Pediatrics: Development, Neonates and the Seriously Unwell Child
The Pediatrics domain tests growth and development, neonatal medicine, common respiratory and gastrointestinal illness, and recognition of the seriously unwell child. Extremes of age change both the differential and the threshold for investigation.
Core rules
- Milestones: social smile 6 weeks; sits unsupported 6–8 months; pincer grasp 9–10 months; walks 12–15 months; two-word phrases 18–24 months; stranger anxiety 6–9 months.
- Growth: plot weight, length and head circumference; crossing two major centile lines in either direction warrants investigation.
- Neonatal jaundice: measure total bilirubin and plot against the hour-specific treatment threshold; check direct bilirubin, blood group, Coombs and FBC if jaundice appears within 24 hours, rises rapidly or persists.
- Bronchiolitis: supportive care - oxygen for saturations below 90–92%, fluids, suction; no routine bronchodilators, steroids or antibiotics.
- Croup: single-dose dexamethasone; nebulised adrenaline for stridor at rest.
- Dehydration: use clinical signs and oral rehydration solution; intravenous fluids for severe dehydration or shock, 10–20 mL/kg boluses.
- Febrile seizure: simple means generalised, under 15 minutes, once in 24 hours, age 6 months to 5 years.
- Cyanotic congenital heart disease: tetralogy of Fallot, transposition; acyanotic: VSD, ASD, PDA. Coarctation may present with differential cyanosis and weak femoral pulses.
Worked example
An 8-week-old presents with a temperature of 38.5 °C and poor feeding. At this age fever has a low threshold for serious bacterial infection and clinical signs are unreliable. The infant undergoes a full septic screen - blood culture, urine culture, lumbar puncture and full blood count - and receives empiric intravenous antibiotics (for example ampicillin plus gentamicin, or a third-generation cephalosporin) while awaiting results.
Traps
- Treating fever in an infant under 3 months as viral without a septic screen.
- Missing bilirubin encephalopathy by relying on visual jaundice rather than a measured level.
- Assuming every murmur is pathological; many are innocent and asymptomatic.
- Over-hydrating in bronchiolitis or DKA.