Pediatrics Past Paper PDF

Index Growth - Page 1 Short Stature & Tall Stature - Page 19 Abnormalities of Head Size & Shape - Page 32 Previous Year Questions (Growth) - Page 46 Important Motor Milestones - Page 60 Social & Language Milestones - Page 66 Previous Year Questions (Normal Development) - Page 75 Developmental and Behavioral Disorders - Page 86 Previous Year Questions (Developmental and Behavioral Disorders) - Page 102 Puberty & Adolescence - Page 107 Important Terminologies and Primitive Neonatal Reflexes - Page 119 Neonatal Resuscitation - Page 142 IUGR and Feeding of Preterm Neonates - Page 161 Neonatal Hypothermia,Hypoglycemia,Sepsis - Page 168 Respiratory Disorders - Page 181 Neonatal Jaundice & Necrotizing Enterocolitis - Page 197 Erythroblastosis Fetalis & Latest Updates - Page 207 Previous Year Questions (Neonatology) - Page 221 Breast Milk & Breast Feeding - Page 240 Micronutrients in Health and Disease - Page 262 Malnutrition - Page 274 Previous Year Questions (Nutrition and Malnutrition) - Page 310 Body Composition & Acid Base Balance - Page 331 Previous Year Questions (Fluid and Electrolyte Disturbances) - Page 368 Genetics Disorders - Page 374 Previous Year Questions (Genetics and Genetic Disorders) - Page 439 Disorders of Carbohydrate Metabolism - Page 453 Disorders of Aminoacid - Page 480 Lysosomal Storage Diseases - Page 501 Previous Year Questions (Inborn Errors of Metabolism) - Page 525 Primary Immunodeficiency - Page 531 Vasculitic Disorders in Children - Page 558 Viral Diseases - Page 568 Bacterial and Protozoal Diseases - Page 600 Congenital Infections - Page 620 Previous Year Questions (Infectious Diseases) - Page 632 Index Immunization and Storage - Page 659 Fetal Circulation & Cyanotic Congenital Heart Disease - Page 686 Acyanotic Congenital Heart Diseases - Page 708 Previous Year Questions (Pediatric Cardiology) - Page 716 Coagulation and Bleeding Disorders - Page 732 Hematological Malignancies in Children - Page 741 Tumors of Infancy and Childhood - Page 768 Previous Year Questions (Pediatric Hematology and Oncology) - Page 778 Disorders in Gastrointestinal System Including Diarrhea - Page 787 Liver Disorders in Children - Page 831 Previous Year Questions (Pediatric Gastroenterology) - Page 850 Respiratory Disorders in Children - Page 871 Previous Year Questions (Pediatric Respiratory Disorders) - Page 916 Acute and Chronic Kidney Disease - Page 933 Congenital Anomalies. - Page 942 Nephritic Syndrome and Nephrotic Syndrome - Page 952 Renal Tubular and Obstructive Disorders - Page 967 Previous Year Questions (Pediatric Nephrology) - Page 977 Musculoskeletal Disorders - Page 994 Previous Year Questions (Musculoskeletal Disorders in Children) - Page 1042 Disorders of Pituitary Gland - Page 1051 Thyroid Disorders in Children and Disorders of Sexual Development - Page 1072 Adrenal Disorders and Disorders in Puberty - Page 1089 Previous Year Questions (Pediatric Endocrinology) - Page 1110 Congenital CNS Malformation and Hydrocephalus - Page 1117 Seizures in Children - Page 1155 Disorders with CNS Involvement and Brain Death - Page 1180 Previous Year Questions (Pediatric Neurology) - Page 1215 Growth 1. A 4-year-old boy brought to OPD by his parents. He has had foul-smelling watery diarrhoea for the last 5 months. His weight and height are below the 50th percentile. To estimate total body fat, a subscapular skin fold thickness is needed. What is the name of this device is used for this purpose? (or) To estimate total body fat, subscapular skin fold thickness is measured by which of the following devices? A. Orchidometer B. Vernier calipers C. Harpenden Calipers D. Shakir's tape ---------------------------------------- 2. A mother brings her 6-month-old boy for a regular check-up. She worries whether her baby's growth might be inadequate. His physical examination is unremarkable, weighing 6.4kg, and his length is 64cm. The boy was born at term gestation via uncomplicated vaginal delivery, and his birth weight was 3.8 kg. Postnatally, in which year of life is the maximum growth? (or) During which year of life does a child experience the maximum growth postnatally? A. In the first year of life B. In the second year of life C. In the seventh year of life D. In adolescence ---------------------------------------- 3. A final year student is presenting a case of a 15-months old child who, upon examination, has a mongoloid slant of eyes, epicanthic fold, and simian crease. Her growth is retarded, with no dentition; there is also history of delayed dentition in one of the siblings. At what age is the dentition considered to be delayed? (or) At what age is the dentition considered to be delayed? A. 18 months B. 6 months C. 16 months D. 13 months ---------------------------------------- 4. Which of the following is true about the growth chart shown below? (or) The WHO Multicentre Growth Reference Study (MGRS), conducted between 1997 and 2003, aimed to create new growth curves for evaluating the growth and development of newborns and young children 1 globally. Which of the following is true about the growth chart shown below? A. It is a growth velocity curve B. It can be used to know whether a child has muscle wasting or not C. It is used for serial assessment of growth status D. It cannot detect failure to thrive ---------------------------------------- 5. A 15-month-old boy was brought to OPD by his mother who complained that her son had not yet developed any teeth. Physical examination shows retarded growth, low muscle tone, short stature, a flat nasal bridge, a protruding tongue, and up-slanting palpebral fissures. There is also delayed dentition in one of the siblings. All of the following could be the underlying causes of delayed dentition except? (or) Which of the following is not a possible underlying cause of delayed dentition in a 15-month-old male? A. Rickets B. Pierre Robin sequence C. Cleidocranial dysostosis D. Down syndrome ---------------------------------------- 6. Until what period of intrauterine life is the product of conception considered embryonic? (or) A 28-year-old female, tested positive for pregnancy by a urine pregnancy kit. For confirmation, she visited her family gynecologist. On examination, it was found that she was pregnant, and the embryonic period is already completed. Until what period of intrauterine life is the product of conception considered embryonic? A. 8 weeks B. 10 weeks C. 12 weeks D. 6 weeks ---------------------------------------- Page 2 2 7. A health surveillance team consisting of a midwife, nutritionist, and a vaccinator is moving door to door to record the height, weight, mid-arm circumference and skin fold thickness of children under the age of 2 years. For field conditions, Salter’s Scale is quite satisfactory as it is easy to carry. Salter's Scale is a useful method employed to measure which of the following parameters? (or) Which parameter would be measured by Salter’s scale? A. Mid-arm Circumference B. Length at birth C. Skin fold thickness D. Body weight ---------------------------------------- 8. How many permanent teeth will the 8-year-old child have after the removal of one incisor from the right upper quadrant and one from the right lower quadrant? (or) Parents bring their 8-year-old child to the dentist after he suffered injury on the face with the football while playing with his friends. One incisor from the right upper quadrant and one from the right lower quadrant was broken and had to be removed. How many permanent teeth will the child have at that time? A. 20 B. 24 C. 12 D. 16 ---------------------------------------- 9. Which of the following parameters is not used for the assessment of growth? A. Weight B. Height C. Mid upper arm circumference D. Mid forearm circumference ---------------------------------------- 10. A mother of two children brings her younger child to the clinic for a well-child visit. His growth charts showed normal growth and development. The mother denies any abnormal complaints and adheres to the dietary guidelines provided by the pediatrician. A child belonging to which of the following age groups is considered a toddler? A. 1- 3 years B. 3-6 years C. 2-4 years D. Till 1 year ---------------------------------------- Page 3 3 11. A one-year-old boy was brought to the clinic for a routine checkup. On examination, the child is healthy and active. The pediatrician measured mid upper arm circumference of the child. What is the normal mid-upper arm circumference for a child in this age? A. 9 cm B. 10 cm C. 11 cm D. 16 cm ---------------------------------------- 12. Which among the following is the growth chart preferred for those below 5 years of age? A. NCHS Growth Charts (1977) B. CDC Growth Charts (2000) C. WHO Growth Charts (2006) D. Indian growth charts ---------------------------------------- 13. A camp was conducted in Anganwadi for the assessment of the growth status of children in that locality in 2022. Which among the following growth charts is depicted below? A. Percentile-based growth chart B. Standard deviation-based growth chart C. Z-score-based growth chart D. Weight for age growth chart ---------------------------------------- 14. A 7-month-old boy is brought to the OPD for general examination. On evaluation, he has an erupted tooth. Which of the following is the normal sequence of eruption of milk teeth? (or) Which of the following is the typical sequence of eruption of milk teeth? A. Lower central incisor → Lateral incisor → canine → 1 st molar → 2 molar B. Lower central incisor → Lateral incisor → 1st molar→ canine → 2 molar C. Lower central incisor → Lateral incisor → 1st molar→ 2 nd molar → canine D. Lateral incisor → Lower central incisor → 1st molar→ 2 nd molar → canine Page 4 4 ---------------------------------------- 15. An infant is brought to the OPD by his parents who express concerns about their son's hearing ability. On physical examination, he has a desquamative rash, hepatosplenomegaly, and generalized non-tender lymphadenopathy. The parents attribute the rash to an allergy. Oral examination findings are shown in the image below. What is the name of the abnormal finding in the image? (or) What is the name of the abnormality shown in the image of an infant with hearing loss, desquamative rash, hepatosplenomegaly, and generalized non-tender lymphadenopathy? A. Rickets B. Hypothyroidism C. Down syndrome D. Hutchinson Teeth ---------------------------------------- 16. A baby girl was brought to the clinic by her parents complaining of teeth present at birth. On examination, the baby is inactive and lethargic. Which of the following conditions is not associated with the presence of teeth at birth? (or) Which condition is not associated with natal teeth? A. Congenital heart disease B. Sotos syndrome C. Short limb dwarfism D. Rickets ---------------------------------------- Correct Answers Question Correct Answer Question 1 3 Question 2 1 Question 3 4 Page 5 5 Question 4 3 Question 5 2 Question 6 1 Question 7 4 Question 8 3 Question 9 4 Question 10 1 Question 11 4 Question 12 3 Question 13 1 Question 14 2 Question 15 4 Question 16 4 Solution for Question 1: Option C: Harpenden Calipers Harpenden calipers are used to measure the skin fold thickness. Measured over the following areas:- Subscapular and suprailiac sites. Biceps Triceps areas Subscapular and suprailiac sites. Biceps Triceps areas Subscapular and suprailiac sites. Biceps Triceps areas Page 6 6 Option A: Orchidometer An orchidometer is a medical device that can precisely measure volume and ascertain the size of the testes, which is a useful index of puberty in males to evaluate male growth and development. It consists of a sequence of ellipsoids (beads) of increasing volume. Option B: Vernier calipers It is used to measure the diameter of an object. Page 7 7 Option D: Shakir's tape It measures the mid-upper arm circumference of pregnant women and children. It helps in the diagnosis of malnutrition. Solution for Question 2: Option A: In the first year of life The first few years following birth are when children grow the fastest. During infancy, growth happens even more quickly than it does during puberty. The average baby is twice as long and three times as heavy at the end of the first year. Page 8 8 Postnatally there are two periods of accelerated growth: The first year of life Growth spurt during puberty (1st year of life > puberty) The first year of life Growth spurt during puberty (1st year of life > puberty) The first year of life Growth spurt during puberty (1st year of life > puberty) Option B: In the second year of life Growth slows considerably in the second year of life. Appetite also decreases The child may acquire 5 pounds (2.27 kg) and gain 4 to 5 inches in height (10 to 12 cm). Option C: In the seventh year of life Growth is not the fastest in the 7th year of life. Option D: In adolescence Growth is rapid when there is a growth spurt during adolescence, but this growth is relatively slower than in the first year of life. 1st year of life > puberty Solution for Question 3: Option D: 13 months The patient described in the clinical vignette is a case of Down syndrome with the delayed eruption of primary teeth. Delayed dentition is usually considered when no teeth have erupted by 13 months. Normally temporary teeth eruption is completed by 2 to 2.5 years of age Causes of delayed tooth eruption: Mnemonic- FRIED ChoP Familial Rickets Idiopathic Endocrine Congenital hypopituitarism Congenital hypothyroidism and hypoparathyroidism Down syndrome Cleidocranial dysostosis Progeria Familial Rickets Idiopathic Endocrine Congenital hypopituitarism Congenital hypothyroidism and hypoparathyroidism Congenital hypopituitarism Congenital hypothyroidism and hypoparathyroidism Down syndrome Cleidocranial dysostosis Progeria Familial Page 9 9 Rickets Idiopathic Endocrine Congenital hypopituitarism Congenital hypothyroidism and hypoparathyroidism Congenital hypopituitarism Congenital hypothyroidism and hypoparathyroidism Down syndrome Cleidocranial dysostosis Progeria Congenital hypopituitarism Congenital hypothyroidism and hypoparathyroidism Solution for Question 4: Option C: It is used for serial assessment of growth status A child's height, weight, and head size are measured using growth charts to compare them to kids of their own age. Doctors can monitor a child's growth using growth charts. These charts could signal a child's medical issue early on. The growth chart shown above is the weight-for-age growth chart. Advantages of weight-for-age as a monitor of growth It is considered a useful indicator for growth monitoring in general terms. It is sensitive to small changes in the child's nutritional status, as reflected by weight, and is a good indicator for detecting growth faltering. The only tools needed are weighing scales and charts - usually easy to carry and relatively cheap. Weighing is a fairly easy and quick task, even for inexperienced health workers. It is considered a useful indicator for growth monitoring in general terms. It is sensitive to small changes in the child's nutritional status, as reflected by weight, and is a good indicator for detecting growth faltering. The only tools needed are weighing scales and charts - usually easy to carry and relatively cheap. Weighing is a fairly easy and quick task, even for inexperienced health workers. It is considered a useful indicator for growth monitoring in general terms. It is sensitive to small changes in the child's nutritional status, as reflected by weight, and is a good indicator for detecting growth faltering. The only tools needed are weighing scales and charts - usually easy to carry and relatively cheap. Weighing is a fairly easy and quick task, even for inexperienced health workers. Option A: It is a growth velocity curve It is the weight for age growth chart, not a growth velocity chart Page 10 10 Growth velocity is how much a child's weight, length, or height has changed from one visit to the next. This lets you track the growth of an individual child. Option B: It can be used to know whether a child has wasting or not Wasting is a decrease in weight for height, but this is a weight for age chart Option D: It cannot detect failure to thrive The growth chart shown above is the weight-for-age growth chart It can be used to detect failure to thrive, i.e. not gaining weight properly Solution for Question 5: Option B: Pierre Robin sequence Delayed dentition: when no tooth has erupted by the age of 13 months. Important causes of delayed dentition: “FRIED ChoP” Familial Rickets Idiopathic Endocrine causes Hypopituitarism Hypothyroidism Hypoparathyroidism Down syndrome Cleidocranial dysostosis (Clavicles absent, large AF, Supernumerary teeth) Progeria So, among the options, only the Pierre-Robin sequence is not associated with delayed dentition. Pierre-Robin sequence is a cause of natal teeth (Natal teeth are teeth that are there when the baby is born) Other causes of natal teeth: Ellis Van Creveld syndrome Sotos syndrome Epidermolysis bullosa Familial Rickets Idiopathic Endocrine causes Hypopituitarism Hypothyroidism Hypoparathyroidism Hypopituitarism Hypothyroidism Hypoparathyroidism Page 11 11 Down syndrome Cleidocranial dysostosis (Clavicles absent, large AF, Supernumerary teeth) Progeria So, among the options, only the Pierre-Robin sequence is not associated with delayed dentition. Pierre-Robin sequence is a cause of natal teeth (Natal teeth are teeth that are there when the baby is born) Other causes of natal teeth: Ellis Van Creveld syndrome Sotos syndrome Epidermolysis bullosa Ellis Van Creveld syndrome Sotos syndrome Epidermolysis bullosa Familial Rickets Idiopathic Endocrine causes Hypopituitarism Hypothyroidism Hypoparathyroidism Hypopituitarism Hypothyroidism Hypoparathyroidism Down syndrome Cleidocranial dysostosis (Clavicles absent, large AF, Supernumerary teeth) Progeria So, among the options, only the Pierre-Robin sequence is not associated with delayed dentition. Pierre-Robin sequence is a cause of natal teeth (Natal teeth are teeth that are there when the baby is born) Other causes of natal teeth: Ellis Van Creveld syndrome Sotos syndrome Epidermolysis bullosa Ellis Van Creveld syndrome Sotos syndrome Epidermolysis bullosa Hypopituitarism Hypothyroidism Hypoparathyroidism Ellis Van Creveld syndrome Sotos syndrome Epidermolysis bullosa Options A, C and D: Rickets, Cleidocranial dysostosis and Down syndrome All these are the known causes of delayed or no eruption of primary teeth. Page 12 12 Solution for Question 6: Correct Option A: 8 weeks The embryonic stage is when the germ layers emerge, organize, and start to form the earliest bodily structures. The nervous system begins to take shape. The heart's embryonic stages mature, and it starts to pump blood. Every organ in the body starts to form during the embryonic stage. It ranges from the day of fertilization (14th day post-ovulation) to 8 weeks of intrauterine life. Solution for Question 7: Option D: Birth weight To measure the weight of children younger than two years old to the nearest 0.1 kg, a weighing sling, known as a Salter Scale, is utilized. Salter’s Spring Scale is quite satisfactory for field conditions as it is easy to carry. The bathroom weighing scale is an unreliable instrument for measuring children's weight. In hospitals or clinics, pan type or bassinet type infant weighing scale is used. Salter spring scale Option A: Mid-arm Circumference Shakir's tape is used to measure mid-upper arm circumference. Page 13 13 It has three coloured zones corresponding to various levels of wasting. Option B: Length at birth If a child is +2 S.D height during childhood, and the parents complain that the child did not gain height after that. Which of the following conditions is not associated with tall stature during childhood but normal adult height? (or) Which of the following conditions is not associated with tall stature during childhood but normal adult height? A. Osteogenesis Imperfecta B. Constitutional tall stature C. Precocious puberty D. Soto’s syndrome ---------------------------------------- 7. Which among the following is the correct statement about short trunk dwarfism? Page 2 20 A. US: LS ratio is decreased B. US: LS ratio is increased C. US:LS ratio is normal D. US = LS ---------------------------------------- 8. A 4-year-old boy is brought to the OPD by his mother due to delayed milestones, short stature, and obesity. A physical examination shows bowing of legs, proximal limb shortening, macrocephaly, and a trident hand. X-ray shows the champagne-glass appearance of the pelvis. What is the most likely cause of his short stature? A. Achondroplasia B. Osteogenesis imperfecta C. Rickets D. Congenital hypothyroidism ---------------------------------------- 9. Which among the following is an etiological factor for tall stature? A. Down syndrome B. Turner syndrome C. Edward syndrome D. Klinefelter syndrome ---------------------------------------- 10. A child was brought to the clinic by his father due to large head size, and physical disability. The pediatrician diagnosed him with Sotos syndrome. Which among the following is the correct standard deviation for height in the above-mentioned condition? A. < -2 SD B. > +2 SD C. > +3 SD D. < - 3 SD ---------------------------------------- Correct Answers Question Correct Answer Question 1 1 Question 2 1 Question 3 1 Question 4 3 Question 5 2 Question 6 1 Page 3 21 Question 7 1 Question 8 1 Question 9 4 Question 10 2 Solution for Question 1: Option A: Constitutional delay in growth and puberty Features Constitutional growth delay Height Short Height velocity Normal Family history Delayed puberty Bone age Less than chronological age Puberty Delayed Rate of growth Slow from infancy Growth hormone Gonadotropin level Page 4 22 The presented curve demonstrates that the child's height stays below and parallel to the 3rd percentile line throughout childhood. It represents the constitutional delay in growth and puberty (the most common cause of short stature - Short stature is defined as height below the third centile or more than 2 standard deviations (SDs) below the median height for age and gender ( + 2 SD: Sotos syndrome is a rare cause for tall stature Sotos syndrome (cerebral gigantism) is associated with large head sizes. It is a rare genetic disorder caused by a mutation in nuclear receptor binding SET domain protein 1(NSD1) on chromosome 5. It is characterized by excessive physical growth during the first few years of life. It causes neurological and physical disability It is characterized by excessive physical growth during the first few years of life. It causes neurological and physical disability It causes tall stature during childhood but normal adult height Height of a child > +2 SD of expected, according to age and sex of the child It is characterized by excessive physical growth during the first few years of life. It causes neurological and physical disability Incorrect Options: Option A, C & D - < -2 SD, > +3 SD & < - 3 SD: These are not the correct standard deviation for tall stature Page 13 31 Abnormalities of Head Size & Shape 1. An infant was brought to the pediatric department for routine vaccination. After the vaccination, the mother took the baby to the doctor as she noticed the baby's asymmetrically flat head and uneven ears. Which of the following is the most likely diagnosis in this infant? (or) What is the most likely diagnosis for an infant brought to the pediatrician with flattening of one side of the skull and uneven ears? A. Plagiocephaly B. Dolichocephaly C. Brachycephaly D. Anencephaly ---------------------------------------- 2. A 1-week-old boy is brought to the clinic by his mother, complaining of seizures, spasms, and rigidity of arms and legs. The baby has had an enlarged head since birth. His vitals are stable. The physician orders an MRI of the baby's head, shown in the image below. Which of the following is the most likely diagnosis for this baby? A. Anencephaly B. Hydranencephaly C. Hydrocephalus D. Hydrops fetalis ---------------------------------------- 32 3. A preterm infant was brought to the pediatrician at 6 months of age for a routine check-up by his mother. The mother described that the baby is irritable, feeds poorly, and has 3 to 4 episodes of vomiting daily. She is concerned about the weird shape of his skull. On examination, the baby was found to be otherwise well. However, his anterior fontanelle was full. A picture of his skull is shown. Which of the following is the most likely diagnosis? (or) What is the most likely diagnosis for a 6-month-old infant with a weird shape of the skull, a full anterior fontanelle, irritability, poor feeding, and frequent episodes of vomiting reported by the mother during the pediatrician visit? A. Craniosynostosis B. Rickets C. Cretinism D. Cleidocranial dysostosis ---------------------------------------- 4. A 2-year-old female child is brought to the pediatric OPD by her mother, who was normal at birth having normal early development. However, she now presents with microcephaly, regression of acquired language and motor milestones, and abnormal stereotypic hand-wringing movements. Which of the following is the most likely diagnosis? (or) What is the most likely diagnosis for a 2-year-old female child who presented with microcephaly and loss of purposeful hand movements, despite having normal early development? A. Angelman syndrome B. Rett syndrome C. Asperger syndrome D. Metachromatic leukodystrophy ---------------------------------------- 5. An 18-month-old boy was brought by his mother to the pediatrician as the child appeared to have a large head size relative to his age, had facial abnormalities, with poor growth. His mother also reported that the child was vomiting and had been more irritable in the last few weeks. Physical examination revealed low muscle tone. Which of the following is the most likely diagnosis? (or) Page 2 33 What is the diagnosis for an 18-month-old boy with a large head size relative to his age, facial abnormalities, developmental delays, low muscle tone, vomiting, and increased irritability observed in the past few weeks? A. Smith-Lemli-Opitz syndrome B. Rett syndrome C. Glutaric aciduria type 1 D. Angelman syndrome ---------------------------------------- 6. A child is brought to the clinic with a sloping forehead, deafness, developmental and physical retardation. On examination, microcephaly, cleft lip and cleft palate, and microphthalmia are evident. Which among the following is the condition that causes these abnormalities?? (or) Which among the following is the condition that causes microcephaly in a child with a sloping forehead? A. Patau Syndrome (Trisomy 13) B. Osteogenesis imperfecta C. Rickets D. Weaver syndrome ---------------------------------------- 7. A child with a nose deformity and a broad deviated thumb is brought to the clinic by his mother. On examination, HC < - 3 SD according to the age and sex of the child, and there is evidence of congenital heart disease. Which among the following conditions causes microcephaly associated with congenital heart disease and nose deformity? (or) Which among the following conditions causes microcephaly associated with congenital heart disease and nose deformity? A. Patau syndrome B. Edward syndrome C. Rickets D. Rubinstein-Taybi Syndrome ---------------------------------------- Page 3 34 8. A 6-year-old boy and his mother visited a clinic complaining that he has large sized head with some abnormalities in the leg. On examination, the pediatrician observes that the child has developed a prominent swelling of the costochondral junctions and indentations along the lower ribs. Which of the following causes macrocephaly in a child with this condition? (or) Which of the following causes macrocephaly in a child presenting with bowing of the legs, prominent swelling of the costochondral junctions and indentations along the lower ribs? A. Scurvy B. Rickets C. Anencephaly D. Schizencephaly ---------------------------------------- 9. A newborn boy is examined by the pediatrician after delivery. An abnormal head shape and palpable ridge in the suture line are found on evaluation. He is diagnosed with craniosynostosis. Which of the following is the normal sequence of fusion of cranial sutures? (or) Which one of the following is the normal sequence of fusion of cranial sutures? A. Metopic suture, Sagittal, Coronal, Lambdoid B. Sagittal suture, Coronal, metopic, Lambdoid C. Coronal suture, Lambdoid, sagittal, coronal D. Lambdoid suture, metopic, sagittal, coronal ---------------------------------------- 10. What is the most common type of craniosynostosis? A. Dolichocephaly B. Trigonocephaly C. Turricephaly D. Brachycephaly ---------------------------------------- 11. A child is brought to the clinic by her parents for a routine checkup. On examination, the child is healthy and active. The fontanelle at the junction of the frontal and parietal bone is closed. What is the age group at which this fontanelle normally gets closed? (or) What is the age at which the fontanelle at the junction of frontal and parietal bones normally gets closed? A. At birth B. At 6 weeks C. At 8 weeks D. At 18 months Page 4 35 ---------------------------------------- Correct Answers Question Correct Answer Question 1 1 Question 2 2 Question 3 1 Question 4 2 Question 5 3 Question 6 1 Question 7 4 Question 8 2 Question 9 1 Question 10 1 Question 11 4 Solution for Question 1: Option A: Plagiocephaly Plagiocephaly is defined as the asymmetric shape of the head due to unilateral flattening that can result from: Asymmetry in the closure of sutures. Asymmetry of brain growth or deformation of the skull. Asymmetry in the closure of sutures. Asymmetry of brain growth or deformation of the skull. It may be frontal or occipital plagiocephaly. Frontal plagiocephaly is caused by premature fusion of coronal and sphenofrontal sutures characterized by: Unilateral flattening of the forehead Elevation of the ipsilateral orbit and eyebrow Prominent ear on the corresponding side Unilateral flattening of the forehead Elevation of the ipsilateral orbit and eyebrow Prominent ear on the corresponding side Occipital plagiocephaly is caused by positioning during infancy. It is more common in immobile children or children with a disability. Fusion of lambdoid suture can cause unilateral occipital flattening and bulging of the ipsilateral frontal bone. Asymmetry in the closure of sutures. Asymmetry of brain growth or deformation of the skull. Unilateral flattening of the forehead Elevation of the ipsilateral orbit and eyebrow Prominent ear on the corresponding side Page 5 36 Option B: Dolichocephaly A condition in which the head is elongated from front to back in the sagittal plane. Dolichocephaly is due to premature closure of the sagittal suture, which produces a long and narrow head with a cephalic index of less than 75. It is characterized by an increased anterior-posterior diameter of the skull. It is also known as scaphocephaly. It is the most common form of craniosynostosis. Option C: Brachycephaly A condition in which the head shape is shortened from front to back along the sagittal plane; typically, the back of the skull (occiput) and face are flatter than normal. Option D: Anencephaly A condition in which a baby is born with an underdeveloped brain and an incomplete skull It is a type of neural tube defect that occurs when the neural tube fails to close at the base of the skull during the third to fourth week of development. Solution for Question 2: Option B: Hydranencephaly The given image shows the enlarged head with the absence of cerebral hemispheres, which are replaced with fluid-filled sacs. This condition is known as hydranencephaly. In hydranencephaly, cerebral hemispheres are absent or represented by membranous sacs with remnants of frontal, temporal, or occipital cortex dispersed over the membrane. Infants in this condition usually have normal or enlarged head circumference at birth that grows at an excessive rate postnatally. The child with hydranencephaly is irritable, feeds poorly, and develops seizures and spastic quadriparesis. It is also associated with: Visual impairment Lack of growth Blindness Deafness Visual impairment Lack of growth Blindness Deafness Visual impairment Lack of growth Blindness Deafness Option A: Anencephaly Absence of a major portion of the brain, skull, and scalp. Page 6 37 It results from failure of closure of the rostral neuropore, the opening of the anterior neural tube. It is not compatible with life. It may be caused by interaction among several genetic and environmental factors. Option C: Hydrocephalus A condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. It results due to an impairment in circulation or absorption of CSF or may be due to increased production of CSF by choroid plexus papilloma. Option D: Hydrops fetalis The condition is characterised by the accumulation of large amounts of fluid in tissues and organs of the body, causing extensive swelling (edema). The main causes of hydrops fetalis include: Heart or lung diseases Severe anemia Genetic or developmental problems Heart or lung diseases Severe anemia Genetic or developmental problems Heart or lung diseases Severe anemia Genetic or developmental problems Solution for Question 3: Option A: Craniosynostosis Craniosynostosis is defined as premature closure of the skull sutures. The patient described in the vignette has scaphocephaly, a type of craniosynostosis. Early sagittal suture closure (before 2 years of age) is known as scaphocephaly. This suture runs from front to back down the center on the top of the head. The result is a cranium that is long and narrow. The skull is narrow from ear to ear and long from front to back. Craniosynostosis can present in children as vomiting, irritability, high-pitched crying, and abnormal head shape and circumference. Page 7 38 Option B: Rickets It is a disease of growing bones due to defective mineralization of the bone matrix at the growth plate in children before the fusion of epiphysis. It can cause a large anterior fontanelle or delayed closure of the anterior fontanelle. However, it does not cause scaphocephaly. Other common features of rickets are Failure to thrive Protruded abdomen Listlessness Increased risk of respiratory infections: Softening of ribs, impairs air movement during respiration Increased risk of fractures Craniotabes Large AF and delayed closure of AF Rachitic rosary (beading of the ribs) Harrison sulcus Failure to thrive Protruded abdomen Listlessness Increased risk of respiratory infections: Softening of ribs, impairs air movement during respiration Increased risk of fractures Craniotabes Large AF and delayed closure of AF Rachitic rosary (beading of the ribs) Harrison sulcus Failure to thrive Protruded abdomen Listlessness Increased risk of respiratory infections: Softening of ribs, impairs air movement during respiration Increased risk of fractures Craniotabes Large AF and delayed closure of AF Rachitic rosary (beading of the ribs) Page 8 39 Harrison sulcus Option C: Cretinism It is a state of low thyroid hormone in the body. Most common preventable and treatable cause of mental retardation in children Characteristic features associated with cretinism are as follows: Prolonged physiological jaundice Myxedematous facies: Large, protruded tongue Skin: Dry and scaly Hypotonia Hypothermia Hoarse cry Constipation Abdominal distension Umbilical hernia Prolonged physiological jaundice Myxedematous facies: Large, protruded tongue Skin: Dry and scaly Hypotonia Hypothermia Hoarse cry Constipation Abdominal distension Umbilical hernia Prolonged physiological jaundice Myxedematous facies: Large, protruded tongue Skin: Dry and scaly Hypotonia Hypothermia Hoarse cry Constipation Abdominal distension Umbilical hernia Option D: Cleidocranial dysostosis It is characterised by the underdeveloped or aplasia of clavicles, also called collar bones and teeth. Other features are Malocclusion of teeth Delayed closure of fontanelle Frontal and parietal bossing Sloping shoulders Short stature Malocclusion of teeth Delayed closure of fontanelle Frontal and parietal bossing Sloping shoulders Short stature Malocclusion of teeth Delayed closure of fontanelle Frontal and parietal bossing Page 9 40 Sloping shoulders Short stature Solution for Question 4: Option B: Rett syndrome The patient described in the clinical vignette is a classical case of Rett syndrome. The hallmark of the disease is the loss of motor skills and language and regression of the previously attained milestones of life (child starts to lose their skills). Other features of Rett syndrome are: X linked dominant inheritance Gene involved - MECP2 gene It is exclusively seen in females Normal head circumference at birth and normal early development Deceleration of head growth and acquired microcephaly Loss of purposeful hand movements with the development of stereotypical hand-wringing movement X linked dominant inheritance Gene involved - MECP2 gene It is exclusively seen in females Normal head circumference at birth and normal early development Deceleration of head growth and acquired microcephaly Loss of purposeful hand movements with the development of stereotypical hand-wringing movement X linked dominant inheritance Gene involved - MECP2 gene It is exclusively seen in females Normal head circumference at birth and normal early development Deceleration of head growth and acquired microcephaly Loss of purposeful hand movements with the development of stereotypical hand-wringing movement Option A: Angelman syndrome It is a defect of gene silencing It is characterized by seizures, ataxia, mental retardation, and inappropriate laughter (happy puppets) Option C: Asperger syndrome Asperger syndrome is a neurodevelopmental disorder within the family of autism spectrum disorder, characterized by significant difficulties in social interaction and non-verbal communication along with restrictive and repetitive behaviors or patterns, interests, and activities Option D: Metachromatic leukodystrophy Lysosomal storage disease Inheritance is autosomal recessive and the gene is located on chromosome 22 Causes progressive demyelination of the central (white matter) and peripheral nervous system. The characteristic metabolic defect is decreased urinary or leucocyte aryl sulphatase activity. Page 10 41 Solution for Question 5: Option C: Glutaric aciduria type 1 Glutaric aciduria type I is a rare autosomal recessive disorder caused by a deficiency of glutaryl CoA dehydrogenase. Clinical manifestations include macrocephaly in infants, followed by neurological symptoms such as hypotonia, irritability, and feeding problems. The patient may present with acute encephalopathic findings such as loss of developmental milestones, seizures, rigidity, and dystonia. Glutaric acid and 3-hydroxyglutaric acid may be elevated in urine, blood, and CSF. Neuroimaging may reveal macrocephaly, fluid accumulation, striatal lesions, ventricular dilation, cortical atrophy, and fibrosis. Treatment involves a low-protein diet, high doses of riboflavin and l-carnitine, early diagnosis, prevention of catabolic states, and aggressive treatment during acute episodes. Option A: Smith-Lemli-Opitz syndrome They have low muscle tone (hypotonia), have trouble eating, and grow more slowly than other babies. Most people with syndactyly have their second and third toes fused, and some have extra fingers or toes (polydactyly ). It is associated with microcephaly. Option B: Rett syndrome X linked dominant inheritance. Mostly affects females (almost exclusively females) Normal head circumference at birth and normal early development. Deceleration of head growth and acquired microcephaly Loss of purposeful hand movements with the development of stereotypical hand-wringing movement Option D: Angelman syndrome It is a defect of gene silencing. It is characterized by seizures, ataxia, mental retardation, and inappropriate laughter (happy puppets) It is associated with microcephaly. Solution for Question 6: Correct Option A - Patau syndrome (Trisomy 13): Patau syndrome, also known as trisomy 13, occurs in approximately 1 in 10,000 births. Characteristics of Patau syndrome include midline cleft lip, flexed fingers with postaxial polydactyly, ocular hypotelorism, bulbous nose, low-set and malformed ears, microcephaly, cerebral malformations Page 11 42 (especially holoprosencephaly), microphthalmia, cardiac malformations, scalp defects, and hypoplastic or absent ribs, along with visceral and genital anomalies. Incorrect Options: Option B, C & D: Osteogenesis imperfecta, Rickets & Weaver syndrome: These are the causes of mac rocephaly, not microcephaly Solution for Question 7: Correct Option D - Rubinstein-Taybi syndrome: It is characterized by microcephaly, nose deformity, broad deviated thumb, and congenital heart disease. It results from a mutation in the gene encoding for the transcriptional coactivator CREB-binding protein (CBP). It is a rare cause of Microcephaly. Incorrect Options: Option A, B, and C - Patau syndrome, Edward syndrome & Rickets: They are not associated with the features given in the question. Solution for Question 8: Correct option B - Rickets: It is a cause of macrocephaly It is due to Vitamin D deficiency Clinical features include: Craniotabes: Due to the softening of cranial bones Frontal and parietal bossing Large AF and delayed closed of AF Delayed dentition and dental caries Rachitic rosary: Beading of costochondral junctions Harrison sulcus: Due to the pulling of softened ribs by the diaphragm Craniotabes: Due to the softening of cranial bones Frontal and parietal bossing Large AF and delayed closed of AF Delayed dentition and dental caries Rachitic rosary: Beading of costochondral junctions Harrison sulcus: Due to the pulling of softened ribs by the diaphragm Craniotabes: Due to the softening of cranial bones Frontal and parietal bossing Large AF and delayed closed of AF Delayed dentition and dental caries Page 12 43 Rachitic rosary: Beading of costochondral junctions Harrison sulcus: Due to the pulling of softened ribs by the diaphragm Incorrect Options: Option A - Scurvy: It is due to Vitamin C deficiency It does not cause Macrocephaly Option C & D - Anencephaly & Schizencephaly: These conditions cause Microcephaly and not macrocephaly Solution for Question 9: Correct Option A - Metopic suture, Sagittal, Coronal, Lambdoid: The correct order of sequence of fusion of cranial sutures is - Metopic suture (2 months) Sagittal suture Coronal suture Lambdoid suture (22-26 months) Incorrect Options: Option B, C & D: Sagittal suture, Coronal, metopic, Lambdoid , Coronal suture, Lambdoid, sagittal, co ronal & Lambdoid suture, metopic, sagittal, coronal: The order is incorrect Solution for Question 10: Correct Option A - Dolichocephaly: Elongated head due to premature fusion of sagittal suture Most common type of craniosynostosis Incorrect Options: Option B, C & D - Trigonocephaly, Turricephaly & Brachycephaly: These are not the most common cau ses of craniosynostosis Solution for Question 11: Correct Option D - At 18 months: It is diamond shaped The fontanelle at the junction of frontal and parietal bones is Anterior fontanelle Page 13 44 It gets closed at around 18 months Incorrect Options: Option A, B & C - At birth, At 6 weeks & At 8 weeks: These are the age groups at which posterior fontanelle gets closed It is at the junction of parietal and occipital bones It is triangular shaped Page 14 45 Previous Year Questions 1. From the list below, who is considered a baby at risk? Infant born with a weight of 2.5 kg Infant receiving artificial feeding Infant of a working mother or single parent Infant born 1 week before expected date of delivery Second-born infant A. 2,3 B. 1,2,3,4 C. 4,5 D. 1,4 ---------------------------------------- 2. A 3-year-old child is brought to the OPD for a regular check-up. His growth chart shows a BMI between the 85th and 95th percentile. Which of the following categories would you place him in? A. Moderate wasting B. Severe acute malnutrition C. Overweight D. Obese ---------------------------------------- 3. A mother expresses concern about her child's unwillingness to eat properly. Her 15-month-old son's length falls 2 standard deviations below the median for his age. What is the most probable medical condition? A. Acute malnutrition B. Severe wasting C. Moderately underweight D. Moderate stunting ---------------------------------------- 4. Gonadal growth corresponds with _____. A. Brain B. Skeletal system C. Lymphoid growth D. Dental growth ---------------------------------------- 5. A 6-year-old child is brought for evaluation of short stature. His height is comparable with his parents' height and his bone age corresponds to his chronological age. What is the diagnosis? A. Familial short stature B. Constitutional delay C. Undernutrition D. Growth hormone deficiency ---------------------------------------- 46 6. What is the most reliable indicator of proper growth in an infant weighing 2.8 kg at birth? A. Increase in length of 25 centimetres in the first year B. Weight gain of 300 grams per month till 1 year C. Anterior fontanelle closure by 6 months of age D. Weight under the 75th percentile and height under the 25th percentile ---------------------------------------- 7. A 16-month-old boy weighs 8 kg. A WHO growth chart (weight-for-age) is provided below. What is the most appropriate advice for this child? A. No malnutrition - assure the mother B. Mild malnutrition - home treatment C. Severe malnutrition - refer to nutrition rehabilitation center D. Moderate malnutrition - teach the mother on how to feed ---------------------------------------- 8. How many primary teeth does a 3-year-old child have? A. 20 B. 24 C. 16 D. 32 ---------------------------------------- 9. A child is brought to the pediatrician with short stature. On evaluation, growth hormone levels are found to be high and insulin-like growth factor (IGF-1) levels are low. What could be the abnormality here? A. GH deficiency B. GHRH deficiency C. GH receptor resistance D. IGF-1 deficiency ---------------------------------------- 10. At what age does a child reach half of their adult height? Page 2 47 A. 12- 18 months B. 20 -24 months C. 32 - 36 months D. 40 - 48 months ---------------------------------------- 11. Where would you place the pulse oximeter to measure preductal oxygen saturation in an infant who was born 3 minutes ago? A. Left upper limb B. Left lower limb C. Right upper limb D. Right lower limb ---------------------------------------- 12. At what age is it recommended to introduce solid foods to an infant while continuing breastfeeding? A. 2 months B. 6 months C. 12 months D. 18 months ---------------------------------------- 13. A 10-year-old child is brought to the OPD with a history of repeated fractures for the past 2 years. On examination, blue sclera and dental abnormalities are noted. There is a family history of similar complaints. Which of the following is the diagnosis? A. Scurvy B. Rickets C. Osteogenesis imperfecta D. Osteomalacia ---------------------------------------- 14. Specific sign of kwashiorkor is: A. Pitting edema B. Weight loss C. Flag sign D. Muscle wasting ---------------------------------------- 15. At what age does transfer of one object to another hand happen? A. 6 months B. 9 months C. 7 months Page 3 48 D. 12 months ---------------------------------------- 16. At what age does stranger anxiety appear? A. 7 months B. 9 months C. 12 months D. 15 months ---------------------------------------- Correct Answers Question Correct Answer Question 1 1 Question 2 3 Question 3 4 Question 4 2 Question 5 1 Question 6 1 Question 7 4 Question 8 1 Question 9 3 Question 10 2 Question 11 3 Question 12 2 Question 13 3 Question 14 1 Question 15 3 Question 16 1 Solution for Question 1: Correct Option A - 2,3: Infants who exclusively consume formula may be in danger because they may not get the vital nutrients and antibodies needed for healthy growth and development. Breast milk is thought to be the best food for infants and newborns because it contains all the necessary nutrients and antibodies that fight infections. Similarly, children with working mothers or those raised by lone parents may be vulnerable due to a lack of availability of care and assistance. Page 4 49 For example, working mothers may struggle to nurse their children or make nourishing meals, and single parents may struggle to obtain the money necessary to provide for all of the baby's needs. These elements may cause malnutrition and other health issues. Therefore, the babies on artificial feed and working mothers/single parents are at risk. Incorrect Options: Option B - 1,2,3,4: Newborns weighing 2.5 kg or less at birth are are not specifically at-risk babies. Option C - 4,5: A baby that is developing normally and shows no other signs of health issues may not b e at risk if born 1 week before the expected date of delivery. Option D - 1,4: Higher birth order is a risk factor but 2nd in place is not a risk factor. Solution for Question 2: Correct Option C - Overweight: In children, BMI is calculated using age, sex, height, and weight, and the result is plotted on a growth chart to determine the child’s BMI percentile. BMI percentiles in children are classified as follows: Underweight: Less than 5th percentile Healthy weight: 5th percentile to less than 85th percentile Overweight: 85th percentile to less than 95th percentile Obese: Equal to or greater than 95th percentile Underweight: Less than 5th percentile Healthy weight: 5th percentile to less than 85th percentile Overweight: 85th percentile to less than 95th percentile Obese: Equal to or greater than 95th percentile In this case, the child’s BMI falls between 85th and 95th percentile, which places him in the overweight category. This means that the child’s weight is higher than what is considered healthy for his age, sex, and height. Underweight: Less than 5th percentile Healthy weight: 5th percentile to less than 85th percentile Overweight: 85th percentile to less than 95th percentile Obese: Equal to or greater than 95th percentile Incorrect Options: Options A, B and D: The BMI in the given clinical scenario does not fit into any of these categories. Solution for Question 3: Correct Option D - Moderate stunting: Stunting is defined as a length-for-age more than two standard deviations below the WHO Child Growth Standards median. This indicates that the child has not grown adequately in height and is considered short for age. In this case, the child’s length-for-age is ≤ -2 SD below the median, which Page 5 50 indicates moderate stunting. The reluctance to take feeds appropriately may be one reason for the child’s stunted growth. Poor nutrition, frequent infections, and inadequate stimulation can also contribute to stunting. Stunting is associated with impaired cognitive development, poor school performance, and reduced economic productivity in adulthood Incorrect Options: Option A - Acute malnutrition: Acute malnutrition refers to a recent and severe deficiency of energy, pro tein, and other nutrients that can lead to wasting and/or edema. The child in this scenario is not showin g signs of acute malnutrition. Option B - Severe wasting: Severe wasting is defined as a weight-for-height greater than three standar d deviations below the WHO Child Growth Standards median. The child’s weight is not provided in the scenario. Option C - Moderately underweight: Moderately underweight is defined as a weight-for-age greater tha n two standard deviations below the WHO Child Growth Standards median. The child’s weight is not pr ovided in the scenario. Solution for Question 4: Correct Option B - Skeletal system: Gonadal growth corresponds with skeletal growth, particularly during puberty. Estrogen in females and testosterone in males play a significant role in developing secondary sexual characteristics and contribute to the growth and maturation of the skeleton. This hormonal influence leads to changes in bone structure and overall height. Incorrect Options: Option A - Brain: Brain undergoes significant development during childhood and adolescence, gonadal growth is not closely associated with the growth of the brain. Various factors, including genetics, nutriti Page 6 51 on, and environmental factors influence brain development Option C - Lymphoid growth: Gonadal growth and lymphoid growth are distinct processes. Lymphoid ti ssues, such as lymph nodes and the spleen, play a role in the immune system but are not directly related to gonadal development. Option D - Dental growth: Gonadal growth is not unrelated to dental growth. Dental development is a s eparate process governed by genetics, nutrition, and oral health practices. Teeth develop independentl y of gonadal growth. Solution for Question 5: Correct Option A - Familial short stature: In familial short stature, the child follows the family's inherited short stature (shortness). The child is short as per definition (height 20 ml) Option B - Stage 4: Tests & scrotum longer Scrotal skin darker Penis increases in length & breadth, glans becomes more prominent. Option C - Stage 3: Further growth of testis Penis increases in length. Solution for Question 10: Correct Option B - Type 0: This is the most severe type that presents during fetal life Most children do not survive Incorrect Options: Option A - Type 2 SMA: Onset: 16-18 months of age These children are usually able to sit unaided but never able to stand so they are often wheelchair bound This is not the most severe type of SMA Option C - Type 1 SMA: It manifests during infancy There is profound hypotonia, flaccid weakness These babies never learn to sit, neck control is achieved later. Global areflexia There is profound hypotonia, flaccid weakness These babies never learn to sit, neck control is achieved later. Global areflexia There is profound hypotonia, flaccid weakness These babies never learn to sit, neck control is achieved later. Global areflexia Option D - Type 3 SMA: Least severe form It usually presents at > 18 months of age These children are usually able to walk but there are global areflexia, fasciculations, and tremors It usually presents at > 18 months of age These children are usually able to walk but there are global areflexia, fasciculations, and tremors It usually presents at > 18 months of age These children are usually able to walk but there are global areflexia, fasciculations, and tremors Page 10 116 Solution for Question 11: Correct Option D - White line of Frenkel: This white line is due to an increase in the width and opacity of the zone of provisional calcification at the end of the metaphysis seen in scurvy. The condition described in the question is Rickets It is characterized by failure to thrive, protruded abdomen, craniotabes, frontal and parietal bossing, large and delayed closure of the anterior fontanelle, rachitic rosary, and Harrison sulcus This is not a radiological finding seen in Rickets This is a radiological finding seen in Scurvy Incorrect Options: Option A, B & C - Blurring of metaphyseal margin / Widening of the growth plate & Soft bones undergo cupping: These are the radiological findings seen in Rickets Solution for Question 12: Correct Option A - Elevated serum calcium level: The condition described in the question is Familial Hypophosphatemic Rickets Elevated srum calcium is not an investigatory finding seen in Familial Hypophosphatemic Rickets In this condition, Serum calcium is usually normal or decreased It is characterized by X-linked dominant inheritance and the involvement of the PHEX gene Gene: PHEX gene (Phosphate regulating gene with Homology to an Endopeptidase on X chromosome) ↓ Normally produces an endopeptidase, that is responsible for the breakdown of FGF-23 Lower limb deformities are common Skull deformities and dental abnormalities seen Absent symptoms of Hypocalcaemia S.Ca S.PO4 Alk Phos 25(OH) Vit D3 1,25(OH) Vit D3 Page 11 117 PTH ↓ - ↑ Nutritional Rickets (N) VDDR Type 1 (↑) VDDR Type 2 N N/↑ Hypophosphatemia Rickets N/↓ Chronic Kidney ds Incorrect Options: Option B, C & D: Increased Alkaline phosphate / Normal PTH & Low serum phosphate: These are the i nvestigatory findings seen in Familial hypophosphatemic rickets Page 12 118 Important Terminologies and Primitive Neonatal Reflexes 1. Which of the following tests is done to assess the passive tone of shoulder flexors in the Ballard score? (or) A 1-day-old male baby was admitted to NICU after being delivered vaginally to a multiparous diabetic woman at home by a midwife. He had a weak cry, flaccid muscle tone, and a pulse of 98 bpm. He was immediately resuscitated for his poor APGAR score. The doctor examined him thoroughly for his physical and neuromuscular maturity. Which of the following tests is done to assess the passive tone of shoulder flexors in the Ballard score? A. Scarf sign B. Square Window C. Arm recoil D. Heel-to-ear ---------------------------------------- 2. Which of the following is considered least significant in causing asymmetric Moro's reflex? (or) A 32-year-old primigravida was brought to the labor room with gestational amenorrhea of 38 weeks. She was having strong uterine contractions with a cervical dilatation of 9cm. She was immediately prepared for a normal vaginal delivery. A junior doctor was conducting the delivery for the first time, assisted by an intern. The head of the fetus was delivered, but the shoulder delivery was unsuccessful with gentle traction and led to shoulder dystocia. The baby was immediately admitted to the pediatric department, and reflexes were checked. On examination, it was noticed that the child had an asymmetric Moro's reflex. Which is considered least significant in causing asymmetric Moro's reflex? A. Erb’s palsy B. Fracture of clavicle C. Down’s syndrome D. Shoulder joint dislocation ---------------------------------------- 119 3. A 4-month-old neonate born full-term came to the hospital for a routine follow-up. Vitals and sub-vitals are within normal ranges. The pediatrician then performs a thorough physical examination of the baby and assesses all primitive reflexes. When he flexes the baby’s head forward, his legs straighten, and his upper extremity is flexed. Which of the following reflexes was tested? (or) Which reflex was tested in a 4-month-old neonate born full-term when the doctor flexed the baby's head forwards and observed the straightening of legs and flexion of the upper extremities? A. Moro’s reflex B. Symmetric tonic neck reflex (STNR) C. Crossed extensor reflex D. Asymmetric tonic neck reflex ---------------------------------------- 4. A 2-month-old baby is brought by his mother to pediatrics outdoors for a regular visit. He is active and feeding well. On examination, a reflex is elicited by rotating the head of the baby to one side, causing the extension of the upper extremity on the side to which the face is rotated and the flexion of the upper extremity on the other side, as shown in the figure. What is the name of this primitive neonatal reflex? (or) What is the name of the reflex observed in a baby, where the rotation of the head to one side causes the extension of the upper extremity on the same side and the flexion of the upper extremity on the other side, as shown in the figure? A. Moro reflex B. Asymmetric tonic neck reflex C. Parachute reflex D. Symmetric tonic neck reflex ---------------------------------------- 5. Which primitive neonatal reflex is being elicited by the physician shown in the picture below? (or) A 38-week-old primigravid woman was brought into the labor room with her water bag ruptured and constant labor contractions. She delivered a baby girl after half an hour. The baby was brought to the pediatrician. The pediatrician found the Apgar score to be 8/10. He held the baby in a supine position and suddenly left the head to fall back. He noticed a symmetrical opening of the arms before they Page 2 120 closed again (extension rather than flexion of the limbs). Which primitive neonatal reflex is being elicited by the pediatrician shown in the picture below? A. Moro’s reflex B. Asymmetric tonic neck reflex C. Parachute reflex D. Symmetric tonic neck reflex ---------------------------------------- 6. A baby with an Apgar score of 9/10 was brought to the pediatrician for his general physical examination. The doctor examined his eyes, skin color, and motor reflexes. He then stimulated the lips of the baby with his finger. Upon doing so, the child turned his face and lips toward the direction of the fingers. Which primitive neonatal reflex is being checked by the doctor? (or) Which neonatal reflex is being checked here? A. Moro’s reflex B. Asymmetric tonic neck reflex C. Rooting reflex D. Swallowing reflex ---------------------------------------- 7. A newborn baby came to the pediatrician for a general physical check-up. Upon taking Apgar's score, it came to be 7/10. Then the baby was put on a soft pad in a supine position, and then his head was gently lifted with just enough support to begin to lift his whole body weight off the pad and then quickly release it. While doing this, the child's upper limb got extended, and then the upper limb got Page 3 121 flexed. What is the first indication of Moro’s reflex in the 28th week of the gestation period? (or) What is the first indication of Moro’s reflex in the 28th week of the gestation period? A. Opening of hands B. Abduction of upper limbs C. Adduction of upper limbs D. Movement of the trunk ---------------------------------------- 8. What tools can be utilized to determine the gestational age of a premature newborn when the mother's last menstrual period and antenatal ultrasound reports are unavailable? (or) A mother delivered her newborn pre-mature baby via cesarian delivery; when further checkups proceeded for the neonate and history was asked, the mother does not remember the date of her last menstrual period, and no antenatal ultrasound reports are available. Which of the following tools can be used to assess the gestational age of the neonate born to this mother? A. Apgar score B. Extended Silverman score C. Expanded new Ballard score D. Downe’s score ---------------------------------------- 9. A 32-year-old, 40 weeks pregnant, came to the emergency department of the hospital for delivery. She was multigravida, and she has a history of diabetes. She delivered a baby via vaginal delivery; upon weighing the baby, it was found out that he was large for his age. What would be the birth weight of the baby? (or) "What would be the expected birth weight of a 40-week-old baby delivered vaginally by a 32-year-old multigravida with a history of diabetes, if the baby is found to be large for gestational age?" A. >90th percentile for the gestational age B. >50th percentile for gestational age C. >3 kg D. >3.5 kg ---------------------------------------- 10. What finding has been elicited in a 9-month-old baby boy during a routine check-up when the infant is held in vertical suspension and slowly lowered to the couch, causing the infant's arms to extend? (or) A 9-month-old baby boy is brought by his mother to the pediatrics OPD for a routine check-up. The baby was born at 38 weeks gestation to a P1G1 mother and is otherwise healthy and vigorous. During the examination, the baby is held in vertical suspension and slowly lowered to the couch, which causes the infant's arms to extend. Which of the following has been elicited in the infant? Page 4 122 A. Hypotonia in a floppy infant B. Asymmetric Tonic neck reflex C. Parachute reflex D. Moro's reflex ---------------------------------------- 11. A 3-day-old neonate was admitted to NICU with a glucose level of 2 mmol/L. She was given a 2ml/Kg IV bolus of 10% dextrose. During a physical examination, the baby was found to have macrosomia, mild microcephaly, large and prominent eyes, an abnormally large tongue, hemihyperplasia, omphalocele and cryptorchidism. The baby also has a greater risk of developing a Wilms tumor. What is the most probable diagnosis? (or) What is the most probable diagnosis for a neonate admitted with a glucose level of 2 mmol/L, presenting with macrosomia, mild microcephaly, an abnormally large tongue, hemihyperplasia, omphalocele, and a greater risk of developing Wilms tumor? A. WAGR syndrome B. Sturge-Weber syndrome C. Denys-Drash syndrome D. Beckwith-Wiedemann syndrome ---------------------------------------- 12. A term baby was delivered in a hospital by LSCS to a 30-year-old female. On examination, the weight of the baby is 1.4 kg. The baby cried soon after birth. How do you classify this baby according to the weight? (or) Classify a full-term baby weighing 1.4 kg at birth. A. Low birth weight baby B. Very low birth weight baby C. Extremely low birth weight baby D. Normal birth weight baby ---------------------------------------- 13. A 22-year-old woman gave birth to a baby weighing 3 kg. The baby cried soon after birth, the length was 50 cm and the head circumference was 33 to 35 cm. Vital signs were within normal limits. What is the normal US: LS ratio of a healthy term neonate? (or) Which of the following is the normal US: LS ratio of a healthy term neonate? A. 1.7 - 1.9:1 B. 1.6 -1.7: 1 C. 1.5 - 1.9:1 D. 1.6 - 1.8:1 ---------------------------------------- Page 5 123 14. A 35-year-old woman comes to the hospital for an antenatal checkup at 9 months. Growth scan showed that the expected birth weight is > 90th centile according to gestational age. Which of the following is not a cause for expected birth weight > 90th centile? (or) Which of the following is not a cause for expected birth weight > 90th centile? A. Beckwith Wiedemann syndrome B. Baby of a diabetic mother C. Sotos syndrome D. Baby of a hypertensive mother ---------------------------------------- 15. A 33-year-old woman with a gestational age of 30 weeks delivers a baby girl. On examination, the baby is emaciated and hypotonic. The skin appears translucent and friable. Abundant lanugo is present. Select the statement that is not a characteristic of babies similar to this newborn. (or) Select the incorrect statement regarding a baby born at 30 weeks gestation with an emaciated body, translucent and friable skin, and abundant lanugo. A. Head appears relatively large B. Anterior fontanelle: Large, wide-open C. Ear cartilage is poorly formed D. Breast buds > 5 mm in size ---------------------------------------- 16. A baby was born to an obese woman at 43 weeks of gestation. Immediately after birth, the baby was examined by the pediatrician. Which of the following will not be found on examination of this baby? (or) Which of the following will not be found on the examination of a baby born to an obese woman at 43 weeks gestation? A. Loose skin folds around thighs and buttocks B. Meconium stained nails, skin, or umbilical coral C. Presence of placental membranes. D. Few hairs ---------------------------------------- 17. A 10-month-old baby boy is brought to the OPD by his parents. On examination, the pediatrician categorized the baby as a high-risk infant. Which among the following is a criterion for high-risk infants? (or) Which among the following is a criterion for high-risk infants? A. Polyhydramnios B. Working mother C. Malpresentation Page 6 124 D. 100 folic acid tablets were not taken during pregnancy ---------------------------------------- 18. A baby was delivered in a hospital by vacuum-assisted delivery. Upon examination, the APGAR score was 8 on 10. The baby is active. What are the components of the APGAR score? (or) What are the components of the APGAR score? A. Appearance, pulse rate, Grimace, Activity, Respiratory effort B. Air entry, pulse rate, grimace, Activity, Respiratory effort C. Appearance, pulse rate, grunt, activity, Respiratory effort D. Appearance, pulse rate, grunt, activity, respiratory rate ---------------------------------------- 19. A newborn was delivered by vacuum-assisted delivery. On examination, the baby is comatose, with severe hypotonia, absent Moro’s reflex, variable heart rate, and mildly dilated pupils. Which among the following is the correct stage of hypoxic-ischemic encephalopathy referred to here? (or) Which is the stage of HIE characterized by a comatose baby with severe hypotonia and absent Moro's reflex? A. Stage 1 HIE B. Stage 2 HIE C. Stage 3 HIE D. Stage 4 HIE ---------------------------------------- 20. A neonate was delivered by vacuum-assisted delivery. On examination, chest retractions are present. Downes score is calculated, and it corresponds to severe respiratory distress. What is the Downes score of this baby? (or) What is the Downes score of a baby with severe respiratory distress? A. Score > 7 B. Score > 6 C. Score > 8 D. Score > 5 ---------------------------------------- 21. A 35-year-old woman delivers a female baby by normal vaginal delivery. A pediatric resident examines the baby and notes an exaggerated Moro's reflex. Which of the following is responsible for this finding? (or) Which among the following conditions is responsible for an exaggerated Moro’s reflex? A. Stage -3 (severe) Hypoxic Ischemic Encephalopathy Page 7 125 B. Down syndrome C. Acute Bilirubin Encephalopathy D. Stage 1 (early/mild) Hypoxic Ischemic Encephalopathy ---------------------------------------- 22. A baby girl was delivered by operative vaginal delivery 3 hours ago due to a prolonged second stage of labor. The pediatrician examined the newborn and noticed a soft, boggy swelling in the scalp that crossed the midline. She reassured the parents that the swelling would pose no complications and resolve spontaneously. Which of the following is a correct statement about this swelling? (or) Select the correct statement about a soft, boggy swelling in the scalp of a newborn crossing the midline developing after operative vaginal delivery. A. May take 24 hours to appear completely B. Takes 5-7 weeks to disappear C. Subperiosteal hemorrhage involving cranial bones D. Does not predispose to neonatal jaundice ---------------------------------------- Correct Answers Question Correct Answer Question 1 1 Question 2 3 Question 3 2 Question 4 2 Question 5 1 Question 6 3 Question 7 1 Question 8 3 Question 9 1 Question 10 3 Question 11 4 Question 12 2 Question 13 1 Question 14 4 Question 15 4 Question 16 4 Question 17 1 Page 8 126 Question 18 1 Question 19 3 Question 20 1 Question 21 4 Question 22 4 Solution for Question 1: Option A: Scarf sign Scarf sign helps in assessing the neuromuscular maturity of a neonate. This manoeuvre is used to test the passive tone of the flexors of the shoulder girdle. The neonate lies supine, and the examiner brings the neonate's arm across the upper chest until the baby resists it. The point on the chest is noted to which the elbow is moved easily, and the score is noted according to the landmark. ENBS (Expanded New Ballard Score) is a commonly used technique to assess the gestational age of a neonate by using physical and neuromuscular criteria of maturity. Preterm babies are usually in a state of physiological hypotonia that increases throughout the fetal growth period. The neuromuscular criteria include posture, square window, arm recoil, popliteal angle, scarf sign, and heel-to-ear sign. Likewise, physical maturity scoring is done by assessing skin, lanugo, plantar surface, breast, eye/ear, and genitals. Option B: Square Window A square window sign helps in the assessment of the flexibility of the wrist of a neonate. The examiner gently applies pressure on the dorsum of the hand while the fingers are straightened, forming an angle between the palm and forearm of the baby. The wrist has the least flexibility at the younger gestational age meaning a more premature baby would have a lesser angle. Option C: Arm recoil This manoeuvre tests the passive flexor tone of the biceps muscle by measuring the recoil angle after a brief extension of the upper arm. The baby lies supine, and the examiner places his one hand beneath the baby's elbow. He flexes the elbow briefly and then extends it before releasing it. The recoil angle is noted to which the forearm springs back to flexion. The extremely premature neonate does not undergo any recoil. Option D: Heel-to-ear This manoeuvre helps to assess the passive flexor tone of the pelvic girdle. It tests the passive or resistance to the extension of posterior hip flexor muscles The examiner brings the neonate’s foot towards the ipsilateral ear. In extremely premature neonates, the resistance to extension of posterior hip flexors is felt when the heel is at or near the ear. Page 9 127 Solution for Question 2: Option C: Down’s syndrome There is generalized hypotonia in Down syndrome. This leads to a poor Moro's reflex. Other causes of absent/poor Moro's reflex are- spastic cerebral palsy, hypoxic-ischemic encephalopathy, brain malformations, and acute bilirubin encephalopathy. Option A: Erb’s palsy Erb’s palsy is a form of brachial plexus palsy resulting from an injury specifically at birth that either stretches, ruptures, or avulses the roots of the plexus from the spinal cord. Due to impaired innervation, Erb's palsy can lead to decreased strength, muscular atrophy, or limb length discrepancies. In neonates, it can cause asymmetrical Moro’s reflex. Injury to the upper trunk C5–C6 nerves It occurs most commonly due to shoulder dystocia during a difficult birth Option B: Fracture of clavicle The most common fracture sustained by neonates during birth is a clavicular fracture, also known as a collar bone. Injuries that can occur secondary to a fracture of the clavicle are pneumothorax, subclavian artery laceration, and brachial plexus injury. In neonates, it is considered one of the important skeletal causes of asymmetric Moro’s reflex. Option D: Shoulder joint dislocation Posterior shoulder dislocation occurs commonly in infants with neonatal brachial plexus palsy. Important causes of asymmetric Moro’s reflex include: Neurological causes: Erb’s palsy, congenital hemiplegia. Skeletal causes: Fracture clavicle, Shoulder joint dislocation. Neurological causes: Erb’s palsy, congenital hemiplegia. Skeletal causes: Fracture clavicle, Shoulder joint dislocation. Neurological causes: Erb’s palsy, congenital hemiplegia. Skeletal causes: Fracture clavicle, Shoulder joint dislocation. Solution for Question 3: Option B: Symmetric tonic neck reflex (STNR) Important neonatal reflexes appearing after birth are the parachute reflex and the symmetric tonic neck reflex. When the child's head flexes forward, extending the back of the neck, the upper extremities will contract and the lower extremities will extend. Conversely, when the child's head is extended backward, contracting the back of the neck, the upper extremities will extend and the lower extremities Page 10 128 will contract. This reflex appears at 4-6 months of age and disappears at 8–12 months. This reflex helps the baby learn to use the upper and lower halves of their body independently of each other. It helps the baby get onto their knees and hands, often called a crawling reflex. Option A: Moro’s reflex Moro reflex is a normal primitive infantile reflex that consists of symmetric abduction and extension of arms, opening of hands followed by adduction and flexion of arms as in an embrace, and crying. This reflex is established after 28–37 weeks of gestation and disappears 5–6 months after birth. It is elicited by placing the baby in the supine position on the examination couch and allowing the head to drop, supported by the examiner's hands. Option C: Crossed extensor reflex When one of the baby's legs is held in an extended position and firm pressure is applied to the sole of the same leg, the baby's free leg flexes, adducts, and then extend. It usually appears at 30-34 weeks of gestation. It disappears at 2 months of age. Option D: Asymmetric tonic neck reflex ATNR is tested when the baby lies supine and the head is rotated to one side. This causes extension of the arm and leg on the ipsilateral side and flexion of the arm and leg on the contralateral side. It is present at 35 weeks of gestation and disappears at 5-6 months of age. Page 11 129 Solution for Question 4: Option B: Asymmetric tonic neck reflex In this case, a primitive neonatal reflex is shown as an asymmetric tonic neck reflex. It appears at 35 weeks of gestation. Elicitation by rotating a baby's head to one side causes extension of the upper extremity on the side to which the face is rotated and flexion of the upper extremity on the other side. It disappears after 5–6 months. If the asymmetric tonic neck reflex prolongs, it shows developmental delay. Option A: Moro reflex Moro’s reflex appears at 28–37 weeks. Components of complete Moro's reflex: symmetric abduction and extension of upper limbs, along with the opening of hands, followed by flexion, adduction of upper limbs and extension of head and trunk, movement of lower limbs, and crying. It normally disappears after 5–6 months. Moro's reflex, once it disappears, never reappears. Option C: Parachute reflex The parachute reflex is a reflex that, once it appears, never disappears. It usually appears at 7-8 months and persists throughout life. It is elicited by holding the child upright and quickly rotating the baby’s body to face forward. The baby will suddenly extend his arms forward to break a fall. It is a safety phenomenon that prevents the baby from falling. Option D: Symmetric tonic neck reflex Page 12 130 It appears at 4-6 months of life. When the child's head flexes forward, extending the back of the neck, the upper extremities contract, and the lower extremities extend. Conversely, when the child's head is extended backward, contracting the back of the neck, the upper extremities will extend and the lower extremities will contract. It disappears after 8-12 months. Solution for Question 5: Option A: Moro’s reflex The pediatrician was checking the Moro reflex in the baby. This is why he held the baby in the supine position and left the head suddenly. By doing so, a baby with normal reflexes and no CNS compromise will extend the limbs symmetrically and then flex them again. Components of complete Moro's reflex are symmetric abduction and extension of upper limbs, along with the opening of hands, followed by flexion and adduction of upper limbs, extension of head and trunk, movement of lower limbs, and crying. It usually appears at 28–37 weeks and shows the flight or fight response of the baby. It is also referred to as the startle reflex and usually disappears at 5–6 months. Moro's reflex, once it disappears, never reappears. Option B: Asymmetric tonic neck reflex It is elicited by rotation of the head or neck that causes extension of the upper extremity on the side to which the face is rotated and flexion of the upper extremity on the side of the occiput. It usually appears at 18–35 weeks It disappears after 5–6 months This reflex is important for brain development and is usually important for a baby’s survival and thrive response. It is helpful for uncomplicated vaginal delivery. Option C: Parachute reflex When the child is held upright and the baby's body is rotated quickly to face forward (as in falling), then the baby will extend their arms forward as if to break a fall. This is called the parachute reflex. It usually appears after 7-8 months. It persists throughout life. Option D: Symmetric tonic neck reflex When the child's head flexes forward, extending the back of the neck, the upper extremities will contract and the lower extremities will extend. Conversely, when the child's head is extended backward, contracting the back of the neck, the upper extremities will extend and the lower extremities will contract. This is also known as the crawling reflex and helps the baby stand on his hands and knees. It appears in 4-6 months Page 13 131 It disappears after 8-12 months. Solution for Question 6: Option C: Rooting reflex The given picture shows the rooting reflex. When the doctor touches the cheek or lip of the baby, the baby turns his face towards the stimulus & makes sucking motions This reflex helps a mother breastfeed her baby. This reflex appears between 26-27 weeks. This reflex disappears between 6-12 months. Option A: Moro reflex In the Moro reflex, the pediatrician holds the baby in the supine position and leaves the head suddenly. By doing so, a baby with normal reflexes and no CNS compromise will extend the limbs symmetrically and then flex them again. This is referred to as Moro's reflex, which is symmetric abduction and extension of upper limbs along with the opening of hands followed by flexion and adduction of upper limbs + extension of head and trunk, movement of lower limbs, and crying. It usually appears at 28–37 weeks and shows the flight or fight response of the baby. It is also referred to as the startle reflex and usually disappears at 5-6 months. Moro's reflex once disappears never reappears. Option B: Asymmetric tonic neck reflex It is elicited by rotation of the head or neck that causes extension of the upper extremity on the side to which the face is rotated and Flexion of the upper extremity on the side of the occiput. Page 14 132 It usually appears at 18–35 weeks It disappears after 5–6 months This reflex is important for brain development and is usually important for a baby’s survival and thrive response. It is helpful for uncomplicated vaginal delivery. Option D: Swallowing reflex Swallowing reflux is important to force the food into the esophagus instead of the trachea. It activates tongue muscles, closes the glottis, elevates the larynx, and stops respiration. It is an involuntary response of the baby. It is also called a defensive airway reflex. Solution for Question 7: Option A: Opening of hands The Moro reflex, also known as the startle reaction, is characterized by reflex arm extension and abduction, hand opening, and crying. It is a stress reaction.' After the first phase described above, the infant flexes his head, curls his body, flexes and draws his arms across his body, and closes his hands as if embracing himself. Unless the legs are already extended, they may extend during both phases. Component of Moro's reflex, gestational age of appearance: Opening of hands: 28 weeks Extension and abduction of upper limb: 32 weeks Anterior flexion of upper limbs: 37 weeks Opening of hands: 28 weeks Extension and abduction of upper limb: 32 weeks Anterior flexion of upper limbs: 37 weeks Opening of hands: 28 weeks Extension and abduction of upper limb: 32 weeks Anterior flexion of upper limbs: 37 weeks Option B: Abduction of upper limbs The child's initial reaction is a spreading movement with the arms abducting. The fists close after a clutching movement in which the arms adduct and flex over the body. At 32 weeks of gestation, the spreading movement, but not the clutching, is common in premature newborns. Option C: Adduction of upper limbs The Moro reflex is an infantile reflex that appears between 28 and 32 weeks of gestation and disappears between the ages of 3-6 months. It is a reaction to a sudden loss of support that consists of three distinct components: pulling the arms in (abduction) and spreading the arms out (adduction) Adduction of the upper limbs is followed by hand closure. Option D: Movement of the trunk Page 15 133 It happens by truncal incurvation This reflex occurs when the infant's spine is stroked or tapped while lying on the stomach. In a dancing motion, the infant will twitch its hips toward the touch. The trunk is thought to respond by turning as a block in the direction of the head turn. Solution for Question 8: Option C: Expanded new Ballard score The New Ballard Score is an extension of the above that includes extremely pre-term babies, i.e. babies born at less than 20 weeks. The scoring is based on the intrauterine changes that the foetus goes through during maturation. Whereas neurological criteria are primarily based on muscle tone, physical criteria are based on anatomical changes. Assess the gestational age of a neonate. It has an accuracy of +/- 1 week It can be used up to four days after birth. The New Ballard score had a sensitivity of 87.7%, a specificity of 96.3%, a positive predictive value of 95.2%, and a negative predictive value of 90.2% for identifying premature babies. Option A: Apgar score Apgar is a quick test that is performed on a newborn between 1 and 5 minutes after birth. Apgar score- evaluate newborn's condition The baby's tolerance for the birthing process is determined by the 1-minute score. The 5-minute score informs the doctor about how well the baby is doing outside of the mother's womb. It provides an accepted and convenient method for reporting the newborn infant's status immediately after birth, as well as the response to resuscitation if necessary; however, it has been inappropriately used to predict the individual adverse neurologic outcome. Option B: Extended Silverman score It is used to evaluate the severity of respiratory distress in newborn and preterm infants who are not receiving respiratory support. The score includes four inspiratory movement categories (thoraco-abdominal, intercostal, xiphoid, and chin movements) and one expiratory movement category (grunting). Option D: Downe’s score If a blood gas analysis instrument or pulse oximetry is not available, Downe’s score is used as an alternative to evaluating clinical respiratory distress. The purpose of this study was to determine the validity of Downe's score for assessing hypoxemia in neonates with clinical respirator

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