Master Pediatrics
for SMLE
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Core Concepts
Growth & Development: Track using WHO growth charts. Understand developmental milestones (gross motor, fine motor, language, social) and recognize deviations. Nutrition: Breastfeeding, Vit D/iron for infants. Malnutrition (marasmus, kwashiorkor) and obesity are key concerns.
Immunization: Crucial for disease prevention. Adhere to national schedules (e.g., Saudi schedule). Know contraindications (anaphylaxis, severe immunocompromise for live vaccines). Key vaccines (DTaP, MMR, Hep B, etc.) and understanding schedules are vital.
Neonatal Care: APGAR scoring, physiological vs. pathological jaundice (within 24 hrs, high rise, conjugated), common issues like Respiratory Distress Syndrome (RDS), sepsis, and congenital anomalies. Routine screenings.
Common Conditions: Focus on respiratory (asthma, bronchiolitis, pneumonia), GI (gastroenteritis, constipation), GU (UTI), and infectious diseases (febrile seizures, meningitis). Child abuse recognition.
Clinical Presentation
- Gastroenteritis: Vomiting, diarrhea, signs of dehydration (sunken fontanelle/eyes, dry membranes, decreased tears/urine, prolonged CRT, lethargy).
- Bronchiolitis: (Infants <2 yrs) Viral prodrome, cough, tachypnea, retractions, expiratory wheeze, crackles.
- Asthma: Recurrent wheezing, cough (especially nocturnal/exercise-induced), dyspnea, chest tightness.
- Pneumonia: Fever, cough, tachypnea, respiratory distress, localized crackles, decreased breath sounds.
- Urinary Tract Infection (UTI): Infants: fever, irritability, poor feeding. Older children: dysuria, frequency, urgency, enuresis, abdominal/flank pain, fever.
- Febrile Seizure: Seizure with fever (6 months-5 years), generalized tonic-clonic, usually <15 mins, single episode/24 hrs. No underlying CNS infection.
- Meningitis: Infants: fever, irritability, bulging fontanelle. Older: fever, headache, photophobia, neck stiffness, Kernig/Brudzinski signs.
- Child Abuse: Unexplained/inconsistent injuries, injuries incompatible with developmental stage, patterned bruises, spiral fractures, retinal hemorrhages.
Diagnosis (Gold Standard)
Gastroenteritis: Clinical. Stool culture for severe/persistent/bloody diarrhea, travel history.
Bronchiolitis: Clinical based on age and presentation. CXR not routinely recommended.
Asthma: Clinical. Spirometry (>5-6 yrs) with bronchodilator reversibility. Peak flow monitoring.
Pneumonia: Clinical with chest X-ray (infiltrates).
Urinary Tract Infection (UTI): Urine culture (clean catch, catheter specimen, suprapubic aspirate). Dipstick for screening.
Febrile Seizure: Clinical after ruling out CNS infection if indicated (e.g., <6 months).
Meningitis: Lumbar Puncture (LP) for CSF analysis (cell count, protein, glucose, Gram stain, culture) is gold standard.
Developmental Delay: Formal developmental assessment. Further workup based on suspected etiology.
Neonatal Jaundice: Total and conjugated serum bilirubin. Transcutaneous bilirubinometry for screening.
Management (First Line)
Gastroenteritis: Oral Rehydration Therapy (ORT) is cornerstone. Zinc supplementation (SMLE focus) reduces severity/duration. IV fluids for severe dehydration/shock.
Bronchiolitis: Supportive care: humidified oxygen for hypoxia, nasal suctioning, hydration. No routine bronchodilators/steroids/antibiotics.
Asthma Exacerbation: Inhaled short-acting beta-agonists (SABA) via spacer. Oral corticosteroids for moderate-severe. Long-term control with inhaled corticosteroids (ICS).
Pneumonia (CAP): Amoxicillin (oral) for uncomplicated bacterial pneumonia. Hospitalize infants/severe cases. Macrolides for atypicals.
Urinary Tract Infection (UTI): Empirical oral antibiotics (e.g., Cefixime) for 7-10 days, adjusted by culture. Renal US + VCUG for atypical/recurrent UTIs.
Febrile Seizure: Reassurance, antipyretics for comfort. Safety during seizure. No routine anticonvulsants.
Meningitis: Prompt IV empirical antibiotics (Ceftriaxone/Cefotaxime + Vancomycin). Dexamethasone may reduce neurological sequelae.
Anaphylaxis: Immediate intramuscular (IM) adrenaline (0.01 mg/kg, max 0.5mg/0.3mg infant) mid-anterolateral thigh. Repeat as needed.
Exam Red Flags
- Fever in an infant <3 months: Urgent evaluation and full septic workup until proven otherwise.
- Non-blanching rash (petechiae/purpura) + fever: Meningococcemia or serious bacterial infection; immediate antibiotics.
- Severe respiratory distress: Grunting, severe retractions, cyanosis, altered mental status, inability to feed.
- Bulging fontanelle: Raised intracranial pressure (e.g., meningitis, hydrocephalus, bleed).
- Significant dehydration/shock: Lethargy, prolonged capillary refill (>3 secs), weak pulses, hypotension.
- Absent red reflex: Suggests congenital cataract, retinoblastoma, vitreous hemorrhage.
- Neonatal jaundice within first 24 hours of life: Always pathological, requires urgent investigation.
- Inconsistent history/physical findings with injury: High suspicion for non-accidental trauma (child abuse).
- Regression of developmental milestones: Suggests neurological or metabolic disorder, requires urgent investigation.
- Acute scrotum: Testicular torsion is a surgical emergency; differentiate from epididymitis.
Sample Practice Questions
A 6-month-old infant is brought to the emergency department with a 2-day history of cough, rhinorrhea, and low-grade fever, followed by increasing respiratory distress, wheezing, and poor feeding. On examination, the infant is tachypneic, has intercostal retractions, and diffuse inspiratory and expiratory wheezes are noted on auscultation. Oxygen saturation is 92% on room air. The child has no prior history of similar episodes or allergies. What is the most likely diagnosis?
A 4-year-old girl presents with a 3-day history of low-grade fever, malaise, and a non-itchy rash. The rash started on her trunk and then spread to her face and extremities. On examination, she has diffuse maculopapular rash, blanching on pressure, and post-auricular and occipital lymphadenopathy. Her mother reports she has not been vaccinated against MMR.
A 2-day-old full-term neonate develops cyanosis that does not improve with oxygen administration. On examination, he is centrally cyanotic, has respiratory distress, and a single loud S2. There are no murmurs appreciated. A pulse oximetry reading shows saturation of 70% in the right hand and 68% in the left foot.
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