Paediatrics: growth, nutrition, immunisation and newborn care

In short

Paediatrics is the medicine of birth to adolescence, and in India its four pillars in both exam and clinic are growth monitoring, nutrition, immunisation and newborn care — the areas that carry the country's under-five and neonatal mortality burden. India's NMR is roughly 19–20 per 1,000 live births and U5MR about 31–32 (SRS/NFHS-5 range; figures are revised yearly), with prematurity, birth asphyxia and infection the leading neonatal causes, and undernutrition an underlying factor in a large share of child deaths. These four topics are examined as long questions and OSCE/clinical stations in MBBS paediatrics, dominate NEET-PG/INI-CET and FMGE paediatrics, and are the core of public-health interviews for NHM/RBSK/NRC posts, district hospital SNCU/NBSU jobs, and medical-affairs or vaccine-industry roles. Everything here follows the current Government of India Universal Immunisation Programme (UIP), WHO/IAP growth standards and NSSK/FBNC protocols.

Explained

Growth: measurement, charts and assessment

• Growth is increase in size (anthropometry); development is acquisition of function. Both must be assessed — a stunted child may be developmentally normal and vice versa.
• Key anthropometry: weight, length (supine, <2 y, infantometer) or height (standing, ≥2 y, stadiometer), head circumference (occipitofrontal, largest), mid-upper arm circumference (MUAC, left arm, midpoint acromion–olecranon), chest circumference, weight-for-height.
• Normal weight landmarks: birth ~2.8–3.0 kg (Indian average); physiological loss up to 7–10% in first week, regained by day 10–14; doubles by 5 months, triples by 1 year, quadruples by 2 years; then ~2 kg/year till puberty.
• Length/height: birth ~50 cm; 75 cm at 1 y, 87–90 cm at 2 y, ~100 cm at 4 y; thereafter 5–6 cm/year. Height doubles by 4 years.
• Head circumference: 34–35 cm at birth, 47 cm at 1 y, 49 cm at 2 y, 52–54 cm adult. Grows 2 cm/month for 3 months, 1 cm/month next 3, 0.5 cm/month next 6. HC > CC at birth; they equal at ~6–12 months; CC exceeds HC thereafter (a malnourished child's crossover is delayed).
• Anterior fontanelle closes 9–18 months; posterior by 6–8 weeks. Teeth: first lower central incisor at 6–8 months; number of teeth ≈ age in months − 6 (first 2 years); 20 deciduous teeth by 2.5–3 years.
• Charts used in India: WHO Multicentre Growth Reference Study standards (2006) for 0–5 years — prescriptive, based on breastfed children, used in Mother and Child Protection (MCP) card; IAP 2015 revised charts for 5–18 years (Indian references, with 23 and 27 adult-equivalent BMI cut-offs for overweight/obesity).
• Z-score (SD score) classification (WHO): weight-for-height/length < −2 SD = wasting (acute); height-for-age < −2 SD = stunting (chronic); weight-for-age < −2 SD = underweight (composite). Below −3 SD = severe.
• Older Indian classifications still examined: IAP classification (weight-for-age % of expected: 71–80% grade I, 61–70% II, 51–60% III, ≤50% IV), Gomez (weight-for-age), Waterlow (wasting + stunting), Welcome Trust (weight deficit + oedema → marasmus, kwashiorkor, marasmic-kwashiorkor).
• Development red flags: no social smile by 2 months, no head control by 4 months, not sitting by 9 months, not walking by 18 months, no words by 18 months, loss of acquired milestones (regression — always abnormal). Screen with Trivandrum Development Screening Chart or DDST-II; RBSK screens for the "4 Ds" — defects at birth, deficiencies, diseases, development delays including disability.
• Milestone anchors: 3 m neck holding, 5 m rolls over, 6 m sits with support/transfers objects, 8 m sits without support, 9 m stands holding, 12 m walks with support + pincer grasp + 1–2 words, 15 m walks alone + scribbles, 18 m runs + tower of 3–4 cubes, 2 y two-word sentences + up stairs, 3 y rides tricycle + knows name/age + copies circle, 4 y copies cross + hops, 5 y copies triangle + skips.

Nutrition: breastfeeding, complementary feeding and malnutrition

• Exclusive breastfeeding (EBF) for 6 months — nothing else, not even water (drops/syrups of vitamins and medicines allowed). Continue breastfeeding to 2 years and beyond.
• Initiation within 1 hour of birth (within 1 hour of caesarean once mother is alert). Colostrum (first 3–4 days, yellow, low volume) is rich in IgA, lactoferrin, vitamin A and leucocytes — never discarded.
• Human milk vs cow's milk: human milk has less protein (≈1.1 g/dL) but whey:casein ≈ 70:30 (easily digested), more lactose, lipase and LCPUFA (DHA/ARA), lower renal solute load; low in vitamin D, vitamin K and iron (iron is highly bioavailable, stores last ~6 months).
• Adequacy of breastfeeding: ≥6 wet nappies/day, weight gain ~25–30 g/day in early infancy, satisfied baby sleeping 2–3 h, audible swallowing. Not judged by breast fullness or crying alone.
• Complementary feeding starts at completed 6 months: thick, energy-dense, locally available food. Frequency: 2–3 times/day at 6–8 months, 3–4 times at 9–23 months, plus 1–2 snacks. Approximate energy from complementary food: 200 kcal/day (6–8 m), 300 (9–11 m), 550 (12–23 m).
• IYCF indicators: early initiation, EBF under 6 months, timely introduction of complementary foods, minimum dietary diversity (≥5 of 8 food groups), minimum meal frequency, minimum acceptable diet.
• Severe acute malnutrition (SAM), 6–59 months — any one of: weight-for-height < −3 SD, MUAC < 11.5 cm, or bilateral pitting pedal oedema. MAM: WFH −3 to −2 SD or MUAC 11.5–12.5 cm.
• Complicated SAM (needs inpatient care at a Nutrition Rehabilitation Centre/NRC): poor appetite on appetite test, oedema, hypothermia, hypoglycaemia, severe dehydration, shock, severe anaemia, lower respiratory infection, failed outpatient therapy, age <6 months.
• WHO 10 steps of SAM management (stabilisation days 1–2, transition 3–7, rehabilitation weeks 2–6): (1) treat/prevent hypoglycaemia, (2) hypothermia, (3) dehydration, (4) correct electrolytes, (5) treat infection, (6) correct micronutrients, (7) cautious feeding, (8) catch-up growth, (9) sensory stimulation, (10) prepare for follow-up.
• Feeds: F-75 (75 kcal/100 mL, low protein) in stabilisation; F-100 (100 kcal/100 mL) or RUTF in rehabilitation. ReSoMal (lower sodium, higher potassium) for dehydration in SAM, not standard ORS — except in cholera/profuse watery diarrhoea.
• Do NOT give iron in the stabilisation phase (free iron feeds bacteria and generates oxidant stress); start after appetite returns, usually from week 2. Vitamin A, folic acid, zinc, potassium and magnesium are given from the start; no added sodium.
• Micronutrient programmes: Vitamin A prophylaxis 1 lakh IU at 9 months with measles-rubella, then 2 lakh IU 6-monthly to 5 years (total 9 doses); IFA under Anaemia Mukt Bharat — IFA syrup 1 mL (20 mg elemental iron + 100 µg folic acid) twice weekly 6–59 months, pink IFA tablets weekly 5–9 years, blue tablets weekly 10–19 years; biannual albendazole (400 mg; 200 mg at 12–23 months) on National Deworming Day.
• Vitamin deficiencies: vitamin D → rickets (craniotabes, rachitic rosary, wrist widening, bow legs, raised ALP, low phosphate); vitamin A → night blindness, Bitot's spots, keratomalacia; vitamin C → scurvy (subperiosteal bleeds, pseudoparalysis); B1 → infantile beriberi; B12/folate → megaloblastic anaemia with developmental regression; zinc → acrodermatitis enteropathica.
• Law: the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992, amended 2003 (IMS Act) bans all advertising and promotion of infant milk substitutes, feeding bottles and foods for children under 2 years, including free samples to mothers and health workers.

Immunisation: schedule, cold chain and practice

• Types of vaccine: live attenuated (BCG, OPV, measles-rubella, rotavirus, JE live, varicella, MMR), killed/inactivated (IPV, whole-cell pertussis, typhoid Vi conjugate is subunit), toxoid (tetanus, diphtheria), subunit/conjugate (Hib, PCV, Hep B, HPV), mRNA/vector (COVID-19 vaccines).
• National Immunisation Schedule (UIP), infants and children:
  • Birth: BCG (0.05 mL intradermal left upper arm), OPV-0, Hepatitis B birth dose (within 24 h).
  • 6, 10, 14 weeks: Pentavalent (DPT + HepB + Hib) 0.5 mL IM antero-lateral thigh, OPV 1-2-3, Rotavirus vaccine (oral), fIPV 0.1 mL intradermal at 6 and 14 weeks, PCV at 6 and 14 weeks (booster at 9 months).
  • 9–12 months: Measles-Rubella (MR) 1st dose, JE-1 in endemic districts, Vitamin A 1st dose, PCV booster.
  • 16–24 months: MR 2nd dose, DPT booster-1, OPV booster, JE-2.
  • 5–6 years: DPT booster-2. 10 and 16 years: Td.
  • Pregnancy: Td at registration and 4 weeks later (single booster if vaccinated within 3 years).
• Optional/IAP-recommended but not in UIP: Hepatitis A, varicella, typhoid conjugate, influenza, MMR, HPV (HPV is being introduced for girls in a phased manner by some states and in the national programme roadmap — check the current operational guideline before quoting a schedule), meningococcal and cholera vaccines for risk groups.
• Cold chain: vaccines stored 2–8 °C in ILR; freezer compartment/−15 to −25 °C for OPV (and measles diluent never frozen). Never freeze: DPT, pentavalent, TT/Td, Hepatitis B, IPV, PCV, rotavirus (liquid) — freezing destroys adjuvanted vaccines. Diluent must be of the same manufacturer and cooled.
• Vaccine vial monitor (VVM): square-in-circle label. Usable while the inner square is lighter than the outer circle (stages 1 and 2); discard at stages 3 and 4. Shake test detects a frozen adjuvanted vaccine (sedimentation flocculates quickly in the frozen vial).
• Open vial policy: multi-dose vials of OPV, pentavalent, HepB, Td, IPV and fIPV may be used up to 28 days if VVM is usable, expiry not passed, septum not submerged and aseptically handled. Not applicable to reconstituted vaccines (BCG, MR, JE live) — discard within 4 hours.
• Contraindications are few: anaphylaxis to a previous dose, severe immunodeficiency/high-dose steroids or pregnancy for live vaccines, encephalopathy within 7 days of pertussis. Not contraindications: mild illness, low-grade fever, diarrhoea, malnutrition, antibiotics, breastfeeding, prematurity (vaccinate by chronological age), family history of seizures.
• AEFI (adverse event following immunisation) is classified as vaccine-product related, vaccine-quality defect, immunisation-error related, immunisation-anxiety related, or coincidental; serious AEFI must be reported and investigated under the national AEFI surveillance system.
• Programmes: UIP (1985), Pulse Polio (1995; India polio-free certified 2014), Mission Indradhanush/Intensified Mission Indradhanush for missed and partially immunised children, U-WIN digital immunisation registry, and MCP card as the household record. Immunisation is free at government facilities; a private-market pentavalent/PCV course can cost several thousand rupees per child, which is why UIP coverage matters.

Newborn care: normal, resuscitation and the sick neonate

• Definitions: neonate = 0–28 days (early 0–7, late 8–28); preterm <37 weeks, term 37–<42, post-term ≥42; low birth weight <2,500 g, very LBW <1,500 g, extremely LBW <1,000 g; SGA = birth weight <10th centile for gestation; perinatal period from 28 weeks gestation to 7 days after birth.
• Essential newborn care at birth: delivery-room warmth (25–28 °C, no draughts), dry and remove wet linen, delayed cord clamping (1–3 min if not asphyxiated), skin-to-skin contact, initiate breastfeeding within 1 h, clean chlorhexidine or dry cord care, vitamin K 1 mg IM (0.5 mg if <1,000 g) to prevent haemorrhagic disease, eye care, weighing, and identification.
• APGAR at 1 and 5 minutes: Appearance, Pulse, Grimace, Activity, Respiration (0–2 each). It is a measure of the newborn's condition and response, not the trigger for resuscitation and not a diagnosis of asphyxia.
• NSSK/NRP resuscitation steps: rapid assessment (term? breathing or crying? tone?) → warmth, position, clear airway if needed, dry, stimulate (the "golden minute") → if apnoeic or gasping or HR <100: positive pressure ventilation with bag and mask (room air for term, 21–30% O₂ for preterm), 40–60 breaths/min → if HR <60 after 30 s of effective ventilation: chest compressions 3:1 with ventilation (90 compressions + 30 breaths/min) → adrenaline 0.01–0.03 mg/kg IV (0.1–0.3 mL/kg of 1:10,000) → volume expansion with normal saline 10 mL/kg if hypovolaemic. Meconium-stained fluid with a non-vigorous baby: no routine intubation for suction — start PPV.
• Thermal care: normal axillary temperature 36.5–37.5 °C; cold stress 36.0–36.4, moderate hypothermia 32–35.9, severe <32. Warm chain 10 steps. Kangaroo mother care (KMC) — continuous skin-to-skin, upright, exclusive breast milk — for stable babies <2,000 g; reduces mortality, infection and hypothermia and is official national policy; "immediate KMC" is now recommended even before full stabilisation.
• Neonatal jaundice: physiological appears after 24 h, peaks day 3–5 (day 5–7 preterm), unconjugated, bilirubin usually <15 mg/dL, resolves by 2 weeks. Pathological red flags: onset <24 h, rise >0.5 mg/dL/hour or >5 mg/dL/day, total >15 mg/dL in term, conjugated fraction >2 mg/dL or >20% of total, jaundice beyond 2 weeks (3 weeks preterm), pale stools and dark urine (biliary atresia — urgent). Causes under 24 h: haemolysis (Rh and ABO incompatibility, G6PD deficiency). Treatment: phototherapy (400–500 nm blue light) and exchange transfusion by AAP/NNF hour-specific nomograms; kernicterus is the dreaded outcome of unconjugated bilirubin crossing the blood-brain barrier.
• Breast milk jaundice (late, prolonged, unconjugated, thriving baby, continue breastfeeding) vs breastfeeding/suboptimal-intake jaundice (first week, with weight loss and poor intake — fix the feeding).
• Danger signs (IMNCI "sick young infant"): not feeding well, convulsions, fast breathing ≥60/min, severe chest indrawing, movement only on stimulation or no movement, temperature ≥37.5 °C or <35.5 °C, umbilical redness extending to skin, more than 10 skin pustules, bulging fontanelle — any one = possible serious bacterial infection, refer urgently.
• Sepsis: early-onset (<72 h, vertical, maternal risk factors — PROM >18 h, maternal fever, foul liquor, >3 vaginal examinations) and late-onset (>72 h, nosocomial/community). Screen (CRP, micro-ESR, ANC, I:T ratio ≥0.2), blood culture is the gold standard; empiric therapy per unit antibiogram.
• Common transient conditions not to over-treat: physiological weight loss, Epstein pearls, milia, erythema toxicum, Mongolian spots, witch's milk, vaginal bleeding, pseudomenstruation, transient tachypnoea.
• Screening and newborn facilities: levels of care — home/delivery point (NBCC), NBSU at CHC, SNCU at district hospital, NICU at medical college; Home Based Newborn Care (HBNC) by ASHA on days 1/3/7/14/21/28 (and day 42 under HBYC); RBSK for birth defects; screening for congenital hypothyroidism, hearing (OAE/BERA) and critical congenital heart disease (pulse oximetry) where available.
• Breastfeeding laws and schemes relevant to newborn care: maternity benefit of 26 weeks for the first two children under the Maternity Benefit Act as amended (now carried into the Code on Social Security, 2020, in force with the Labour Codes from 21 November 2025), Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram (free delivery and newborn care including transport), and the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 banning sex determination.

Fluids, drugs and the paediatric prescription

• Dosing is by weight (mg/kg) or body surface area; never an adult fraction by guesswork. Always write the weight on the prescription.
• Maintenance fluids — Holliday-Segar: 100 mL/kg/day for the first 10 kg, 50 for the next 10, 20 for each kg above 20; isotonic fluid (normal saline or Ringer lactate, usually with 5% dextrose) is preferred over hypotonic to avoid hyponatraemia.
• Neonatal fluids start at 60–80 mL/kg/day on day 1 and increase ~15 mL/kg/day to 150 mL/kg/day, adjusted for weight loss, urine output and sodium.
• Dehydration (IMNCI/WHO): no dehydration → Plan A (home fluids + zinc); some dehydration → Plan B, ORS 75 mL/kg over 4 hours; severe → Plan C, Ringer lactate 100 mL/kg (infant <12 m: 30 mL/kg in 1 h then 70 mL/kg in 5 h; older: 30 mL/kg in 30 min then 70 mL/kg in 2½ h).
• Zinc 20 mg/day (10 mg if <6 months) for 14 days in every episode of diarrhoea — reduces duration and recurrence. Low-osmolarity ORS (245 mOsm/L) is the standard.
• Pneumonia (IMNCI): fast breathing cut-offs ≥60/min (<2 m), ≥50 (2–12 m), ≥40 (12 m–5 y); chest indrawing or any danger sign = severe pneumonia, refer; non-severe pneumonia — oral amoxicillin.
• Drugs to avoid in children: tetracyclines <8 years (teeth), fluoroquinolones routinely (cartilage concern), aspirin in viral fever (Reye syndrome), codeine, ceftriaxone with calcium in neonates, sulphonamides and chloramphenicol in neonates (kernicterus, grey baby syndrome).

Key points

• Z-score - deviation from the WHO median in SDs; < −2 abnormal, < −3 severe; the current standard, replacing percentage-of-expected classifications.
• Wasting vs stunting - wasting is low weight-for-height (acute, reversible); stunting is low height-for-age (chronic, largely irreversible after 2 years).
• MUAC < 11.5 cm - SAM in 6–59 months, independent of weight; 11.5–12.5 cm is MAM.
• SAM triad - WFH < −3 SD, MUAC < 11.5 cm, or bilateral pitting oedema; any one suffices.
• F-75 then F-100 - stabilisation feed then catch-up feed; no iron until the rehabilitation phase.
• ReSoMal - low-sodium, high-potassium rehydration fluid for SAM, not standard ORS (except cholera).
• EBF 6 months - breast milk only; complementary feeding from completed 6 months, breastfeeding to 2 years.
• Colostrum - IgA- and vitamin A-rich first milk; never discarded.
• IMS Act, 1992 (amended 2003) - total ban on promoting infant milk substitutes, bottles and foods for under-2s.
• UIP birth doses - BCG, OPV-0, Hepatitis B within 24 hours; fIPV intradermal at 6 and 14 weeks.
• Freeze only OPV - DPT, pentavalent, HepB, IPV, PCV, Td and rotavirus must never be frozen; shake test detects freezing.
• VVM stages 1–2 usable - discard when the inner square is as dark as or darker than the outer circle.
• Open vial policy 28 days - for specified multi-dose liquid vaccines; reconstituted BCG/MR/JE discard in 4 hours.
• Vitamin A - 1 lakh IU at 9 months, then 2 lakh IU 6-monthly to 5 years (9 doses total).
• Golden minute - dry, warm, position, stimulate within 60 s; start PPV if apnoeic/gasping or HR <100.
• 3:1 compressions - 90 compressions and 30 breaths per minute when HR <60 after effective ventilation.
• Jaundice on day 1 is always pathological - think haemolysis (Rh, ABO, G6PD); conjugated jaundice beyond 2 weeks = biliary atresia until excluded.
• KMC - continuous skin-to-skin for babies <2,000 g; national policy, proven mortality reduction.

Formulas and examples

Example 1 — classifying a malnourished child. A 24-month-old boy weighs 7.4 kg and is 78 cm long; MUAC 10.9 cm; no oedema.

• Expected weight at 2 years = (2 × 2) + 8 = 12 kg → weight-for-age = 7.4/12 = 61.7% → IAP grade II malnutrition (61–70%).
• Expected height at 2 years ≈ 87 cm → height-for-age = 78/87 = 89.7% → stunted.
• MUAC 10.9 cm < 11.5 cm → SAM by WHO/national criteria regardless of weight-for-age.
• Appetite test with RUTF: if he eats and has no complication → outpatient care; if he refuses → admit to NRC on the 10 steps.

Example 2 — F-75 prescription in stabilisation. Child weighs 7.4 kg (as above), admitted to an NRC.

• Stabilisation target 100 kcal/kg/day → 7.4 × 100 = 740 kcal/day.
• F-75 provides 75 kcal/100 mL → volume = 740 × 100/75 = 987 mL/day, say 990 mL.
• 12 feeds 2-hourly → 990/12 ≈ 82 mL per feed (standard tables give ~11 mL/kg per 2-hourly feed: 7.4 × 11 ≈ 81 mL — consistent).
• On transition to F-100 at 150 kcal/kg/day → 1,110 kcal → 1,110 mL of F-100/day ≈ 139 mL × 8 feeds 3-hourly.

Example 3 — maintenance fluid and drug dose. An 18 kg five-year-old with non-severe pneumonia, to be given amoxicillin 40 mg/kg/day in two divided doses and maintenance fluid.

• Fluid = 100 × 10 + 50 × 8 = 1,000 + 400 = 1,400 mL/day ≈ 58 mL/hour.
• Na⁺ at 3 mEq/kg/day = 54 mEq/day; a day's 1,400 mL of 0.9% NS would supply ~215 mEq, so isotonic fluid is used for resuscitation/short-term and the plan reviewed daily with electrolytes.
• Amoxicillin = 40 × 18 = 720 mg/day → 360 mg twice daily; using 250 mg/5 mL syrup = 7.2 mL per dose.
• BSA (Mosteller), height 110 cm: √(110 × 18/3600) = √0.55 = 0.74 m².

Example 4 — severe dehydration, Plan C. A 9-month-old weighing 8 kg with sunken eyes, lethargy and skin pinch going back very slowly.

• Severe dehydration, age <12 months → Ringer lactate 100 mL/kg = 800 mL.
• First 30 mL/kg = 240 mL over 1 hour; then 70 mL/kg = 560 mL over the next 5 hours.
• Reassess every 15–30 min; give ORS 5 mL/kg/hour as soon as the child can drink; zinc 10 mg/day (age <6 m is 10 mg; at 9 months give 20 mg/day) for 14 days; continue breastfeeding throughout.

Example 5 — corrected age and catch-up. A baby born at 30 weeks, now 6 months (26 weeks) old chronologically.

• Prematurity = 40 − 30 = 10 weeks → corrected age = 26 − 10 = 16 weeks ≈ 3.7 months.
• Assess milestones at ~4 months (neck holding, social smile), not 6 months, and plot growth on corrected age till 2 years.
• Immunise by chronological age — pentavalent/OPV/fIPV/PCV are due at 6, 10, 14 weeks after birth irrespective of prematurity.

Where it is used

• District hospitals and medical colleges: SNCU and NICU posts, NBSU at CHCs, paediatric OPD growth monitoring, NRC inpatient SAM management — the day-to-day work of a junior resident and medical officer.
• National Health Mission roles: RBSK mobile health teams (school and anganwadi screening), HBNC supervision of ASHAs, immunisation session planning and cold-chain audit, AEFI investigation committees — common entry jobs for MBBS graduates.
• ICDS/Poshan Abhiyaan and anganwadi systems: growth monitoring on the MCP card, take-home rations, Poshan Tracker data, village health and nutrition days — medical officers validate and train.
• Vaccine industry and medical affairs: Serum Institute of India, Bharat Biotech, Biological E, Panacea — clinical trial monitoring, pharmacovigilance/AEFI case processing, medical science liaison roles requiring exact schedule and cold-chain knowledge.
• Private paediatrics and corporate hospitals: well-baby clinics, lactation support, IAP-schedule immunisation counselling, developmental follow-up of preterm graduates.
• Public health and policy: state immunisation officers, UNICEF/WHO/NIPI consultants, NFHS and SRS data analysis, NNF/IAP guideline work and NSSK/FBNC/IMNCI training faculty.

Interview questions

• Q: How do you diagnose SAM in a 10-month-old in a field setting without a weighing scale? A: By MUAC < 11.5 cm or the presence of bilateral pitting pedal oedema — either alone establishes SAM.
• Q: Why is iron withheld in the stabilisation phase of SAM? A: Free iron is unbound by low transferrin, promotes bacterial growth and oxidative damage; it is started only after appetite returns in the rehabilitation phase.
• Q: Which vaccine in the UIP may be frozen, and why does freezing matter? A: Only OPV may be kept frozen; aluminium-adjuvanted vaccines (DPT, pentavalent, HepB, PCV, IPV, Td) lose potency irreversibly on freezing and are detected by the shake test.
• Q: A preterm baby born at 32 weeks is now 6 weeks old. When is pentavalent given? A: At 6 weeks chronological age — immunisation follows chronological, not corrected, age; growth and development are plotted on corrected age.
• Q: Is APGAR used to decide resuscitation? A: No. Resuscitation is decided within seconds by tone, breathing and heart rate; APGAR records the condition and the response at 1 and 5 minutes.
• Q: When is neonatal jaundice always pathological? A: When it appears within 24 hours of birth, rises faster than 5 mg/dL/day, is conjugated, or persists beyond 2 weeks in a term baby.
• Q: Differentiate breast milk jaundice from breastfeeding jaundice. A: Breastfeeding (suboptimal-intake) jaundice occurs in the first week with poor intake and weight loss and is corrected by better feeding; breast milk jaundice is later, prolonged, unconjugated, in a thriving baby, and breastfeeding is continued.
• Q: Why are WHO 2006 standards called "standards" and not "references"? A: They are prescriptive — derived from healthy, breastfed children raised in optimal conditions across six countries including India — so they describe how children should grow, not how a given population happens to grow.
• Q: What does the open vial policy not apply to? A: Reconstituted vaccines — BCG, measles-rubella and live JE — which must be discarded within 4 hours of reconstitution.
• Q: A mother asks for formula because "milk is not enough" on day 2. What do you check? A: Attachment and positioning, frequency of feeds, wet nappies and weight loss; colostrum is low in volume but sufficient, and the IMS Act bars promoting substitutes.
• Q: What are the IMNCI fast-breathing cut-offs? A: ≥60/min under 2 months, ≥50/min from 2–12 months, ≥40/min from 12 months to 5 years.
• Q: Which fluid for severe dehydration in a child with SAM? A: ReSoMal orally/by nasogastric tube for dehydration in SAM; intravenous fluid only for shock, cautiously, because of the risk of heart failure — standard high-volume Plan C is avoided.

Common mistakes

• Using the adult or an old percentage-of-expected classification when the question expects WHO Z-scores, or quoting BMI adult cut-offs for a 10-year-old instead of IAP 2015 charts.
• Measuring height standing in a child under 2 years (must be recumbent length) or MUAC on the right arm or over clothing.
• Giving standard ORS and iron early in SAM, or full Plan C intravenous volumes to a child with SAM.
• Treating mild fever, diarrhoea, malnutrition or antibiotic use as contraindications to immunisation, and so creating a partially immunised child.
• Plotting a preterm baby's growth on chronological age, or conversely delaying vaccines to corrected age.
• Calling day-1 jaundice physiological, or reassuring a 3-week-old with pale stools instead of investigating biliary atresia urgently.
• Starting chest compressions before 30 seconds of effective ventilation has been given, or using high oxygen concentration routinely in term newborn resuscitation.

Related topics

Obstetrics: antenatal care, labour and complications · Community medicine: national health programmes and vital statistics · Paediatric infectious diseases and IMNCI · Nutrition and micronutrient deficiencies · Neonatal resuscitation and NSSK training · Growth, puberty and adolescent health