Master Pediatrics
for SMLE

What the SMLE Tests in Pediatrics

The SMLE Pediatrics section tests the ability to recognise and manage common acute and chronic paediatric conditions, with emphasis on age-specific presentations, developmental milestones, and emergency triage. Candidates must apply evidence-based guidelines for conditions such as febrile seizures, bronchiolitis, asthma exacerbations, diabetic ketoacidosis, and neonatal jaundice. Key decisions include when to start antibiotics in febrile infants, when to perform a lumbar puncture, and how to interpret growth charts and developmental screening tools. The exam also assesses knowledge of immunisation schedules, fluid and electrolyte management in children, and recognition of child abuse and safeguarding concerns. Clinical reasoning is tested through scenarios requiring differential diagnosis, appropriate investigations, and first-line treatments, often with reference to UK or international guidelines like NICE or WHO.

High-Yield Concepts

• Febrile Seizure Criteria: Simple febrile seizure: generalised, <15 minutes, single in 24 hours, no recurrence within same febrile illness. No routine EEG or neuroimaging needed. First-line antipyretic is paracetamol (15 mg/kg/dose) or ibuprofen (10 mg/kg/dose), but antipyretics do not prevent recurrence. Consider lumbar puncture if meningeal signs or in infant <12 months with incomplete immunisation.
• Neonatal Jaundice Management: Use NICE phototherapy thresholds: for term infants without risk factors, phototherapy at serum bilirubin >290 μmol/L at day 4. Exchange transfusion threshold >345 μmol/L. Always check direct Coombs test, blood group, and G6PD if indicated. Pathological jaundice appears <24 hours of age or rises >85 μmol/L/day.
• Bronchiolitis Severity and Treatment: Mild: saturations ≥92%, no respiratory distress, manage at home. Moderate: saturations <92%, grunting, chest recession, give oxygen via nasal cannula to target SpO2 94-98%. Severe: apnoea, exhaustion, poor feeding, consider CPAP or intubation. Do not routinely use bronchodilators, steroids, or antibiotics. Palivizumab prophylaxis for high-risk infants (e.g., congenital heart disease, prematurity <32 weeks).
• Paediatric Asthma Acute Exacerbation: Mild-moderate: salbutamol via pMDI + spacer (2-4 puffs, repeat up to 10 puffs if needed). Severe: oxygen to target 94-98%, back-to-back salbutamol via nebuliser (2.5 mg <5 years, 5 mg ≥5 years), add ipratropium bromide (250 mcg <5 years, 500 mcg ≥5 years). Life-threatening: IV salbutamol (15 mcg/kg over 10 min) or IV magnesium sulfate (40 mg/kg, max 2 g). Oral prednisolone: 1-2 mg/kg/day for 3-5 days (max 40 mg/day).
• Diabetic Ketoacidosis (DKA) in Children: Diagnosis: hyperglycaemia >11 mmol/L, venous pH <7.3, bicarbonate <15 mmol/L, ketonaemia/ketonuria. Fluid resuscitation: 10-20 mL/kg 0.9% saline over 1 hour (max 1 L) if shocked. Then deficit replacement: 0.9% saline + 5% dextrose when glucose <14 mmol/L. Insulin infusion: 0.1 units/kg/hour IV. Monitor potassium: replace if <5.5 mmol/L. Avoid bicarbonate unless pH <6.9 with impaired cardiac function.
• Developmental Milestones (Red Flags): By 6 months: no social smile; by 12 months: no babbling or no pincer grasp; by 18 months: no single words; by 2 years: no two-word phrases; by 3 years: no three-word sentences or difficulty with stairs. Loss of previously acquired skills is always a red flag. Use the Ages and Stages Questionnaire (ASQ) or Denver II for screening.
• Child Abuse: Non-Accidental Injury (NAI): Suspect NAI if: bruising in non-mobile infants, burns in glove/stocking pattern, spiral or metaphyseal fractures, subdural haemorrhage with retinal haemorrhages. Skeletal survey for children <2 years. CT head if neurological signs. Safeguarding: admit to hospital, inform paediatric consultant, refer to social services, consider child protection plan.
• Immunisation Schedule (UK Routine): 8 weeks: 6-in-1 (DTaP/IPV/Hib/HepB), Rotavirus, MenB. 12 weeks: 6-in-1 second dose, PCV13. 16 weeks: 6-in-1 third dose, MenB second, Rotavirus second. 1 year: Hib/MenC, MMR, PCV13 booster, MenB booster. 3 years 4 months: MMR second, DTaP/IPV booster. 12-13 years: HPV (Gardasil 9, 2 doses). 14 years: Td/IPV, MenACWY.

Common Traps in Pediatrics Questions

• Do not give ibuprofen to a child with asthma if they are already on salbutamol — it can trigger bronchospasm in sensitive individuals.
• In febrile seizures, do not perform a lumbar puncture just because the child is febrile; only do so if meningeal signs are present or the child is <12 months with incomplete immunisation.
• For neonatal jaundice, do not start phototherapy based on visual assessment alone — always check serum bilirubin levels and plot on the NICE nomogram.
• In bronchiolitis, do not routinely prescribe antibiotics or bronchodilators — they are not indicated unless there is coexistent bacterial infection or asthma.
• In DKA, do not give insulin before fluid resuscitation — this can precipitate hypokalaemia and shock.
• Do not assume a child with a limp has a simple sprain; always consider septic arthritis or slipped capital femoral epiphysis, especially in children <5 years or adolescents, and check CRP, ESR, and hip ultrasound.

How to Revise Pediatrics for the SMLE

Prioritise acute paediatric emergencies: febrile seizures, DKA, asthma exacerbation, bronchiolitis, and neonatal jaundice. Memorise NICE thresholds and treatment algorithms, especially for fluid resuscitation and insulin dosing. Practice interpreting growth charts and developmental screening: questions often present a child with delayed milestones and ask for the most likely diagnosis or next step. Be comfortable with UK immunisation schedule and catch-up regimens. For safeguarding, remember the classic fracture patterns and retinal haemorrhage triad. Questions are typically scenario-based with a single best answer; focus on the first-line intervention rather than all possible options. Review antibiotic choices for common infections (e.g., otitis media: amoxicillin 5-7 days; pneumonia: amoxicillin first-line). Use NICE Clinical Knowledge Summaries for quick reference.

Practise it: MedLumen has 50 Pediatrics questions for the SMLE, each with a full explanation and references.