Iran Specialty Board - Pediatrics cheat sheet

Apgar is scored at 1 and 5 minutes (0–2 each for heart rate, respiratory effort, muscle tone, reflex irritability, color); it guides resuscitation but does not define asphyxia.

Surfactant (poractant alfa 2.5 mL/kg or beractant 4 mL/kg) is given via endotracheal tube for RDS; early rescue within 2 h of birth reduces pneumothorax and mortality versus delayed selective dosing.

Neonatal hypoglycemia threshold: <47 mg/dL (2.6 mmol/L) in the first 48 h warrants feeding and recheck; <25 mg/dL (1.4 mmol/L) or symptomatic requires IV dextrose 10% 2 mL/kg bolus.

Physiologic jaundice appears after 24 h; jaundice within the first 24 h is always pathologic and requires total/direct bilirubin, blood type, Coombs, and hematocrit.

Phototherapy thresholds follow hour-specific bilirubin nomograms (Bhutani); exchange transfusion is reserved for levels near 20–25 mg/dL or signs of bilirubin encephalopathy.

Kernicterus risk rises with bilirubin >25 mg/dL, hemolysis, prematurity, sepsis, and acidosis; acute signs include lethargy, poor suck, hypertonia, and retrocollis.

Necrotizing enterocolitis presents with feeding intolerance, bloody stools, abdominal distension, and pneumatosis intestinalis; management is bowel rest, decompression, and antibiotics.

Neonatal sepsis: group B Streptococcus and E. coli predominate in early-onset disease; empiric ampicillin plus gentamicin is standard until cultures are negative at 36–48 h.

Normal growth velocity: birth length increases ~50% by 1 year; height doubles by 4 years; weight doubles by 5 months and triples by 1 year.

Mid-parental height: boys = (father + mother + 13 cm)/2; girls = (father + mother − 13 cm)/2; target range is ±8.5 cm.

Bone age by Greulich-Pyle or Tanner-Whitehouse; a bone age lagging chronologic age by >2 years suggests constitutional delay or GH deficiency.

Developmental milestones: social smile 6 weeks, head control 3 months, sits unsupported 6–8 months, walks 12–15 months, two-word phrases 18–24 months.

Red flags: no social smile by 3 months, no sitting by 9 months, no walking by 18 months, loss of skills at any age - refer for developmental evaluation.

Autism screening with M-CHAT-R/F at 18 and 24 months; diagnosis requires deficits in social communication plus restricted/repetitive behaviors across settings.

ADHD diagnosis requires symptoms before age 12, present in ≥2 settings, lasting ≥6 months, and causing functional impairment; stimulants are first-line pharmacotherapy.

Failure to thrive: weight <3rd percentile or crossing two major percentile lines; evaluate caloric intake, absorption, and endocrine/renal causes.

Breast milk or iron-fortified formula for the first 12 months; whole cow milk is avoided before 12 months because of low iron and high renal solute load.

Exclusive breastfeeding for ~6 months, then complementary foods; vitamin D 400 IU/day and iron 1 mg/kg/day from 4–6 months for breastfed infants.

Phenylketonuria: phenylalanine hydroxylase deficiency; newborn screening, low-phenylalanine diet, and sapropterin for responsive patients; untreated causes intellectual disability.

Galactosemia: avoid galactose/lactose; classic form presents with jaundice, hepatomegaly, cataracts, and E. coli sepsis in the neonate.

Maple syrup urine disease: branched-chain ketoacid dehydrogenase deficiency; sweet-smelling urine, encephalopathy, and elevated leucine, isoleucine, and valine.

Medium-chain acyl-CoA dehydrogenase deficiency: hypoketotic hypoglycemia triggered by fasting or illness; avoid prolonged fasting and give IV dextrose during illness.

Obesity: BMI ≥95th percentile for age and sex; screen for hypertension, dyslipidemia, fatty liver, and type 2 diabetes with fasting glucose or HbA1c.

Fat-soluble vitamin deficiencies: A (night blindness, xerophthalmia), D (rickets), E (hemolysis, neuropathy), K (bleeding) - consider in malabsorption and cholestasis.

Routine schedule: DTaP, IPV, Hib, PCV, and rotavirus at 2, 4, and 6 months; MMR and varicella at 12–15 months; Tdap booster at 11–12 years.

Hepatitis B: birth dose within 24 h for all infants; HBsAg-positive mothers receive vaccine plus HBIG within 12 h.

Contraindications to live vaccines (MMR, varicella, rotavirus, LAIV): severe immunodeficiency, pregnancy, and high-dose steroids; HIV with severe immunosuppression.

Kawasaki disease: fever ≥5 days plus ≥4 of conjunctivitis, oral changes, rash, extremity changes, and cervical lymphadenopathy; treat with IVIG 2 g/kg plus aspirin.

Scarlet fever: group A Streptococcus; penicillin or amoxicillin for 10 days prevents rheumatic fever; rash is sandpaper-like with circumoral pallor.

Meningococcal disease: petechial/purpuric rash, rapid progression; empiric ceftriaxone plus vancomycin; droplet precautions and chemoprophylaxis for close contacts.

Tuberculosis: positive tuberculin skin test ≥10 mm in children without risk factors; ≥5 mm in immunocompromised or close contacts; IGRA preferred over age 2.

Lyme disease: erythema migrans plus doxycycline (all ages) or amoxicillin for 10–14 days; doxycycline is safe for children under 8 for short courses.

Anaphylaxis: epinephrine 0.01 mg/kg IM (max 0.5 mg) into the anterolateral thigh; repeat every 5–15 min; adjuncts include fluids, oxygen, and antihistamines.

IgE-mediated food allergy: symptom onset within minutes to 2 h of ingestion; skin prick or specific IgE testing; oral food challenge is the diagnostic gold standard.

Cow milk protein allergy: extensively hydrolyzed formula is first line; amino acid formula for severe or refractory cases; soy is not recommended under 6 months.

Asthma controller step-up: low-dose ICS at step 2; add LABA or medium-dose ICS at step 3; refer at step 4–5.

Primary immunodeficiency red flags: ≥4 ear infections/year, ≥2 sinus infections/year, ≥2 pneumonias, failure to thrive, or family history of immunodeficiency.

X-linked agammaglobulinemia: absent B cells, low all immunoglobulin classes, recurrent sinopulmonary infections after 6 months; treat with IVIG.

Severe combined immunodeficiency: presents with failure to thrive, chronic diarrhea, and opportunistic infections; live vaccines are contraindicated; HSCT is curative.

Hereditary angioedema: C1 inhibitor deficiency with low C4; presents with recurrent angioedema without urticaria; treat with C1 inhibitor concentrate or icatibant.

Acyanotic lesions with left-to-right shunt: VSD, ASD, PDA; murmur intensity and timing guide evaluation; large shunts cause failure to thrive and pulmonary overcirculation.

Cyanotic lesions with decreased pulmonary flow: tetralogy of Fallot, tricuspid atresia; hypercyanotic spells are treated with knee-chest position, oxygen, morphine, and IV fluids.

Ductal-dependent lesions (transposition, pulmonary atresia, critical coarctation) require prostaglandin E1 infusion to maintain ductal patency.

Kawasaki disease: coronary artery aneurysms are the major complication; echocardiography at diagnosis, 2 weeks, and 6–8 weeks; giant aneurysms >8 mm.

Infective endocarditis prophylaxis: amoxicillin 50 mg/kg (max 2 g) 30–60 min before dental procedures only for high-risk lesions (prosthetic valve, prior endocarditis, unrepaired cyanotic CHD).

Heart failure in infants: tachycardia, tachypnea, poor feeding, hepatomegaly; treat with diuretics, ACE inhibitors, and digoxin in selected cases.

Long QT syndrome: QTc >480 ms in children; avoid competitive sports and QT-prolonging drugs; beta-blockers reduce syncope and sudden death.

Supraventricular tachycardia in infants: rate >220 bpm, narrow QRS; vagal maneuvers then adenosine 0.1 mg/kg IV rapid push (max 6 mg first dose).

Asthma diagnosis: recurrent wheeze, cough, and dyspnea with reversible airflow obstruction; spirometry with bronchodilator response ≥12% confirms.

Acute asthma exacerbation: albuterol 2.5–5 mg nebulized every 20 min ×3, ipratropium, and systemic steroids (prednisolone 1–2 mg/kg/day for 3–5 days).

Cystic fibrosis: autosomal recessive CFTR mutation; newborn screening with immunoreactive trypsinogen; sweat chloride ≥60 mmol/L is diagnostic.

Cystic fibrosis pulmonary exacerbation: treat with airway clearance, inhaled bronchodilators, dornase alfa, and IV antipseudomonal antibiotics.

Croup: barking cough and inspiratory stridor; dexamethasone 0.15–0.6 mg/kg single dose; nebulized epinephrine for moderate-to-severe stridor.

Bronchiolitis: RSV most common; supportive care with oxygen and hydration; bronchodilators and steroids are not routinely recommended.

Foreign body aspiration: sudden choking and unilateral wheeze; rigid bronchoscopy is both diagnostic and therapeutic.

Primary ciliary dyskinesia: chronic wet cough, situs inversus in ~50% (Kartagener syndrome), and low nasal nitric oxide.

Gastroesophageal reflux disease: conservative measures first; proton pump inhibitors for persistent symptoms; avoid in uncomplicated regurgitation of infancy.

Celiac disease: tissue transglutaminase IgA plus total IgA; duodenal biopsy showing villous atrophy confirms; lifelong gluten-free diet.

Intussusception: colicky pain, currant-jelly stools, and sausage-shaped mass; air or contrast enema is both diagnostic and therapeutic.

Pyloric stenosis: nonbilious projectile vomiting at 3–6 weeks; ultrasound shows pyloric thickness >3 mm and length >15 mm; correct hypochloremic hypokalemic metabolic alkalosis before surgery.

Hirschsprung disease: delayed meconium passage, abdominal distension; rectal biopsy shows absent ganglion cells; treat with pull-through surgery.

Inflammatory bowel disease: Crohn disease is transmural with skip lesions and perianal disease; ulcerative colitis is mucosal and continuous from the rectum.

Biliary atresia: jaundice persisting beyond 2 weeks with direct hyperbilirubinemia and acholic stools; Kasai portoenterostomy before 60 days improves outcomes.

Acute liver failure: coagulopathy (INR ≥1.5) plus encephalopathy; evaluate for acetaminophen toxicity, viral hepatitis, and metabolic disease.

Nephrotic syndrome: edema, proteinuria >3.5 g/day or urine protein/creatinine >2, hypoalbuminemia, and hyperlipidemia; minimal change disease is most common in children.

Steroid-sensitive nephrotic syndrome: prednisone 60 mg/m²/day for 4–6 weeks then alternate-day tapering; biopsy if steroid-resistant or atypical features.

Acute post-streptococcal glomerulonephritis: hematuria, hypertension, and edema 1–3 weeks after pharyngitis; low C3 with normal C4; supportive care.

Hemolytic uremic syndrome: microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury; most cases follow Shiga toxin-producing E. coli; avoid antibiotics and antimotility agents.

Vesicoureteral reflux grading I–V by voiding cystourethrogram; antibiotic prophylaxis for grades III–V or recurrent febrile urinary tract infections.

Urinary tract infection in infants: obtain urine culture before antibiotics; febrile infants <2 months require parenteral antibiotics and admission.

Hyponatremia correction: raise sodium no faster than 8–10 mEq/L per 24 h to avoid osmotic demyelination; 3% saline for symptomatic cases.

Hyperkalemia in renal failure: calcium gluconate, insulin plus glucose, albuterol, and sodium polystyrene sulfonate; dialysis for refractory cases.

Type 1 diabetes: polyuria, polydipsia, weight loss; diagnose with glucose ≥200 mg/dL plus symptoms or fasting glucose ≥126 mg/dL or HbA1c ≥6.5%.

Diabetic ketoacidosis: pH <7.3, bicarbonate <15 mEq/L, ketonemia; fluid resuscitation over 48 h and insulin infusion 0.05–0.1 U/kg/h; avoid rapid osmolar shifts.

Congenital hypothyroidism: newborn screening with elevated TSH; treat with levothyroxine 10–15 mcg/kg/day started within 2 weeks to prevent intellectual disability.

Growth hormone deficiency: short stature, low growth velocity, delayed bone age; confirm with GH stimulation testing and treat with recombinant GH.

Precocious puberty: breast or pubic hair before 8 years in girls and 9 years in boys; GnRH stimulation test and pelvic ultrasound; GnRH agonist therapy.

Congenital adrenal hyperplasia: 21-hydroxylase deficiency causes virilization in girls and salt wasting; elevated 17-hydroxyprogesterone; treat with hydrocortisone and fludrocortisone.

Turner syndrome: short stature and ovarian dysgenesis; karyotype shows 45,X; treat with GH and estrogen replacement at puberty.

Hypocalcemia in neonates: serum calcium <7 mg/dL; treat with IV calcium gluconate; monitor for QT prolongation and seizures.

Iron deficiency anemia: microcytic hypochromic with low ferritin; treat with oral ferrous sulfate 3–6 mg/kg/day of elemental iron for 3 months after normalization.

Sickle cell disease: hydroxyurea reduces vaso-occlusive crises; penicillin prophylaxis until age 5; acute chest syndrome is treated with oxygen, antibiotics, and transfusion.

Thalassemia major: chronic transfusion therapy with iron chelation (deferoxamine, deferasirox); monitor ferritin and cardiac T2*.

Immune thrombocytopenia: isolated thrombocytopenia with petechiae and bruising; IVIG or corticosteroids for significant bleeding; avoid platelet transfusion unless life-threatening.

Acute lymphoblastic leukemia: most common childhood malignancy; presents with pallor, fever, bone pain, and hepatosplenomegaly; bone marrow aspirate confirms.

Wilms tumor: abdominal mass in children 2–5 years; nephrectomy plus chemotherapy; associated with WT1 mutations and Beckwith-Wiedemann syndrome.

Neuroblastoma: median age 2 years; elevated urinary catecholamines; treat with surgery, chemotherapy, and stem cell transplant for high risk.

Hemophilia A: factor VIII deficiency; prolonged PTT with normal PT; treat bleeding with factor VIII concentrate; desmopressin for mild disease.

Febrile seizures: age 6 months–5 years, fever, no CNS infection; simple seizures last <15 min and occur once in 24 h; no routine anticonvulsants.

Status epilepticus: seizure >5 min; first-line benzodiazepine (lorazepam 0.1 mg/kg IV or midazolam IM); second-line fosphenytoin or levetiracetam.

Neonatal seizures: subtle signs (lip smacking, bicycling, apnea); treat with phenobarbital 20 mg/kg loading; EEG monitoring is essential.

Bacterial meningitis: empiric ceftriaxone plus vancomycin; add ampicillin for infants <3 months to cover Listeria; dexamethasone before first antibiotic dose.

Cerebral palsy: nonprogressive motor impairment from early brain injury; spastic diplegia most common in preterm infants; treat with PT, botulinum toxin, and spasticity management.

Duchenne muscular dystrophy: X-linked dystrophin deficiency; Gowers sign, calf pseudohypertrophy, elevated CK; treat with corticosteroids and exon-skipping agents.

Migraine: recurrent headache with nausea, photophobia, and phonophobia; abortive treatment with NSAIDs or triptans; preventive therapy for frequent attacks.

Hydrocephalus: enlarged head circumference, sunsetting eyes, vomiting; treat with ventriculoperitoneal shunt or endoscopic third ventriculostomy.

Pediatric basic life support: 30:2 compression-to-ventilation for single rescuer, 15:2 for two rescuers; compressions at 100–120/min at one-third chest depth.

PALS: epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000) every 3–5 min; defibrillate 2 J/kg, then 4 J/kg for shockable rhythms.

Anaphylaxis: epinephrine 0.01 mg/kg IM (max 0.5 mg) into the anterolateral thigh; repeat every 5–15 min as needed.

Fluid resuscitation: 20 mL/kg isotonic crystalloid bolus for shock; reassess after each bolus; consider blood products in hemorrhagic shock.

Poisoning: activated charcoal 1 g/kg within 1 h of ingestion if airway is protected; naloxone for opioid toxicity; N-acetylcysteine for acetaminophen overdose.

Status epilepticus: benzodiazepine first, then fosphenytoin 20 mg/kg IV or levetiracetam 60 mg/kg IV; consider continuous infusion for refractory cases.

DKA management: isotonic fluid bolus 10–20 mL/kg over 1 h, then insulin 0.05–0.1 U/kg/h; monitor for cerebral edema with headache, bradycardia, and hypertension.

Traumatic brain injury: avoid hypotension and hypoxia; maintain normocapnia; hypertonic saline or mannitol for elevated intracranial pressure.