PLABABLE

VERSION 5.7

PAEDIATRICS
 Marfan Syndrome

Autosomal dominant genetic disorder caused by

mutation in fibrillin gene

Easy way to remember clinical features : MARFANS

● M - Mitral valve prolapse
● A - Aortic dissection and aneurysm
● R - Regurgitant aortic valve
● F - Fingers long (arachnodactyly)
● A - Arm span > height
● N - Nasal voice (high arched palate)
● S - Sternal excavation

Other important clinical features :

Joint hypermobility + kyphoscoliosis + recurrent
pneumothorax + lens dislocation

Differential Diagnosis
● Ehler-Danlos syndrome
● Fragile X syndrome
● Homocystinuria

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Marfan Syndrome

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 Normal Puberty

● Normal puberty age :

Girls → 8 - 13 years old
Boys → 9 - 14 years old

● First sign of puberty :

Females → Breasts begin to develop
Males → Testicular enlargement

● Early or precocious puberty :

Females → Before 8 years of age
Males → Before 9 years of age

● Delayed puberty :
Females → No breast development till 13 years
or breasts developed but no periods till 15 years

Males → No testicular development till 14 years

PLABABLE
 Delayed Growth and Puberty

Brain trainer:

What is the most common cause of short stature and

delayed puberty? What investigation may be
indicated?

➔ Constitutional delay in growth and puberty

➔ Wrist x-ray for bone age

PLABABLE
 Infantile Spasms

● Start at around 6 months

● Also called salaam/jackknife attacks
● West syndrome → MES (Mental retardation, EEG
changes, infantile Spasms)
● Episodes of repetitive movements that last for a
few seconds with symmetrical contractions of
neck, trunk and extremities

PLABABLE
 APGAR

Apgar score is a scoring system used to evaluate a

newborn baby. It is done at 1 minute and 5 minutes
after birth. It may be repeated at 10 minutes if scores
remain low. The Apgar score is calculated by adding
the total score of 5 components.

PLABABLE
 Traffic Light System

The traffic light system is used for identifying children

under the age of 5 who may be at high risk.

If a child has a fever and at least one of the following

(red light ) symptoms then they are deemed high
risk.

Colour
● Blue or pale

Respiratory
● Grunting
● RR > 60
● Moderate chest indrawing

Circulation / hydration
● Reduced skin turgor

Other
● Non-blanching rash
● Bulging fontanelle
● Focal neurological signs
● Seizures

PLABABLE
 BRAIN TRAINER

Brain trainer:

A 30 year old female gave birth to a full term baby 6

hours back. She was admitted due to prolonged
rupture of the membranes. The baby now has a
temperature of 39℃ and breathing difficulties.

What is the most likely causative organism?

➔ Group B streptococcus (GBS)

GBS infection is the most common cause of

early-onset neonatal infections.

PLABABLE
 Pyloric Stenosis

Presentation
● Persistent non-bilious vomiting weeks after birth
● Usually an hour after feeding
● Constant hunger, weight loss, and dehydration
● Olive shaped mass in the abdomen
● Electrolyte abnormalities
● Metabolic alkalosis

Diagnosis:
Initial and most urgent investigation → Serum K+
Definitive diagnosis → Ultrasound
Treatment:
● Fluid replacement and correction of electrolyte
imbalance (first-line)
● Pyloromyotomy (definitive treatment)

PLABABLE
 Duodenal Atresia

Congenital atresia of the portion of the duodenum

Presentation
● Persistent bilious or non-bilious vomiting and
abdominal distension
● Polyhydramnios
● Double bubble sign on abdominal X-ray
● Associated with Down’s syndrome

Treatment
● Abdominal decompression using NG tube
● Fluid replacement and electrolyte monitoring
● Duodenoduodenostomy (definitive treatment)

PLABABLE
 Oesophageal Atresia & TEF

Atresia → Oesophagus ends blindly

TEF → Oesophagus connected with trachea

Presentation
● Polyhydramnios during pregnancy
● Difficulty in feeding following birth
● Associated with VACTERL anomalies

Treatment
● Surgical treatment is definitive
● Fluid and electrolyte management

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Oesophageal Atresia & TEF

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 Important “Bubble” Radiological
Signs

Radiological sign Condition

No gastric bubbles Oesophageal atresia

Single bubble Gastric atresia

Double bubble ● Duodenal atresia

● Malrotation and
volvulus

Triple bubble Jejunal atresia

PLABABLE
 Intussusception

Invagination or telescope of one segment of the

bowel into the other

Presentation:
● Acute coliky abdominal pain in an infant
→ Patient may draw knee to chest for relief
● Abdominal obstruction and bilious vomiting
● Red-currant jelly stool
● Palpable sausage-shaped mass in the abdomen

Investigations
● Abdominal X-ray: dilated gas filled abdomen
with multiple air-fluid levels
● USG: donut sign and target sign

Treatment
● Electrolyte and fluid correction
● Air enema (If there is no perforation, peritonitis
or shock)
● Open surgery - resection and anastomosis

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Intussusception

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 Meckel’s Diverticulum

Remember the rule of 2 →

● 2-3 year old child
● 2 inches long
● 2 feet away from ileo-caecal valve

Presentation
● Most are asymptomatic
● Painless rectal bleeding
● If obstruction → Vomiting and abdominal pain

Investigations
● Initial → Radioisotope scan
● Laparotomy

Treatment
● Symptomatic patients, patients with complications
→ Surgical resection

Complications
● Haemorrhage
● Diverticulitis
● Intestinal obstruction

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 Management Of Hernia In
Children

Umbilical hernia
● Asymptomatic umbilical hernia → Reassure
(closes spontaneously by the 4th year)
● Asymptomatic umbilical hernia in >4 year old →
Refer to paediatric surgeon
● Incarcerated/strangulated hernia → Urgent
referral to paediatric/general surgery team
Inguinal hernia
● All infants with asymptomatic inguinal hernia →
Refer to secondary care due to high risk of
incarceration
● Older children with asymptomatic inguinal hernia
→ Routine referral to secondary care
● Incarcerated or strangulated hernia →
Emergency referral to secondary care

What happens in secondary care?

● Asymptomatic inguinal hernias in neonates →
Operated before discharge from maternity unit
● Asymptomatic inguinal hernia in <6months old →
Operated on next available list
● Asymptomatic inguinal hernia >6 months old →
Elective repair
PLABABLE
 Necrotising Enterocolitis

● More common in premature infants

Remember the mnemonic “ABCD” →

● Air in the bowel wall (on abdominal plain film)
● Bloody stools
● Cannot tolerate feeds
● Distended abdomen

Investigations
Abdominal x-ray (initial), blood film,culture and
coagulation studies

Treatment
● Initial → Stop feeds
● NG tube free drainage and aspiration
● Fluid and electrolyte balance
● Antibiotics → Penicillin + gentamicin +
metronidazole
● Pneumoperitoneum present → Surgery

PLABABLE
 Scarlet Fever

Features
● Cause: Streptococcus pyogenes
● Sandpaper like rash on the chest and back and
then spreads to the limbs (image below)
● Sore throat and fever
● Strawberry tongue (image below)
● Swollen lymph nodes

Treatment
● Penicillin for 10 days
● If pen allergic: azithromycin for 10 days

PLABABLE
 Congenital Hypothyroidism

Features
● Common cause: thyroid agenesis or dysgenesis
● Symptoms: feeding difficulties, lethargy and low
frequency of cry
● Signs: large fontanelles, macroglossia, jaundice,
umbilical hernia, and hoarse voice

Diagnosis: Routine newborn heel prick - High TSH

and low T4

Treatment
● Thyroxine hormone replacement

Early treatment is necessary to prevent permanent

neurological damage

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Congenital Hypothyroidism

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 Cystic Fibrosis

Autosomal recessive disease caused by a defect in

the CFTR gene
Features
● Meconium ileus at birth
● Pancreatic insufficiency - Steatorrhea
● Recurrent respiratory tract infections
● Finger clubbing
● Absent vas deferens

PLABABLE
 Cystic Fibrosis

Most common lung infections

● Staphylococcus aureus (common children)
● Pseudomonas aeruginosa (common in adults)
● Haemophilus influenzae

Diagnosis
● Screening test → Newborn heel prick test
● Sweat chloride testing
● Genetic testing for CFTR gene
● Chest X-ray or CT - bronchiectasis

Treatment
● Chest physiotherapy
● Bronchodilators
● Dornase alfa and hypertonic saline to reduce
viscosity of mucous
● Pancreatic enzyme replacement (pancreatic
insufficiency)
● Chronic P. aeruginosa infection with nebulised
colistimethate sodium or tobramycin
● Lung transplantation in a case of respiratory
failure

PLABABLE
 Newborn Screening

Newborn physical examination

→ Within 72 hours of birth and then again at 6-8
weeks

Newborn hearing screening test

→ Automated otoacoustic emission test
→ Usually performed before the baby is discharged
→ Ideally, the test is done within the first 4-5 weeks

Newborn bloodspot screening (heel prick test)

→ Performed ideally when the newborn is 5 days
old

Important diseases that are screened for → (CCC)

● Sickle Cell disease
● Cystic fibrosis
● Congenital hypothyroidism

PLABABLE
 Non-Accidental Injury

Presentation
● Delayed time to medical presentation
● Step-father or boyfriend accompanies child
● Bruises of varying degrees and colours
● Bruising at unusual sites
● Fracture history, particularly: rib and spinal

Management
● Admit to ward and manage pain
● Involve the local safeguarding children team
● Refer to social services
● Treat any other underlying medical conditions

Differential diagnosis
● Henoch-Schönlein purpura
● Haemophilia
● Idiopathic thrombocytopenic purpura
● Leukaemia
● Osteogenesis imperfecta

PLABABLE
 Non-Accidental Injury Vs Other
Distractors

How to differentiate Non-accidental injury from other

distractors?

● Idiopathic thrombocytopenic purpura

→ Presents with isolated thrombocytopenia

● Haemophilia
→ Prolonged APTT
→ Spontaneous bleeding in joints

● Henoch-Schönlein purpura
→ Look for PAAN in the question
Purpura, Arthralgia, Abdominal pain,
Nephropathy (hematuria, proteinuria)

● Osteogenesis Imperfecta
Remember the mnemonic “BBBBB”
→ Bruises
→ Bone (Increased chance of fracture)
→ Blue sclerae
→ Biting problems (Teeth imperfections)
→ Bad hearing
PLABABLE
 Non-Accidental Injury Vs
Osteogenesis Imperfecta

The greatest difficulty in questions with a recurrent

fracture in a toddler is choosing between
non-accidental injury (NAI) or osteogenesis
imperfecta (OI)
Sometimes when no clues are given,
it is worth looking at the mechanism
of the injury and the type of fracture

Example, a toddler who sustains a

spiral fracture of the humerus during
a fall off the bed when sleeping.

Does that fit?

No!

A fall off the bed is a minor fall. Spiral fractures of the

humerus involves twisting motions such as an adult
pulling the toddler’s hand with force in a twisting
motion
→ Think NON ACCIDENTAL INJURY!

PLABABLE
 Nocturnal Enuresis

Primary nocturnal enuresis:

Bedwetting in a child who has never achieved
consistent nighttime dryness

Secondary nocturnal enuresis:

Bedwetting in a child who has previously been dry
for at least 6 months

Causes
● Developmental delay
● Urinary tract infection / constipation
● Type 1 DM

PLABABLE
 Primary Bedwetting

Primary bedwetting without daytime symptoms

< 5 years old ≥ 5 years old

Reassure <2/week ≥2/week

Reassure + Positive
reward system

Rapid control Long term

needed control
needed
→ Desmopressin
(oral or sublingual) → Enuresis
alarm (1st
line) + reward
NEVER PICK NASAL system
DESMOPRESSIN FOR
BEDWETTING IN CHILDREN

PLABABLE
 Primary Bedwetting

Primary bedwetting with daytime symptoms

Causes → Overactive bladder, congenital

malformations, neurological disorders, urinary
tract infections, and chronic constipation

Consider referring all children >2 years old to

secondary care or enuresis clinic

If the cause is overactive bladder

● Start with bladder retraining or behavioural

therapy
● Oxybutynin can be tried if above fails
● Desmopressin (oral or sublingual) can also be
tried alone or in combination with antimuscarinic
drugs like oxybutynin or tolterodine under
specialist supervision

PLABABLE
 Secondary Bedwetting

Secondary bedwetting

Causes → Diabetes, UTI, constipation,

psychological problems (behavioural or
emotional problems), family problems
(emotional upset, child abuse)

Cause identified Cause not identified

Eg. glucose in urine or OR cause cannot be
infection managed in primary
care

Manage in primary Referral to a

care paediatrician or an
enuresis clinic

PLABABLE
 Infant Respiratory
Distress Syndrome

Risk factors
● Premature infants
● Caesarean delivery
● Maternal diabetes
● Meconium aspiration syndrome

Presentation
● Respiratory distress
● Subcostal and intercostal retractions
● Tachypnoea
● Expiratory grunting
● Cyanosis if severe

Investigations
● Monitor oxygen saturation
● Arterial blood gas analysis
● Chest X-ray - ground glass appearance

Treatment
● Endotracheal surfactant replacement
● Intermittent positive pressure ventilation
● Fluid and electrolyte monitoring

PLABABLE
 Infant Respiratory
Distress Syndrome

Inadequate surfactant in the lungs causing alveoli to

collapse resulting in respiratory distress

IRDS can be prevented by giving glucocorticoids to

the mother before delivery

PLABABLE
 Transient Tachypnoea Of The
Newborn

● Most common cause of respiratory distress in

term infants
● Cause → Delay in resorption of lung liquid
● Main clinical feature → Respiratory distress

Investigation
● Chest x-ray → Fluid in the horizontal fissure

Management
● Administer oxygen
● Features of respiratory distress usually settle in a
day (can sometimes go on for a few days)

Look out for important risk factors such as

caesarean section in the medical history.

PLABABLE
 Meconium Aspiration Syndrome

Respiratory distress developing shortly after birth

with radiological evidence of aspiration
pneumonitis and the presence of
meconium-stained amniotic fluid

Risk factors
● Post date (>42 weeks gestation)
● Maternal hypertension
● Oligohydramnios
● Placental insufficiency

Treatment
● Airway suctioning
● Maintenance of oxygen saturation
● Fluid and electrolyte monitoring

PLABABLE
Meconium Aspiration Syndrome

PLABABLE
 Infant In Respiratory Distress

Any infant in respiratory distress

Blood gas and oxygen saturation are vital

investigations (usually mentioned in the question)

Next most appropriate action

Chest x-ray → Helps to identify the cause and

rule out important conditions like pneumothorax
and diaphragmatic hernia

Other investigation → Blood culture

Absence of fever does not rule out sepsis in

infants

PLABABLE
 Infant In Respiratory Distress

Condition Chest x-ray findings

Infant respiratory distress ● “Ground glass”
syndrome appearance
● Reduced lung volume

Congenital pneumonia ● Patchy shadowing or

consolidation

Transient tachypnoea of ● Streaky perihilar

the newborn changes
● Fluid in the horizontal
fissure

PLABABLE
 Newborn Jaundice

Infants are prone to get jaundice as they have high

RBC count and immature liver to process bilirubin

Physiological jaundice
● Presents from 24 hrs to 2 weeks after birth
● Usually harmless but needs continuous
observation.
● Needs treatment if the bilirubin level is high

Pathological jaundice
● Presents within 24 hrs and or persists even after
2 weeks after birth
● Very high bilirubin level
● Baby is irritable, and is not feeding well

Causes
● Haemolytic disease of the newborn
● Infection and sepsis
● Increased hemolysis due to haematoma
● Liver disorders such as Dubin-Johnson syndrome
● Hypothyroidism
● Biliary atresia
● Cystic fibrosis

PLABABLE
 Newborn Jaundice

Treatment
Depends upon the bilirubin level and the age of the
baby
● Phototherapy if bilirubin is mildly above the
cut-off for age
● Exchange transfusion if bilirubin is highly
elevated above the cut-off for age

PLABABLE
 Newborn Jaundice

Jaundice present at birth or within 24 hours

● Pathological and needs further investigations
● Likely haemolytic (rhesus/ABO
incompatibility/G6PD) or sepsis

Jaundice starting 24 hours to 2 weeks

● Likely physiological
● Most jaundice fall into this category

Jaundice beyond 2 weeks

● Needs urgent paediatric assessment

Bilirubin
Mostly Mostly
Unconjugated Conjugated

Think of breast Think of biliary

milk jaundice atresia
PLABABLE
 Biliary Atresia

● Jaundice with pale stools and dark urine

● Presents in 3-4 weeks of life
● Hepatomegaly
● Splenomegaly in late presentation

Diagnosis →
● Conjugated hyperbilirubinaemia
● Raised GGT
● Abdominal ultrasound
● Cholangiogram
● Percutaneous biopsy (definitive diagnosis)

Treatment → Kasai procedure

(hepatoportoenterostomy)

Any child with jaundice beyond 2 weeks should be

investigated with conjugated bilirubin.

PLABABLE
 Biliary Atresia

Unconjugated
bilirubin

Hepatic
conjugation

Conjugated
bilirubin

Conjugated Conjugated
bilirubin bilirubin

Conjugated Conjugated
bilirubin bilirubin

Hence the reason you would see

more conjugated bilirubin in serum PLABABLE
 Biliary Atresia Vs Galactosemia

Biliary atresia Galactosemia

● Prolonged jaundice ● Prolonged jaundice

● Pale stools ● Vomiting
● Dark urine ● Liver enlargement
● Liver enlargement ● Yellow stools
● Low weight for age ● Lethargy
● Pale urine
● Low weight for age
● Feeding difficulties

Presents with features of Does not present with

obstructive jaundice → features of obstructive
Pale stools and dark jaundice → Yellow stools
urine + pale urine

Exclude other causes of prolonged jaundice before

making the diagnosis:
● Congenital hypothyroidism
● Breast milk jaundice
● Congenital infections → CMV, toxoplasmosis

PLABABLE
 Breast Milk Jaundice

● Most common cause of prolonged unconjugated

hyperbilirubinaemia
● Infants become jaundiced in the 2nd week of life
● They are usually well
● Jaundice resolves within 6 weeks but may
continue up to 4 months

Investigation
● Perform split bilirubin test (shows increased
unconjugated bilirubin levels)

Management
● Occasionally, breastfeeding may be stopped for
24 hours and formula is given till the diagnosis is
established
● In majority of infants, interrupting breastfeeding is
not necessary or advisable

PLABABLE
 Febrile Seizure

Convulsions occurring in children from 6 months to 6

years of age without any underlying cause of seizure
such as CNS infection or electrolyte disturbance

Classified into
● Simple (<15 min, generalised and tonic-clonic),
● Complex (>15 min or focal)
● Febrile status epilepticus (>30 min without
complete recovery)

Management
● Patient in recovery position and check ABC
● Seizure episode >5 min then give rectal
diazepam
● R/O other causes of seizures such as meningitis,
hypoglycemia and electrolyte imbalance

PLABABLE
 Febrile Seizure

Parents often ask:

● Will this seizure happen again?
● Will my child develop epilepsy in the future?

Both are easy to answer using a rule of thirds

● ⅓ of the patients who experience a febrile seizure

chance will experience another before the age of
6

● ⅓ of the these patients will go on to develop

epilepsy

● Therefore, roughly 10% of complex febrile

seizures patients develop epilepsy

PLABABLE
 Seizures Without Fever

Always start with obtaining a capillary glucose level

Hypoglycaemia is a common cause of seizure in an

otherwise well child

PLABABLE
 Developmental Milestones

This figure is intersected at 4 different levels of

the body which represent different time frames.

● 3 months → Neck - Holds neck

● 6 months → Body - Rolls in both directions
● 9 months → Knees - Crawling
● 12 months → Feet - Walks

PLABABLE
 Developmental Milestones

For fine motor skills, remember this pattern:

● 2 years → Draws a line
● 3 years → Draws a circle
● 4 years → Draws a cross and square
● 5 years → Draws a triangle
● 6 years → Draws a diamond

If a certain milestone is not reached by the

respective date you should refer for a specialist
community paediatric assessment:
● Unable to sit unsupported at 12 months of age
● Unable to walk by 18 months of age
● No speech at 18 months of age (at 15 months
onwards, if unable to speak monosyllabic words
and difficulty understanding speech, consider
arranging hearing test)
● Unable to run by 2.5 years of age
● Unable to hold objects placed in hand by 5
months of age
● Unable to reach for objects by 6 months of age

PLABABLE
 Developmental Milestones

The BIG 2
What should you be able to do at 2 years of age?

Strings 2 words together

E.g. Mama sit
Knows more than 50
words

Walks independently
Can run tip toe

Can draw a straight line

PLABABLE
 Sudden Infant Death Syndrome

To reduce the risk of sudden infant death

syndrome (SIDS), advise parents the following:
● Avoid smoking near infants
● Put infants to sleep on their backs (not their front
or sides)
● Avoid overheating by heavily wrapping infants
● Blankets should not be higher than their
shoulders
● Infants should be placed with their feet at the foot
of the cot
● Avoid bringing baby into the bed after parents
have consumed alcohol or sedative medications
● Avoid sleeping with infant on sofa
● Avoid using a pillow
● Use sheets and blankets rather than a duvet

PLABABLE
Sudden Infant Death Syndrome

PLABABLE
 Breath Holding Spells Vs Reflex
Anoxic Seizures

Breath holding spells Reflex anoxic seizures

Follows a child who is Child may or may not be

crying vigorously crying
Turns blue and then Stops breathing and then
stops breathing turns pale

● Both conditions are precipitated by anger,

stress or anxiety
● They both involve loss of consciousness
for <1 minute

Management for both conditions is the same

● Reassure
● Advice parents to put the child in recovery
position
● Check ferritin and treat iron deficiency if
present

Reflex anoxic seizures does not involve tongue

biting → Helps differentiating it from epilepsy

PLABABLE
 Malrotation & Volvulus

Brain trainer:

A neonate presents with acute onset of green,

bilious vomiting and blood per rectum.
What is the most likely diagnosis?

➔ Malrotation and volvulus

PLABABLE
 Diagnosis

Brain trainer:

➔Henoch-Schönlein Purpura
PLABABLE
 Henoch-Schönlein Purpura

Systemic IgA-mediated vasculitis characterised by

immune-complex deposition, most commonly
seen in children

→ Look out PAAN in the stem:

Purpura
Arthralgia
Abdominal pain
Nephropathy (hematuria, proteinuria)

PLABABLE
 Henoch-Schönlein Purpura

Clinical features
● Skin purpura → Buttocks, lower legs, extensor
surfaces
● Joint pain
● Abdominal pain and bloody diarrhoea
● Glomerulonephritis (Hematuria and proteinuria)
● Recent h/o URTI or gastroenteritis

Management
● Symptomatic treatment such as pain killers for
arthralgia
● Most people recover without any active
intervention
PLABABLE
 Haemolytic Uraemic Syndrome

Microangiopathic
hemolytic
anaemia

TRIAD

Acute renal Thrombocytopenia

failure

● Followed after an episode of bloody diarrhea due

to E. coli O157:H7
● Treatment includes fluid and electrolyte
management, antihypertensive therapy and
dialysis

PLABABLE
 HUS vs HSP

Haemolytic Uraemic Henoch-Schönlein

Syndrome Purpura
E.coli Autoimmune vasculitis
Prodrome of diarrhea
URTI or GIT infection
that turns bloody
Purpura
Abdominal pain
Fever
Renal involvement
Microangiopathic
haemolysis Arthralgia
(schistocytes)
Supportive: fluids,
antihypertensives, Supportive (NSAIDs)
dialysis

● HSP has platelets in the normal range

PLABABLE
 Nephrotic Syndrome

Proteinuria resulting in hypoalbuminemia due to

increased permeability of proteins. Most common
cause in children is minimal change disease.

Clinical features
Can be memorised using the mnemonic “PALE”

● P → Proteinuria (massive)
● A → HypoAlbuminemia
● L → HyperLipidemia
● E → oEdema (pedel, periorbital and facial)
Another important feature → Hypercoagulability

Treatment
● Steroids
● Cyclophosphamide (resistant cases)

PLABABLE
 Urinary Tract Infection

Presentation
● Fever
● Abdominal pain
● Loin pain
● Dysuria
● Increased frequency

Risk factors
● Stasis of urine such as in renal calculi, VUR,
phimosis etc.
● Constipation
● Sexual abuse
● Previous history of UTI

Investigation
● Urine culture and sensitivity by either clean
catch urine sample or catheter sample or
suprpubic aspiration
● Dipstick testing - nitrites

Treatment
● Nitrofurantoin MR 100mg BD
● Trimethoprim 200 mg BD

PLABABLE
 Urinary Tract Infection
In Infants Less Than 6 Months

Imaging schedule for infants <6 months age

Test Responds Atypical Recurrent
to treatment UTI UTI
in 48 hrs
Immediate NO YES YES
Ultrasound
Ultrasound YES NO NO
within 6 weeks
DMSA 4-6 NO YES YES
months
following
infection
MCUG NO YES YES

Important change regarding imaging for children >6

months is that MCUG is only performed if:
● There is dilation of the ureter on ultrasound
● Poor urine flow
● Family history of VUR
● Non - E. coli infection

PLABABLE
 Urinary Tract Infection
Above 3 years

Straightforward UTI
No imaging
Responds well to required
treatment within 48
hours

Atypical UTI ● USS during

infection
● DMSA not
required

Recurrent UTI ● USS within 6

weeks
● DMSA 4-6
months after
infection

PLABABLE
 Recurrent Urinary Tract Infection
Above 3 years

Recurrent UTI above 3 years old

1st test → US (done within 6 weeks)

2nd test → DMSA (done 4 to 6 months after

infection)

Special tip to remember:

MCUG can never be the right answer for a child

above 3 years old

M. C. U. GEE

Never over ThrEE

PLABABLE
 Vesicoureteric Reflux

Vesicoureteric reflux is the retrograde flow of

urine from the bladder to the ureters and kidney

Clinical Features
● Usually asymptomatic
● May present as a UTI due to increased risk

Investigations
● Initial investigations →
○ Urinalysis, urine culture and sensitivity
○ Renal ultrasound (may show ureteral dilation)
● Gold standard → Micturating cystourethrogram
● Parenchymal damage detected → Technetium
scan (DMSA)

Indication Treatment
VUR grade I-IV Low dose antibiotic
prophylaxis
(trimethoprim)
Failed prophylaxis Surgical correction
Parenchymal damage
Breakthrough UTI
Persistent high grade
reflux (grades IV-V) PLABABLE
 Acute Epiglottitis

Acute epiglottitis is a life-threatening condition and

can lead onto obstruction of the airway
Common organisms:
● Unvaccinated individuals → H. Influenzae
(Hib)
● Vaccinated individuals → Streptococcus

Presentation
● Drooling of saliva
● Muffled voice - Hot potato voice
● High temperature
● Odynophagia and dysphagia
● Stridor (sign of airway obstruction)

Investigation
● Laryngoscopy - gold standard
● Lateral neck X-ray - thumb sign
● Throat swab

Treatment
● Intubation if signs of airway obstruction are
present
● IV antibiotics
● Fluids

PLABABLE
 Croup

Laryngotracheobronchitis is a type of URI in children

caused most commonly by Parainfluenza virus

Clinical features
● Barking cough
● Hoarse voice
● Inspiratory stridor
● Fever

Treatment
● Most appropriate - Dexamethasone

● Initial management for severe cases - O2 with

nebulised adrenaline

PLABABLE
 Bronchiolitis

Acute viral infection of the lower respiratory tract

commonly seen in children < 2 yrs old

Clinical features
● Persistent cough
● Respiratory distress
● Wheeze
● Bilateral crepitations
● Tachypnoea
● Chest retractions
● Common cause: Respiratory syncytial virus

Treatment
● Oxygen (±humidified) and IV fluids (symptomatic)

PLABABLE
 Bronchiolitis Vs Croup

Expiratory wheeze Inspiratory stridor

Age group between

Age group less than
6 months and 3
1 year old
years

Likely bronchiolitis Likely croup

PLABABLE
 Bronchiolitis Vs Croup

Remember the mnemonic “HER SPA”

Bronchiolitis Croup

● H → Humidified ● S → Stridor, Starts

oxygen after Six months,
● E → Expiratory Single dose of
wheeze Steroids
● R → Respiratory ● P → Parainfluenza
syncytial virus ● A→ Adrenaline
(nebulised adrenaline)

PLABABLE
Inspiratory Stridor and Expiratory
Stridor

Extrathoracic pathologies
cause an inspiratory stridor
(e.g. any pathologies from
larynx and above)

Intrathoracic pathologies
cause an expiratory stridor
(e.g. pathologies from lower
trachea downwards)

Croup (laryngotracheobronchitis) as an example

involves both extrathoracic and intrathoracic regions
but since it is mainly the larynx that is involved, it
causes an INSPIRATORY stridor

Click on this to watch a video

of inspiratory stridor

PLABABLE
 Differential Diagnosis Of Stridor
In Children

Condition Key Features

Acute epiglottitis ● Toxic appearance
● Absent cough
● Muffled voice
● Drooling of saliva
● Thumbprint sign (on
lateral neck x-ray)
Croup ● Does not appear toxic
● Barking cough
● Hoarse voice
● No drooling of saliva
● Steeple sign on chest x-ray
Inhaled foreign ● Choking
body ● Hoarseness or inability to
speak
● Investigation →
Laryngoscopy
Laryngomalacia ● Most common cause of
congenital stridor
● Usually normal thriving
infants
● Inspiratory stridor worsens
during crying, feeding and
in supine position

PLABABLE
 Pertussis

Whooping cough caused by Bordetella pertussis

Look for the child without immunisations who has a

bout of cough followed by episodes of a blue
face/lips

Clinical features
● Paroxysmal cough
● Vomiting after coughing
● Inspiratory whoop
● Infants may not have the inspiratory whoop but
may have episodes of apnoea or cyanosis

Investigation
● Pernasal or nasopharyngeal swabs

Treatment
● Macrolides

PLABABLE
 Osteogenesis Imperfecta

Features
● Autosomal dominant disorder
● Defect in type 1 collagen

Remember the mnemonic “patients don’t BITE”

→ Bone → Increased chance of fracture
→ I (eye) → Blue sclerae
→ T → Teeth imperfections
→ Ear → Hearing loss

PLABABLE
 Congenital Adrenal Hyperplasia

Autosomal recessive disorder and is most commonly

caused due to 21-hydroxylase deficiency

Clinical features
● Males: hyperpigmentation and penile
enlargement
● Females: ambiguous genitalia with an enlarged
clitoris
● Vomiting
● Hyponatremia
● Hyperkalemia
● Shock

Treatment
● Glucocorticoids - hydrocortisone and
prednisolone
● Mineralocorticoid - fludrocortisone
● Surgical management for ambiguous genitalia

PLABABLE
 Congenital Adrenal Hyperplasia

Brain trainer :

An overweight 23 year old woman complains of

excessive hair growth and acne on her face and
chest. She reached pubarche at age 11 and has a
history of irregular periods. What is the most
appropriate biochemical test to perform?

➔ 17-hydroxyprogesterone

21 alpha hydroxylase deficiency

↓
Cortisol deficiency
↓
High ACTH levels
↓
Adrenocortical hyperplasia
↓
Excessive progesterone and
17-hydroxyprogesterone
↓
Excessive testosterone and androstenedione
(resulting in the features mentioned in the STEM)

PLABABLE
 Kawasaki Disease

Systemic vasculitis most commonly affecting the

children from 6 months to 5 years of age

Clinical features
Remember the mnemonic “CRASH & Burn”

● Conjunctivitis (non- exudative)

● Rash (polymorphous, non vesicular)
● Adenopathy (cervical)
● Strawberry tongue
● Hands (palmar erythema and swelling)
&
● Burn (fever lasting ≥ 5 days)

Image: A - Conjunctivitis, B - Strawberry tongue,

C to H - skin desquamation and rashes
PLABABLE
 Kawasaki Disease

Complications (especially if untreated)

● Coronary artery aneurysm
● Myocardial infarction

Treatment
● Intravenous immunoglobulin (IVIg) →
Mainstay of treatment
● High dose aspirin

PLABABLE
 Scarlet Fever Vs Kawasaki
Disease

Scarlet Fever Kawasaki Disease

Fever responsive to Fever >39°C not

antipyretics responsive to antipyretics
(lasts for 5 days or more)
Tender lymphadenopathy Painless
lymphadenopathy

Blanching rash with Non specific

pastia lines polymorphous rash

Perform rapid antigen Perform serial

test and culture echocardiography

Treatment → Antibiotics Treatment → High dose

aspirin and IVIG

Can cause rheumatic Can cause aneurysm

fever, poststreptococcal formation
glomerulonephritis

PLABABLE
 GORD

Clinical features
● Recurrent regurgitation
● Episode of choking
● Feeding issues
● Pneumonia

Most commonly resolves on its own by the age of 1

Risk factors
● Premature birth
● Obesity (child)

Treatment
● Smaller and more frequent meals
● Trial of thickened formula
● Alginate therapy
● PPI or H2RA (in severe cases)

PLABABLE
 Cow’s Milk Protein Allergy

Clinical features
● Itching
● Erythema
● Urticaria
● Acute angioedema
● Colicky abdominal pain
● Vomiting and diarrhea
● More common in formula fed babies

Treatment
● Hydrolysed milk product (after stopping cow’s
milk)
● If breast-fed, mother should eliminate cow’s milk
in her diet

PLABABLE
 BRAIN TRAINER

Brain trainer:

A 10 year old boy has recently been diagnosed with

type 1 diabetes mellitus. Since this, the child has
not been cooperating and is socially isolated.

Who should the patient be referred to?

➔ Psychologist
The patient needs talk therapy in order to come to
terms with his newly diagnosed chronic disease. A
psychiatrist can be involved if the case becomes
more complex.

PLABABLE
 Rash With Fever

Measles Erythematous macules and papules

on the face, neck and shoulders
Koplik's spots (tiny bluish-white
papules with erythematous areolae)
Scarlet fever Sore throat
Sandpaper like rash
Strawberry tongue
Rubella Pink macules and papules starting
on the forehead and spreading to
the face, trunk and extremities on
the first day

Fades from the face on the second

day and the rest of the body by the
third day
Erythema Slapped cheek appearance
infectiosum
(Parvovirus
B19)

PLABABLE
 Measles or Scarlet fever

Child with a rash below with rhinorrhoea, a dry

cough and conjunctivitis.
Measles or Scarlet fever?

PLABABLE

Measles!
Scarlet fever would present with a sore throat
which is not seen here.

PLABABLE
 Measles or Rubella

Both measles and rubella present in a similar way.

There are a couple of clinical features that can help
to distinguish between them.

Measles Rubella

No cervical Cervical
lymphadenopathy lymphadenopathy is seen

Koplik spots on buccal Forschheimer spots on

mucosa soft palate

Measles is also called Rubella is also called

“rubeola” “german measles”

PLABABLE
 Immunisation Schedule

Vaccines
● Diphtheria, hepatitis B,haemophilus influenzae
type b, polio, tetanus, pertussis (6-in-1)
● Measles, mumps, and rubella (MMR)
● Streptococcus pneumoniae (PCV)
● Streptococcus agalactiae (MenB)
● Rotavirus
● Human papillomavirus (HPV)
● Influenza

PLABABLE
Contraindications To Vaccination

Generally, vaccination is contraindicated when:

● History of confirmed anaphylactic reaction to a
previous dose of the vaccine
● History of confirmed anaphylactic reaction to a
component of the vaccine

Live vaccines are contraindicated in:

● Immunosuppressed patients
● Pregnancy

Delay vaccination if the child has a febrile illness

(with a high temperature) or has an infection

Remember that the baby can still be vaccinated if:

● The baby has a minor illness without a high
temperature - such as a cold
● The baby has allergies, asthma, eczema and
food intolerances
● Baby was born prematurely

PLABABLE
 Vaccination and Egg Allergies

Two
Twovaccines
vaccinesininthe
theUK
UKschedule
schedulecontain
contain
smallamounts
small amountsofofeggeggprotein
protein

MMR
MMRvaccine
vaccine Flu vaccine

Grows on cells from Grows on

chick embryos hens’ eggs

Does not trigger an Can trigger an

allergic reaction allergic reaction

Can receive MMR To give egg-free

vaccine (even if inactivated flu
allergic to egg) vaccine (if allergic
to egg)

PLABABLE
 Umbilical Granuloma

PLABABLE

If the umbilical granuloma is not infected, there

are two options for treatment:
● Table salt or
● Silver nitrate

Table salt usually started first

PLABABLE
 Hand, Foot and Mouth Disease

PLABABLE

PLABABLE

● Affects mainly children

● Self limiting
● Caused by Coxsackievirus

PLABABLE
 Brain Trainer

Brain trainer:

A 10 year old boy presents to the GP clinic with

ongoing abdominal pain for a month. It occurs with
some features of a migraine lasting for about an
hour. This interferes with his daily activities and so
he misses school whenever it occurs. His mother
was recently diagnosed with breast cancer.

What is the single most appropriate management?

➔ Obtain further history from teachers and
family

Recent cancer diagnosis → Triggers a change in

behaviour → Ask the mother and teachers if the child
is enjoying school or not

Consider abdominal migraines in a stem where a

child presents with similar symptoms

PLABABLE
 Causative Agents For Common
Illnesses

Condition Causative agent

Scarlet Fever Streptococcus pyogenes

Impetigo Staphylococcus aureus

Rubella Rubella virus

Roseola Human herpesvirus type 6

(HHV-6)

Chickenpox Varicella-zoster virus (VZV)

Measles Morbillivirus (paramyxovirus)

Mumps Paramyxovirus

Erythema Parvovirus B19

infectiosum

Hand, foot and Coxsackievirus A16 and

mouth disease Enterovirus 71

PLABABLE
 Rashes And School

Condition Recommendation
Scarlet Fever Keep away from school and nursery
until 24 hours from starting antibiotic
treatment
Impetigo Keep away from school and nursery
until lesions are crusted and healed,
or 48 hours after starting antibiotic
treatment
Chickenpox ● Keep away from school and
nursery until vesicles have
crusted over AND at least 5 days
have passed from onset of rash
● Keep away from pregnant women
Measles Keep away from nursery or school
for four days from onset of rash
Rubella Keep away from school or nursery
for four days from onset of rash
Do NOT withdraw from school or nursery in:
● Hand, foot and mouth disease
● Cold sores (herpes simplex)
● Molluscum contagiosum
● Roseola
● Parvovirus B19 (once the rash has developed)
PLABABLE
 Roseola

PLABABLE

● Commonest rash of its kind under 2 years old

(commonly seen even under 3 years of age)
● Fever (often 40°C) lasting 3 to 5 days
● Rash starts around 3 to 5 days after fever
subsides
● Rose-pink or red raised spots
● In most cases, child is well
PLABABLE
 Roseola

Memory tool → “Rose 3”

For the boys who like

For the girls who like
basketball, remember
flowers remember “3
“D Rose 3 shoes from
roses”
Adidas”

What does “Rose 3” stand for?

● Rose → Roseola
● Common below age 3
● Fever last for 3 days
● Rash (after the fever) last for 3 days
● 3 + 3 = Human herpesvirus-6

PLABABLE
 Roseola

PLABABLE

Fever + Rash + Hx of runny nose in an otherwise

well child

Management → No specific treatment

Viral exenthems usually need no specific treatment

PLABABLE
 Reactive Lymphadenopathy

Reactive lymphadenopathy is commonly seen in

children after an acute infection. May be tender.

Cervical lymphadenopathy does not need further

investigation if it occurs acutely post upper
respiratory tract infection in an otherwise well
child (normal bloods, no weight loss, no features
of Kawasaki)

PLABABLE
 Lymphadenopathy In Children

Must know causes of lymphadenopathy in children:

● Reactive lymphadenopathy → Common cause
● Haematological malignancies
● CMV
● EBV
● Kawasaki disease
● TB

Reactive Lymphadenopathy
● Follows an acute infection
● If FBC acceptable and no red flags present →
Reassure and discharge

Red Flags
Features of more than 1 of the following should
prompt an urgent referral especially if there are no
signs of local infection :
● Non tender, firm lymph nodes
● Hard lymph nodes
● Lymph nodes >2 cm
● Progressively enlarging lymph nodes

PLABABLE
 Dysgraphia

A learning disability that affects writing abilities

Who can help support children with dysgraphia?

→ Educational psychologist

Educational psychologist help create a therapy plan

for children to improve their coordination and
handwriting skills. They consult with multidisciplinary
teams to advise on the best approach to help the
child’s development.

PLABABLE
 Plagiocephaly

Refers to a condition where an infant’s head

becomes deformed as the result of external
forces applied

Usually from lying down in one head position for

extended time (months and years)

What needs to be done?

● Reassurance
● Encourage changing baby’s position when
lying down
● Encourage infant to sit up or have more
tummy time during waking hours

PLABABLE
 Idiopathic Thrombocytopenic
Purpura (ITP)

● Most common cause of thrombocytopenia in

childhood

Features
● Sudden onset of purpura in a usually well child
● Usually ages 2 years old to 10 years old
● Onset after 1 to 2 weeks of a viral infection
(usually URTi)
● May have bleeding (epistaxis, menorrhagia, GI
bleed)
● Low platelets (remaining full blood count usually
normal)

Management
● Prednisolone → First line if treatment required
● IVIG → If bleeding and or unresponsive to
corticosteroids
● Platelet transfusion → Only in life-threatening
bleeding

What is a life threatening bleed?

Intracranial haemorrhages or high volume bleeding
resulting in hypotension or prolonged capillary refill
and requiring fluid resuscitation or blood transfusion

PLABABLE
 Idiopathic Thrombocytopenic
Purpura (ITP) differentials

ITP is a diagnosis of exclusion, so always

consider the other differentials

Acute leukaemia → Lymphadenopathy, anaemia or

hepatosplenomegaly

Aplastic anaemia → Features of anaemia +

recurrent infections

Henoch-Schönlein purpura (HSP) → Abdominal

and joint pain as well

Haemolytic uraemic syndrome → Diarrhoea,

anaemia, and oliguria

Meningococcal septicaemia → Systemic upset +

fever

PLABABLE
 Brain Trainer

Brain trainer:

An 8 year old child was brought to the ER with

severe burns on his limbs and chest. The paediatric
doctor has failed to insert a peripheral intravenous
line due to significant burns.
What is the next most appropriate method to
deliver fluids for this patient?

➔ Intraosseous access

Useful in → Major burns, septic shock and cardiac

arrest when it is difficult to place an intravenous line

Where to place → 2.5cm below the tibial tuberosity

at the proximal tibia

AVOID THE EPIPHYSEAL GROWTH PLATE

WHEN USING THIS METHOD

PLABABLE
 Patent Ductus Arteriosus

Common in preterm infants

Clinical features
● May be asymptomatic
● Apnoea
● Bradycardia
● Increased oxygen requirements
● Bounding peripheral pulses

● Continuous ‘machinery’ murmur may be

present.
● It is common for the murmur to disappear with
time (may even disappear by the time the
baby is discharged from the paediatric ICU).

Diagnosis → Echocardiography

Management
● May close spontaneously
● Indomethacin or ibuprofen (effective in majority
of the cases)

PLABABLE
 Innocent Murmur

Remember the letter “S” to memorise the features of

an innocent murmur → “S” (innoSent murmur)

● Short duration
● Soft
● Sweet (not harsh-sounding)
● Systolic
● Single (no associated clicks or gallops)
● Sensitive (changes with position or respiration)
● Supine (murmur is heard loudest in supine
position)
● Left Sternal edge

PLABABLE
 Lateral Neck Masses

Lateral neck masses

Lymphangioma
Branchial cyst
(Cystic hygroma)

Fluctuant + Translucent
non-translucent +
doesn’t move on
swallowing

Fluctuant lump + transilluminates → Cystic

hygroma

PLABABLE
 Neonatal Conjunctivitis

Sticky red eyes in neonates

→ Refer to secondary care

Purulent discharge + lid swelling in neonates

→ Refer to secondary care

PLABABLE
 Brain Trainer

Brain trainer:

A 30 year old woman who had a primary infection

of cytomegalovirus during pregnancy gave birth 3
days back. The baby is asymptomatic.

What is the most common complication that can

occur in this child?

➔ Hearing loss
Congenital CMV is the leading non-genetic cause
of sensorineural hearing loss

PLABABLE
 Vitamin D Supplementation

● All children and adults living in the UK are

advised to take vitamin D supplementation of 400
IU throughout the year.

● Children aged 0-1 year are advised to take

vitamin D supplements at slightly lower doses of
340-400 IU.

PLABABLE
 Perforated Hymen

Important Clinchers →
Horse riding + Red staining of underpants

Next most appropriate action →

Examination of genitalia in clinic (without
anaesthesia)

Stop the examination if the child becomes

uncomfortable or withdraws permission to continue.

When to consider general anaesthesia?

→ If the child refuses examination and requires

medical attention, such as bleeding or a foreign
body, are suspected

PLABABLE
 Tourette’s Syndrome

● Young, mostly male (6-8 years old)

● Tics → Repetitive movements or gestures that
are disruptive in the classroom
● Jerks, blinks, sniffs, nods and obscene verbal
ejaculations

Diagnosis → Clinical diagnosis

Treatment → Behavioural therapy (habit- reversal)

Risperidone and haloperidol may also be tried

Asperger syndrome
● The question would mention impaired social
skills (helps differentiate it from Tourette’s
syndrome)
● Repetitive behavioural patterns
● Normal IQ and language or, in some cases,
superior
● Tics may be mentioned in the question but it is
more specific to Tourette’s syndrome

PLABABLE
 Obstructive Sleep Apnoea
Syndrome In Children

Occurs due to enlarged tonsils and adenoids

Clinical features
● Snoring
● Mouth breathing
● Witnessed apnoeic episodes
● Nasal speech

Sleep deprived children tend to be

hyperactive with reduced attention spans,
in contrast with adults who often fall asleep
during the day.

Investigation
● Gold standard instrument → Overnight
in-laboratory polysomnography (PSG)

Single most appropriate action → Refer to ENT

surgeon

PLABABLE
 Brain Trainer

Brain trainer:

An 8 year old child was diagnosed with meningitis

and admitted into the paediatric intensive care unit.
He received 14 days of IV antibiotics. He is on his
last day of intravenous antibiotic treatment. The
patient appears to be recovering well and has no
complaints.

What is the most likely outcome for this patient?

➔ Complete recovery

Other outcomes → Hearing loss, mental

retardation, learning and behavioural difficulties

PLABABLE
 Maintenance Fluid Replacement

Maintenance fluid over 24 hours:

100 mL/kg for the first 10 kg

50 mL/kg for the next 10 kg
20 mL/kg for remaining kg

➔ Divide the total by 24 for the hourly rate

➔ Replace over 24 hours unless in hypernatraemia,

replace over 48 hours

➔ Reduce by ⅓ if there is a risk of inappropriate

ADH secretion

PLABABLE
 Fluid Replacement (Oral)

➔ Where possible, rehydrate with oral fluids unless

in shock, red flags (lethargy, tachycardic,
tachypnoea, sunken eyes) or continues vomiting

➔ 50 mL/kg PLUS maintenance fluid in small

frequent drinks

➔ Oral rehydration solution (ORS) contains both

sodium and glucose

➔ Losses can be replaced with 5 mL/kg oral

rehydration solution after each watery stool/vomit

PLABABLE
 Fluid Replacement (IV)

➔ Use an isotonic solution:

Sodium chloride 0.9% with glucose 5%

➔ 50 mL/kg + maintenance fluids

➔ If in shock, give 20 mL/kg bolus of sodium

chloride 0.9% then give 100 mL/kg in addition
to maintenance fluids

PLABABLE
 Brain trainer

A 32 kg child who is dehydrated requires intravenous

fluid replacement. What is the total volume of fluid
required and the rate per hour?

To correct for dehydration

50 ml/kg fluid = 1600 ml

Maintenance fluids
100 ml/kg x 10kg = 1000ml
50 ml/kg x 10kg = 500ml
20 ml/kg x 12kg = 240ml

Total = 1740 ml

Aim to correct the dehydration over 24 hours (or 48

hours if the patient is hypernatraemic or in diabetic
ketoacidosis)

○ Total fluid requirement:

1740 ml + 1600 ml = 3340 ml over 24 hours

○ Total fluid requirement: 140 ml/hour

PLABABLE
 Abdominal Migraine

Child + recurrent central abdominal pain >1

hour + interferes with school + episodic
headaches + well in between episodes

Examination + FBC, urinalysis, UnE

→ Normal
TTG IgA and faecal calprotectin test
→ Negative

Have you thought of Abdominal migraine?

Next step?

Reassure, no further investigations or

treatment needed

PLABABLE
 Image Attributions

https://commons.wikimedia.org/wiki/File:Marfan_Patient.jpeg
Mileny ES Colovati 1 , Luciana RJ da Silva 1 , Sylvia S Takeno 1 , Tatiane I Mancini 1 ,
Ana R N Dutra 1 , Roberta S Guilherme 1 , Cláudia B de Mello 2 , Maria I Melaragno 1
and Ana B A Perez CC BY 2.0

https://commons.wikimedia.org/wiki/File:DuodAtres.png
Kinderradiologie Olgahospital Klinikum Stuttgart CC BY-SA 3.0

https://commons.wikimedia.org/wiki/File:Intussusception.png
BruceBlaus CC BY-SA 4.0

https://commons.wikimedia.org/wiki/File:Scarlet_Fever.jpg
www.badobadop.co.uk CC BY-SA 3.0

https://en.wikipedia.org/wiki/File:Scharlach.JPG
Martin Kronawitter CC BY-SA 2.5

https://commons.wikimedia.org/wiki/File:Blausen_0286_CysticFibrosis.png
BruceBlaus CC BY 3.0

https://commons.wikimedia.org/wiki/File:X-ray_of_infant_respiratory_distress_syndrome_(I
RDS).png
Mikael Häggström, M.D.CC0 1.0

https://en.wikipedia.org/wiki/File:Esophageal_atresia_contrast.png
DrM!KEY

https://commons.wikimedia.org/wiki/File:Purpura_Schonlein_Henoch.JPG
Public domain

https://www.flickr.com/photos/30478819@N08/32971073298
Marco Verch CC BY 2.0

https://commons.wikimedia.org/wiki/File:Characteristically_blue_sclerae_of_patient_with_
osteogenesis_imperfecta.jpg
Herbert L. Fred, MD and Hendrik A. van Dijk CC BY-SA 3.0

https://commons.wikimedia.org/wiki/File:Kawasaki.PNG
Dong Soo Kim CC BY-SA 4.0

https://en.wikipedia.org/wiki/File:Verkalkte_aneurysmatische_Coronarien.jpg
Wkmatzek Public domain

https://www.flaticon.com/free-icon/https_1008792
This cover has been designed using resources from Flaticon.com

https://commons.wikimedia.org/wiki/File:Plagioc%C3%A9phalie.JPG
Gzzz, CC BY-SA 4.0

https://en.wikipedia.org/wiki/Neonatal_conjunctivitis#/media/File:Gonococcal_ophthalmia_
neonatorum.jpg
By CDC/ J. Pledger
PLABABLE