
6. Outline the metabolism and function of Vitamin D in human body. Describe in detail the etiology and pathological changes in rickets (99/2)25
7. What are the causes of non nutritional rickets? How will you manage such a child? (04/2)3+7
8. Classify the various causes of rickets and outline how to differentiate them (05)5+5
9. Diagnostic approach to a child with resistant rickets (06)10
10. Resistant Rickets (06/1)10
11. Discuss calcium and vitamin D metabolism. Outline an approach to a case of Resistant Rickets (07/1)10
12. Discuss the pathophysiological basis of clinical and radiological manifestations of nutritional rickets. (09/1)10
13. Describe vitamin D metabolism. Describe diagnostic approach to a 3 year old child with rickets who has shown no response to treatment with 6 lac I.U. of vitamin D. (09/2) 4+6
14. Outline the clinical features, radiological changes, diagnosis and treatment of nutritional vitamin D deficiency rickets. (10/2) 2+2+2+4
15. Write in brief the role of vitamin D in health and disease in children. Outline the management of Vitamin D deficiency disorder. (12/1) 6+4
16. Hypervitaminosis D 4(Apr16)Rpt 3marks (1/16)
17. a. Outline the physiology of vitamin D 4
b. Diagnosis and treatment of vitamin D dependent Rickets.3+3 (1/16)


1. Scurvy- radiological changes. How are they produced? What is the role of Blood Level of Vit C in the diagnosis (05)10


1. Enumerate the functions and therapeutic uses of Vit E (98/1)15
2. Vitamin E and its role in human nutrition (92/2)15


1. Hypervitaminosis in Children (96/1) 12


1. What are the dietary sources of copper? What are the diseases associated with abnormal copper metabolism? Describe investigat., clinical features and treatment of any one of them. (09/2)1+2+7


1. Relevance of Zinc in human nutrition (92)15
2. Role of Zinc in health and diseases of children (97/1)10
3. Effects of Zinc supplementation in persistent diarrhea (98/2)10
4. Give dietary requirements of Zinc in children and discuss its role in childhood immunity and infections (07/1) 10
5. Write short notes on: Zinc supplementation – when and how? (11/2) 5


1. Sources, deficiency state and uses of magnesium in children.
2. Magnesium in therapy 3(14/1)
3. Mechanism of action, therapeautic dose, and adverse effects in children of magnesium sulphate. 5(1/16)


1. Anti-infective properties of Human milk (95/2)10
2. Differences in the composition of Milk secreted by mothers delivering Term and Preterm babies (96/2)10
3. Bioactive factors in Human Milk (98/1)15
4. Discuss the physiology of Breast Milk secretion and advantages of breast feeding with special reference to metabolic aspects. What are the causes of lactation failure (99/1) 25
5. Enlist the problems of breastfeeding and outline the management of the same (05) 4+6
6. Explain the occurrence of low prevalence of Hypoglycemia and iron deficiency anemia in breast fed infants (05)10
7. How would you assess the adequacy of breast milk for a 2 months old baby. Enumerate 4 features of good attachment of a baby to the breast. What can be the problems with poor attachment (06)10
8. Compare the composition of human milk with cow’s milk. Outline the difference in the milk composition of a mother with a premature neonate from that of a term neonate. Describe the immunological factors present in human milk. (08/2) 10


1. Prevention of Iodine deficiency (95/1)15


1. Prevention of Fluoride toxicity (95/1)15
2. Fluoride and disease 2 (Apr16)


1. Approach to a child with obesity (99/1)15
2. Define obesity in childhood. List the causes of obesity in children. Outline strategies for its prevention. (04/2)2+3+5
3. What is Obesity? Discuss the management in children (05)3+7
4. Approach to a child with Obesity (06/1)(07/2)10
5. Outline the diagnostic measures and clinical manifestations of obesity. Enlist the differential diagnosis of childhood obesity. (09/2) 2+3+5
6. Define syndrome X. Outline the diagnostic criteria and laboratory work up for obese children. (10/1)2+3+5
7. Define obesity. List causes of obesity. Discuss approach to a child with obesity. (11/1)2+3+5
8. A 2 year old toddler presents with a weight of 25 kg. Discuss the possible causes, evaluation and treatment for this child. (14/1)3+4+3


1. Metabolism of fat absorption along with role of MCT in nutrition (03/1)15
2. What is Complimentary Feeding? Discuss the feeding problems in first year of life (05)5+5
3. How would you assess the nutritional status of a child whose age is not known (05)10
4. Describe the attributes of complimentary feeding. What is the safe age of introduction of complementary feeding in your opinion – Justify. Describe some foods appropriate for complimentary feeding. (08/2)10
5. Daily nutritional requirements as recommended Daily Allowance (RDA) in infants and children. (10/1)5+5
6. Define complimentary feeding. Outline the attributes of complimentary foods. Enumerate the recommendations on complimentary feeding, as per the National guidelines on Infant and Young Child Feeding (IYCF) (10/2) 2+2+6
7. Name the micronutrients required for various body functions. Discuss briefly their dietary sources and the effects of deficiency of mineral micronutrients (trace elements). (11/2)3+2+5
8. Outline the nutritional support of a critically ill child. List the complications during management of such a child. (12/1)7+3
9. Enteral feeding in the sick child 4(14/1)
10. Role of micronutrient in pediatric health and diseases. 5(Apr16)



1. Define Shock. Describe the pathophysiology and management of septic shock in children (94/2)25 Rpt(04/2)5+5
2. Management of Cardiogenic shock (96/1)12
3. Discuss the classification and causes of shock in children (97/1)15
4. Shock-pathogenesis of different types and pathological changes in different organs (03/1)25
5. Discuss the management of an infant with Shock (00/1)25
6. How do you classify Shock in children? Write its etiopathogenesis and management (06)10
7. Discuss the pathophysiology of cardiogenic shock. How are the various hemodynamic parameters affected in cardiogenic shock? Discuss steps in monitoring and treatment of cardiogenic shock. (08/2)10
8. Define fluid refractory shock. Describe the management strategy for a 2 year old child with fluid refractory shock. (10/1) 3+7
9. Define septic shock. Describe the etiopathogenesis and clinical features in a 15 month old child presenting with septic shock. (11/2)2+4+4
10. Discuss the pathophysiology of septic shock. Describe the international consensus definition for pediatric sepsis. (13/1)5+5
11. Define SIRS, sepsis, severe sepsis and septic shock. Discuss the management of septic shock. (13/2) 1+1+1+1+6
12. Etiology and management of cardiogenic shock. (14/2) 3+7
13. Pathophysiology and management of Refractory shock 5(15/2)
14. What is the defining criteria of systemic inflammatory response syndrome (SIRS).Name the mediators involved and their mode of action. 5+5(15/2)
15. Etiology , pathogenesis, clinical features and management of cardiogenic shock? 2+3+2+3 (15/2)


1. List the causes of Hypokalemia. Discuss the clinical features, laboratory diagnosis and management of Hypokalemia (06)10
2. Define hypokalemia. Enlist its causes and outline clinical features and its treatment (09/2) 1+3+2+4
3. Discuss the diagnostic algorithm for investigating persistent hypokalemia in a child. (13/2)10
4. Define hyperkalemia. Discuss management of hyperkalemia (14/2)2+8
5. Hyperkalemia 3 (Apr16)


1. List the causes of Hyponatremia. Discuss the clinical features, lab
diagnosis and management of Hyponatremia . (05)3+4+3
2. Enumerate common causes of Hyponatremia (06)5
3. Define hypernatremia. Describe the pathophysiological changes and steps of management of hypernatremia. (10/1)2+4+4
4. Define hyponatremia. Enumerate the etiology of hyponatremia.
Describe the management of hypovolemic hyponatremia. (10/2) 2+3+5
5. Define hypernatremia. Enumerate the etiology of hypernatremia.
Describe the management of hypernatremic dehydration.(11/1) 3+4+3
6. Write short notes on: Causes and management of hypernatremia in children. (13/2)5
7. Hypernatremia 3 (Apr 16)
8. Hypernatremic dehydration 5(1/16)


1. Etiology, pathogenesis, clinical features and management of Hypophosphatemia 2+3+2+3(Apr 16)


1. Define pH and base excess. Discuss briefly regulation of Acid-base homeostasis and management of Respiratory Acidosis (93/1)15
2. Physiological compensatory mechanisms during Metabolic Acidosis (97/1)15
3. Describe briefly how the acid-base balance of body is maintained in health (98/1) 25
4. Anion Gap (98/2) (00/1)10
5. Pathophysiology of Acid-base disorders (03/1)15
6. Anion Gap (03/2)15
7. Define anion gap and its utility. Outline the major causes of metabolic acidosis in children. Outline the treatment of renal tubular acidosis. (04/2)2+4+4
8. Outline the normal mechanism of acid-base regulation in children. What is anion-gap? Describe the causes and management of a child with metabolic acidosis (07/2)10
9. List the causes of metabolic alkalosis. Describe the pathophysiology, clinical features and treatment. (08/2)10
10. Classify metabolic acidosis based on anion gap. Mention the various causes of lactic acidosis. Describe the approach to diagnosis of inborn error of metabolism in an infant. (08/2)10
11. Classify and enlist the causes of metabolic alkalosis. Outline the treatment modalities. (10/1)3+3+4
12. Define anion gap. Enlist causes of increased anion gap acidosis and discuss its management in brief. (11/1)2+3+5
13. What is anion gap? Discuss the acid base distribution in metabolic acidosis. Enumerate the causes of increased anion gap and normal anion gap metabolic acidosis. 1+5+(2+2)(15/2)


1. Why children are more vulnerable to develop dehydration (96/2)10
2. One year old infant with AGE develops Abdominal Distension. Discuss the differential diagnosis (97/1)10
3. Pathogenesis and Management of Hypernatremic Dehydration (97/2) 15
4. Management of Acute Diarrhea in children (98/1)15
5. Management of Hypernatremic Dehydration (02/1)15
6. Hypernatremic Dehydration (03/1)15
7. Hyponatremic Dehydration (03/2) 15
8. Steps in management of patient with Hypernatremic Dehydration (06)10
9. A one year old infant weighing 5.5kg presents with Acute Dysentery and severe dehydration. Discuss its complete management (06/1)10
10. A one year old baby weighing 5.5kg comes in severe dehydration. Discuss complete management (07/2)10
11. Discuss causes, predisposing factors and pathophysiology of Hypernatremic dehydration in young children (07/1)10
12. Describe the pathophysiology of hyponatremic dehydration. Briefly discuss the management of a child with serum sodium of 110meq/liter presenting with moderate dehydration and seizures (08/2) 10


1. Pathophysiology of regulation of Plasma Osmolality (06)10
2. Discuss etiopathogenesis, clinical manifestations and management of Bartter Syndrome. (13/2) 2+4+4
3. Define osmolarity. Discuss the mechanism of regulation of plasma osmolarity in the human body. (14/2) 2+8
4. How is plasma osmolality calculated?Discuss its determinants.What are the diagnostic criteri of SIADH? 3+4+3 (Apr 16)
5. Pathophysiology and regulation of plasma osmolality 5(1/16)
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CME: OSCE Workshop 2017

Monday, November 7, 2016   at  10:55:00 PM


Is organizing a 3 day DNB clinical training and OSCE workshop

Date: Feb 23, 24th & 25th 2017
Details of venueQuality Inn Sabari
Reg fee: 7500 Rs

  • Registration is limited to 75 seats only!
  • First cum first basis
  • For Details contact Dr. Janani Sankar - 9841078101

    Update 12 Nov 2016

    For Registration:
    You can send a DD or cheque favouring "THE CHILDS TRUST MEDICAL RESEARCH FOUNDATION".

    Please message your names to 9841078101 or mail your names to
    will register your names and the payment can be made subsequently.
                                           For more updates

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    Pediatrics FAQ 6: Adoption

    Wednesday, October 26, 2016   at  12:06:00 AM


    Social, emotional and legal process that provides a new family when the birth family is unable or unwilling to parent.

    Adoption process : 

    Step:1 Preparation for adoption

    Couple should be prepared mentally and physically with mutual consent to adopt.
    Age difference between atleast one of the parent and the baby to be adopted should not be > 40yrs.
    Adoption to be done through approval agency.

    Documents required,
    1. Age proof certificate
    2. Income Certificate
    3. Marriage registration certificate
    4. Doctor certificate regarding health and infertility status
    5. Photograph

    Step : 2 Pre adoption counselling – home study report

    Done by social worker of approved agency who visits adopting family.

    Step : 3 Selection of a child

    Agency will identify a suitable / compatible child
    Social worker will arrange to see the child
    Agency will make available particulars of the child (child study report) and get a complete examiantion of child including
    1. Anthropormetry , immunization status
    2. Inv: CBC, CHEST X-RAY, LFT, RFT, Urine and stool analysis,
    3. USG abdomen , ECHO , HIV , HbSAg, Thyroid screening, Special tests – for hemolytic anemia, IEM, chromosomal anomaly.
    All documents, home study report, child study report, letter of acceptance of child – filled in court with application and referred to scrutinizing agent (Indian counsil of child welfare).
    Order will be issued by the court and deed of adoption will be executed

    Step4: - Follow up and post adoption counselling
    1. Nutritional status
    2. Immunization
    3. Growth and development

    Step 5 – Encourage, insists and help the parent to tell the child about his / her adoption – most vital step. (6-10 yrs)

    About Author:
    Dr Shailesh Gophane is DCH from J.J. Hospital, Mumbai and DNB from Port Trust Hospital Mumbai. This is a series of Notes for dnb pediatrics theory exams. They are not the alternative to reading Nelson's thoroughly, but these notes will prove helpful during final days of revision and may be helpful to overcome any loopholes if you are not having enough time to cover whole system. December 2015 had 6 repeat questions from these notes.

    is a  community of students, just like you, trying to help each other
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    CME: Books to Bedside 2017

    Tuesday, October 11, 2016   at  12:12:00 AM

    Date and Venue: Jan 6 to 8, 2017 at Nagpur, India. 
    Theme: Supportive care in pediatrics, neonatology, Pediatric ICU

    Basic topics like fluids, electrolytes, acid base disturbances, non-invasive ventilation & many more. 

    A pre-conference workshop on Applied Basic Life Sciences, Non-Invasive Ventilation and Simulation based Pediatric ICU training on 6th of Jan 2017

    Workshop on Pediatric Bronchoscopy

    Workshop on hospital entrepreneurship

    Eminent International & renowned national faculties in pediatric super specialities

    Programme details:
    Contact: Dr Anand Bhutada
    9922066527, 0712-76095915, 0712-2527319

    Read more»

    OSCE: Immunization

    Friday, October 7, 2016   at  1:16:00 PM

    Question: 1
    What are the recent updates to the IAP Immunization schedule?

    Answer 1

    Preferably be avoided in primary vaccination series (at 6, 10 and 14 weeks)
    Instead of OPV at 6, 10, 14 weeks and 15 months, So OPV only at birth, 6 months, 9 months and 5 years
    Hepatitis B vaccine:
    The final (third or fourth) dose in the Hepatitis B vaccine series should be administered no earlier than age 24 weeks and at least 16 weeks after the first dose
    MMR vaccine:
    At 9 months and 15 months, No need for booster at 5 years
    Typhoid conjugate vaccine:
    (TypBar) given at 9 to 12 months, with a booster at 2 years of age
    Hepatitis A:
    Single dose for live attenuated H2-strain Hep-A vaccine
    Two doses for all killed Hep-A vaccines are recommended at 12 months and 18 months
    Only 2 doses of either of the two HPV vaccines for adolescent/pre-adolescent girls aged 9-14 years
    For girls 15 years and older, and immunocompromised individuals 3 doses are recommended
    For two-dose schedule, the minimum interval between doses should be 6 months.
    For 3 dose schedule, the doses can be administered at 0, 1-2 and 6 months

    Question: 2
    What are special vaccines you would advise for high risk category children?

    Answer: 2

    High-risk category of children:
    1. Congenital or acquired immunodeficiency (including HIV)
    2. Chronic cardiac, pulmonary, hematologic, renal and liver disease
    3. Children on long term steroids, salicylates, immunosuppressive or radiation therapy
    4. Diabetes mellitus, CSF leak, Cochlear implant, Malignancies
    5. Children with functional/ anatomic asplenia/ hyposplenia
    6. Laboratory personnel and healthcare workers
    7. Travelers
    IAP recommended vaccines for High-risk children
    1. Influenza Vaccine
    2. Meningococcal Vaccine
    3. Japanese Encephalitis Vaccine
    4. Cholera Vaccine
    5. Rabies Vaccine
    6. Yellow Fever Vaccine
    7. Pneumococcal vaccine (PPSV 23)

    Question: 3
    1. What is pre-exposure prophylaxis for rabies and for whom should we advise?
    2. What are the advantages of giving it?
      Answer: 3
      1. Children having pets in home
      2. Children perceived with higher threat of being bitten by dogs such as hostellers, risk of stray dog menace while going outdoor
      3. Veterinarians, those who work with animals
      4. Three doses are recommended to be given intramuscularly on days 0, 7 and 28
      In case of bite,
      Two doses are to be given on days 0 and 3. Rabies immunoglobulin (RIG) are not needed in these children.

      Question: 4
      11 year old boy adopted, no medical records available and BCG scar is not seen. The adoptive parents want to know what vaccines have to be given. What will you advise?

      Answer: 4
      1. TDaP vaccine- single dose
      2. MMR- 2 doses at 4-8 weeks gap
      3. Hep B- 3 doses at 0,1 and 6 months
      4. Hepatitis A- 2 doses at 0, 6 months
      5. Typhoid- 1 dose every 3 years
      6. Varicella- 2 doses at 4-8 weeks

      Question: 5
      Influenza Vaccine
      1. What are the types of influenza vaccines in India?
      2. When is a LAIV not recommended?
      3. What is IAP recommended target prioritization for influenza vaccines?
        Answers: 5


        Trivalent inactivated vaccines (TIV) and Live Attenuated Influenza vaccines (LAIV).
        LAIV not recommended below 2 years of age, in high-risk individuals and in pregnant women.
        (1-Highest priority, 4-Lowest priority)

        1.Elderly (> 65 years) / nursing-home residents
        2.HIV/AIDS, and pregnant women (especially to protect infants 0–6 months)
        3.Other groups: Health care workers, asthmatics, and children from ages 6 months to 2 years.
        4.Children aged 2–5 years and 6–18 years, and healthy young adults.

        Question: 6
        Meningococcal Vaccine
        What are the categories to be vaccinated as per IAP recommendations?

        Answers: 6

        A.During disease outbreaks
        B. Vaccination of persons with high-risk conditions/situations
        1. Complement component deficiencies
        2. Functional/anatomic asplenia/hyposplenia
        3. HIV
        4. Healthcare workers exposed routinely to Neisseria meningitides
        5. Adjunct to chemoprophylaxis
        C. International travellers – Study abroad/ Hajj/ Sub-Sahara Africa

        Question: 7
        Answers yes or no
        1. Can BCG be given in symptomatic HIV cases
        2. Can OPV be given in symptomatic HIV cases
        3. Can measles, MMR and Varicella be given in symptomatic HIV cases
          Answer: 7
          1. No
          2. Yes – if IPV not affordable
          3. Yes, if CD4+ count > 15%

          Question: 8
          1. What solution is used to swab the site prior to vaccination?
          2. When will you consider the BCG administration technique to be successful?
          3. What is the normal reaction at the vaccine site following successful vaccination?
          4. What condition is associated with BCG vial contamination?
            Answer: 8
            1. Normal saline
            2. A wheal of 5 mm at injection site
            3. A papule develops by 2-3 weeks, increases to size of 4-8mm by 5-6 weeks, ulcerates and heals with scarring by 6-12 weeks
            4. Toxic shock syndrome

            Question: 9
            Which is the Polio vaccine of choice for outbreak control?Which Polio vaccine type is more efficacious – Trivalent OPV or Bivalent OPV?What is enhanced IPV?

            Answer: 9
            1. OPV
            2. Bivalent OPV more efficacious than Trivalent OPV – as competition between different serotypes is eliminated
            3. Enhanced IPV contains
            type 1 – 40 Ag U
            type 2 – 8 Ag U
            type 3- 32 Ag U

            Question: 10
            1. What are the conditions that predispose to VDPV
            2. Name the Polio serotypes more frequently associate with VAPP and VDPV

            Answer: 10

            a) Dropping immunization coverage
            b) High population densities
            c) Tropical conditions
            d) previous eradication of wild polio virus
            VAPP – Type 2
            VDPV – Type 3

            Question: 11
            What is VVM and how will you interpret?


            Answer: 12


            Question: 13
            1. What is AEFI and when will you consider it serious?
            2. What are the different types?

            Answer: 13

            AEFI is adverse Event Following immunization
            An AEFI will be considered serious, if it:
            Results in death
            Is life-threatening
            Requires in-patient hospitalization or prolongation of existing hospitalization
            Results in persistent or significant disability/incapacity
            Is a congenital anomaly/birth defect or
            Requires intervention to prevent permanent impairment or damage.
            Types of AEFI:

            1. Vaccine reaction:
            Event caused by the vaccine or precipitated by the vaccine when given correctly eg. VAPP after OPV

            2. Programme error:
            Event caused by an error in vaccine preparation, handling, or administration. Egs- TSS after measles vaccine due to improper storage

            3. Injection reaction:
            Event from anxiety about, or pain from the INJECTION, rather than vaccine. Eg abscesses

            4. Coincidental:
            Event that happens after immunization, but NOT caused by it. Eg SIDS

            5. Unknown:
            The cause of the event cannot be determined.

            Question: 14
            What are the recommended time limits for using vaccines after reconstitution?

            Answer: 14
            1. Varicella : 30 mins (and protect from light)
            2. MMRV: 30 mins (and protect from light)
            3. Yellow fever: 1 hour
            4. MEASLES/MMR : 4 to 6 hours
            5. Meningococcal PS vaccine: 30 mins
            6. DTaP/Hib combination: 30 mins

            Question: 15
            How do you store vaccines in the refrigerator?

            Answer: 15

            1. Freezer: OPV
            2. Top shelf: BCG, Measles, MMR
            3. Middle shelf: T- vaccines, IPV, Hib, Combination vaccines, HPV, Typhoid, Hep A, PCV, influenza, rota virus
            4. Lower: Varicella

            Name some contraindications and precautions for vaccination.

            Answer: 16

            A condition in a recipient which greatly increases chances of a serious adverse reaction. Egs- severe allergic reactions
            OSCE Immunisation 1

            A Condition in recipient which might increase chance or severity of a serious adverse reaction or might compromise ability of vaccine to produce immunity

            osce immunisation 2

            Question: 17
            What is freeze watch indicator?

            Answer: 17

            Small vial of red liquid attached to a white card and covered in plastic.
            Vial breaks if temperature drops below 0 Celsius for >1 hour
            Useful for T vaccine

            Disclaimer: These OSCE are for helping each other, and are not copyrighted, in case there is any copyright from any author, please inform us, we will remove the content

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