1. Lesions & Cause: Angular cheilitis / stomatitis and glossitis due to Riboflavin (Vitamin ${\text{B}}_2$) deficiency.
2. Other clinical features: Nasolabial dyssebacea (seborrheic dermatitis), magenta tongue, interstitial keratitis, photophobia, excessive lacrimation, corneal vascularization, normocytic normochromic anemia.
3. Confirmatory tests:
   • Erythrocyte glutathione reductase activity coefficient (EGRAC) ($>1.4$ indicates deficiency)
   • Urinary excretion of riboflavin ($<30\mu \text{g/day}$).
4. Treatment: Oral riboflavin $3\text{--}10\text{ mg/day}$ until complete recovery.

Nutrient	Daily Requirement
Vitamin A	$400\text{--}500\mu \text{g}$ ($1330\text{--}1650\text{ IU}$)
Folate	$50\text{--}150\mu \text{g}$
Vitamin ${\text{B}}_{12}$	$0.5\text{--}1.0\mu \text{g}$
Biotin	$20\mu \text{g}$
Riboflavin (${\text{B}}_2$)	$0.5\text{--}1.5\text{ mg}$
Vitamin E	$5\text{--}15\text{ IU}$
Niacin (${\text{B}}_3$)	$5\text{--}15\text{ mg}$
Thiamine (${\text{B}}_1$)	$0.5\text{--}1.5\text{ mg}$
Ascorbic acid (Vitamin C)	$40\text{--}50\text{ mg}$
Vitamin D	$400\text{ IU}$ ($10\mu \text{g}$)

Food Item ($100\text{ g}$)	Energy (kcal)	Protein (g)
Rice	$\approx 350\text{ kcal}$	$7\text{ g}$
Bengal gram	$\approx 360\text{ kcal}$	$17\text{ g}$
Groundnut	$\approx 560\text{ kcal}$	$25\text{ g}$
Fish	$\approx 80\text{ kcal}$	$6\text{--}15\text{ g}$
Egg (2 medium eggs)	$\approx 160\text{ kcal}$ ($80\text{ kcal}$/egg)	$12\text{--}13\text{ g}$ ($6\text{ g}$/egg)
Dates	$\approx 317\text{ kcal}$	$2.5\text{ g}$
Apple	$\approx 59\text{ kcal}$	$0.2\text{ g}$
Almond	$\approx 655\text{ kcal}$	$20\text{ g}$

1. WHO-ORS vs ReSoMal Composition:
   • Sodium: WHO-ORS $=75\text{ mmol/L}$ vs ReSoMal $=45\text{ mmol/L}$
   • Potassium: WHO-ORS $=20\text{ mmol/L}$ vs ReSoMal $=40\text{ mmol/L}$
   • Glucose: WHO-ORS $=75\text{ mmol/L}$ vs ReSoMal $=125\text{ mmol/L}$
   • Osmolarity: WHO-ORS $=245\text{ mOsm/L}$ vs ReSoMal $=300\text{ mOsm/L}$
2. Nutritional content:
   • One chapatti / one bread slice $=70\text{ kcal}$ and $2\text{ g}$ protein
   • One egg $=80\text{ kcal}$ and $6\text{ g}$ protein
   • One tsp mashed potato $=40\text{ kcal}$ and $0\text{ g}$ protein
3. Fill in the blanks:
   • Dextrose content of 1 liter Ringer's Lactate $=\mathbf{0}\text{ g}$ (zero)
   • ${\text{Na}}^{+}$ content of $1\text{ mL}$ of $3\mathrm{\%}\text{NaCl}=\mathbf{0.513}\text{ mEq}$ ($\approx 0.5\text{ mEq}$)
   • Elemental Calcium in $1\text{ mL}$ of $10\mathrm{\%}$ calcium gluconate $=\mathbf{9.3}\text{ mg}$ ($\approx 9\text{ mg}$ or $0.465\text{ mEq}$)
   • ${\text{K}}^{+}$ content of 1 liter of Isolyte-P $=\mathbf{20}\text{ mEq/L}$

1. National Prophylaxis Schedule (total 9 doses from 9 months to 5 years):
   • 1st dose: $100,000\text{ IU}$ ($1\text{ lakh IU}$) orally at 9 months of age (along with measles/MR vaccine)
   • 2nd to 9th doses: $200,000\text{ IU}$ ($2\text{ lakh IU}$) orally every 6 months up to 5 years of age.
2. Daily requirement: $400\text{--}600\mu \text{g}$ retinol ($1330\text{--}2000\text{ IU}$).
3. Manifestations of Hypervitaminosis A:
   • Acute: Increased intracranial pressure (pseudotumor cerebri, bulging fontanelle), vomiting, irritability, headache.
   • Chronic: Cortical hyperostosis/bone pain, dry scaly skin, alopecia, hepatomegaly, anorexia.

• 1 - B: Chronic renal failure (High Pi, Low $1,25(\text{OH}{)}_2\text{D}$, High PTH, Low/Normal Ca)
• 2 - F: Fanconi syndrome (Normal Ca, Low Pi due to renal wasting, Normal PTH, High ALP)
• 3 - E: X-linked Hypophosphatemic rickets (Normal Ca, Low Pi, Normal PTH, Low/inappropriately Normal $1,25(\text{OH}{)}_2\text{D}$)
• 4 - A: Vitamin D-Dependent Rickets Type 1 (Low $1,25(\text{OH}{)}_2\text{D}$ due to $1\alpha$-hydroxylase defect)
• 5 - C: Vitamin D-Dependent Rickets Type 2 (Markedly elevated $1,25(\text{OH}{)}_2\text{D}$ due to end-organ receptor resistance)
• 6 - D: Nutritional Vitamin D Deficiency (Low/Normal Ca, Low Pi, High PTH, Variable $1,25(\text{OH}{)}_2\text{D}$, Low $25(\text{OH})\text{D}$)

1. Diagnosis: Severe Vitamin A Deficiency (Xerophthalmia) with Bitot's spot / keratomalacia in a child with severe acute malnutrition.
2. WHO Staging of Xerophthalmia:
   • XN: Night blindness
   • X1A: Conjunctival xerosis
   • X1B: Bitot's spots (triangular, pearly-white foamy plaques on bulbar conjunctiva)
   • X2: Corneal xerosis
   • X3A: Corneal ulceration / keratomalacia involving $<1/3$ of cornea
   • X3B: Corneal ulceration / keratomalacia involving $\ge 1/3$ of cornea
   • XS: Corneal scars (secondary to healed keratomalacia)
   • XF: Xerophthalmic fundus
   • This child presents in stage X1B (Bitot's spot) progressing to corneal involvement.

1. Nutrient content per sachet ($1\text{ g}$ or $2\text{ g}$) of HMF:
   • Protein: $0.22\text{ g}$
   • Fat: $0.1\text{ g}$
   • Sodium: $1.5\text{ mg}$
   • Calcium: $50\text{ mg}$
   • Vitamin D: $250\text{ IU}$
   • Thiamine (${\text{B}}_1$): $12\mu \text{g}$
   • Vitamin ${\text{B}}_{12}$: $0.05\mu \text{g}$
   • Zinc: $0.18\text{ mg}$
2. Protein Quality Indices:
   • Egg: $\text{BV}=96\mathrm{\%}$, $\text{NPU}=96\mathrm{\%}$, $\text{PER}=3.8$ (Reference protein)
   • Meat: $\text{BV}=74\mathrm{\%}$, $\text{NPU}=76\mathrm{\%}$, $\text{PER}=3.2$
   • Bengal gram: $\text{BV}=74\mathrm{\%}$, $\text{NPU}=61\mathrm{\%}$, $\text{PER}=1.3$
   • Wheat: $\text{BV}=66\mathrm{\%}$, $\text{NPU}=61\mathrm{\%}$, $\text{PER}=1.3$

1. Diagnosis: X-Linked Hypophosphatemic Rickets (XLH) (Familial hypophosphatemic rickets / Vitamin D-resistant rickets).
2. Inheritance: X-linked dominant.
3. Gene mutation: Mutation in the PHEX gene (Phosphate-regulating endopeptidase homolog, X-linked) on chromosome Xp22.1 $\to$ elevated fibroblast growth factor 23 (FGF-23).
4. Treatment:
   • Oral phosphate supplements ($1\text{--}4\text{ g/day}$ in 4–5 divided doses)
   • Active vitamin D: Calcitriol ($20\text{--}40\text{ ng/kg/day}$ or $0.25\text{--}2\mu \text{g/day}$) or Alfacalcidol ($25\text{--}50\text{ ng/kg/day}$)
   • Novel targeted therapy: Burosumab (anti-FGF-23 monoclonal antibody).
5. Four endocrinal causes of short stature:
   • Growth hormone deficiency (isolated GHD or panhypopituitarism)
   • Hypothyroidism (cretinism / juvenile hypothyroidism)
   • Cushing syndrome (hypercortisolemia)
   • Poorly controlled Diabetes Mellitus (Mauriac syndrome) / Pseudohypoparathyroidism.

1. Name: Trivandrum Development Screening Chart (TDSC).
2. Uses & Age: Simple community-based screening tool for rapid assessment of developmental delay in children from 0 to 24 months (or TDSC 0–6 years).
3. How to use: A vertical line (or pencil) is placed vertically at the exact chronological age (or corrected age for preterms) of the child. If the child fails to perform any milestone that lies to the left of the vertical line, the child is flagged for developmental delay.
4. Other tools:
   • Denver Developmental Screening Test (DDST / Denver II)
   • Developmental Assessment Scales for Indian Infants (DASII)
   • Baroda Development Screening Test (DST)
   • Bayley Scales of Infant and Toddler Development (BSID).

1. Mosteller's Formula:
   ${\text{BSA (m}}^2\text{)}=\sqrt{\frac{\text{Height (cm)}\times \text{Weight (kg)}}{3600}}$
2. Prednisone dose calculation:
   • $\text{BSA}=\sqrt{\frac{80\times 12}{3600}}=\sqrt{\frac{960}{3600}}=\sqrt{0.2667}\approx 0.516{\text{ m}}^2\approx 0.52{\text{ m}}^2$
   • Dose ($40{\text{ mg/m}}^2$) $=0.52\times 40\approx \mathbf{20}\text{ mg}$ as a single alternate-day dose.
3. Half-normal saline ($0.45\mathrm{\%}\text{NaCl}$): Contains $77\text{ mEq/L}$ of ${\text{Na}}^{+}$, $0\text{ mEq/L}$ of bicarbonate, and $0\text{ kcal/L}$.
4. $50\mathrm{\%}$ Glucose: Contains $0.5\text{ g/mL}$ ($50\text{ g}/100\text{ mL}$).
5. $10\mathrm{\%}$ Calcium gluconate: Contains $0.465\text{ mEq/mL}$ ($\approx 9.3\text{ mg/mL}$) of elemental calcium.
6. $20\mathrm{\%}$ Mannitol: Contains $0\text{ mEq/L}$ of ${\text{Na}}^{+}$, $0\text{ mEq/L}$ of ${\text{HCO}}_3^{-}$, and $0\text{ kcal/L}$.

1. Age categorization:
   • Young infants: 0 to 2 months (birth up to 2 months)
   • Older infants and children: 2 months up to 5 years.
2. Color codes:
   • Pink: Urgent pre-referral treatment and emergency hospital referral.
   • Yellow: Specific medical treatment and advice at primary health facility.
   • Green: Home management, counseling on feeding/fluids, and home care.
3. Six steps of IMNCI case management:
   • Step 1: Assess the young infant / child
   • Step 2: Classify the illness (using color-coded triage)
   • Step 3: Identify specific treatment
   • Step 4: Treat the child (administer pre-referral or clinic drugs)
   • Step 5: Counsel the mother (feeding, fluids, when to return immediately)
   • Step 6: Provide follow-up care.
4. Advice for "Some Palmar Pallor" (classified as Anemia):
   • Give oral iron and folic acid (IFA) daily for 14 days
   • Give age-appropriate deworming (Albendazole if child $\ge 12$ months and not given in past 6 months)
   • Counsel mother on iron-rich complementary feeding
   • Advise follow-up in 14 days.

• i - c: Bile salt-stimulated lipase (BSSL) $\to$ Kills Amoeba and Giardia trophozoites
• ii - d: Low PABA in human milk $\to$ Protects against malaria
• iii - e: Bifidus factor $\to$ Promotes growth of Lactobacillus bifidus (acidifies gut)
• iv - a: Lactoferrin $\to$ Chelation of iron, inhibiting E. coli
• v - b: Human $\beta$-casomorphin $\to$ CNS development and mucosal protection

Part A:

• 1 - c: Ujjawala Scheme $\to$ Prevention of trafficking and rescue/rehabilitation
• 2 - d: Sharda Act $\to$ Prevention of child marriage
• 3 - e: Kishori Shakti Yojana $\to$ Adolescent girl health and empowerment
• 4 - b: ASHA $\to$ National Rural Health Mission (NRHM)
• 5 - a: Vande Mataram Scheme $\to$ Safe Motherhood Services / Antenatal care

Part B:

• i - e: Copper $\to$ Refractory anemia, neutropenia, sensory ataxia
• ii - c: Selenium $\to$ Cardiomyopathy (Keshan disease)
• iii - a: Chromium $\to$ Hyperglycemia / insulin resistance
• iv - b: Molybdenum $\to$ Central scotoma / lens dislocation / encephalopathy
• v - d: Manganese $\to$ Reddening of hair / bone changes

1. Diagnosis: Acrodermatitis Enteropathica (congenital zinc malabsorption triggered upon weaning from breast milk to cow's milk).
2. Mode of inheritance: Autosomal recessive (mutation in SLC39A4 gene encoding ZIP4 zinc transporter).
3. Confirmatory laboratory investigation: Low plasma zinc level ($<70\mu \text{g/dL}$), low serum alkaline phosphatase (a zinc-dependent metalloenzyme).
4. Treatment: Lifelong oral zinc supplementation: $1\text{--}3\text{ mg/kg/day}$ of elemental zinc (as zinc sulfate, acetate, or gluconate). Rapid clinical resolution occurs within days.

1. Diagnosis: Infantile Tremor Syndrome (Nutritional Tremor Syndrome).
2. Investigations:
   • Peripheral blood smear: Megaloblastic anemia (macrocytosis, hypersegmented neutrophils) and/or dimorphic anemia.
   • CT Head: Reversible cerebral/cortical atrophy with prominent sulci and ventriculomegaly.
3. Liver biopsy findings: Diffuse fatty changes (hepatic steatosis).
4. Treatment:
   • Vitamin ${\text{B}}_{12}$ (Cobalamin) $100\text{--}1000\mu \text{g}$ IM daily/alternate day, plus Folic acid ($1\text{--}5\text{ mg/day}$) and Iron.
   • For control of tremors: Carbamazepine ($10\text{--}20\text{ mg/kg/day}$) or Propranolol ($1\text{--}2\text{ mg/kg/day}$) or Phenobarbital.
   • Adequate protein-calorie diet.

1. Anthropometric Indices:
   • Kanawati & McLaren Index:
     $\frac{\text{MUAC (cm)}}{\text{Head Circumference (cm)}}=\frac{8.5}{40}=\mathbf{0.21}$
     (Normal $>0.31$; $<0.25$ indicates severe PEM).
   • Rao's Weight-for-Height Index:
     $\frac{\text{Weight (kg)}}{{\text{Length (cm)}}^2}\times 100=\frac{5.5}{72\times 72}\times 100=\frac{550}{5184}=\mathbf{0.106}$
     (Normal $0.14\text{--}0.16$; $<0.14$ indicates severe wasting/PEM).
   • Shakir's MUAC measure: $8.5\text{ cm}$ ($<11.5\text{ cm}$ indicates Severe Acute Malnutrition [SAM]).
   • Impression: All three indices confirm Severe Acute Malnutrition (Severe PEM).
2. Indications for inpatient admission in SAM:
   • Age $<6$ months or weight $<4\text{ kg}$
   • Severe bilateral pitting edema (kwashiorkor Grade +++)
   • Failed appetite test / unable to feed
   • High fever or hypothermia ($<{35}^{\circ }\text{C}$)
   • Severe dehydration, shock, or severe electrolyte imbalance (e.g., ${\text{Na}}^{+}<120\text{ mEq/L}$)
   • Severe anemia ($\text{Hb}<4\text{ g/dL}$ or $<6\text{ g/dL}$ with respiratory distress)
   • Hypoglycemia, severe infection (pneumonia, sepsis, meningitis), or severe lethargy/coma.

1. Clinical disorder: Kwashiorkor (edematous protein-energy malnutrition with "flaky paint" dermatosis, moon facies, and flag sign of hair).
2. Essential diagnostic triad:
   • Retarded physical growth (stunting/wasting)
   • Psychomotor changes (apathy, irritability, misery)
   • Generalized bilateral pitting edema.
3. Etiological Hypotheses in PEM:
   • Classical energy-protein theory: Marasmus $=$ Energy deficiency $>$ Protein deficiency; Kwashiorkor $=$ Severe protein deficiency with relatively preserved carbohydrate intake.
   • Gopalan's Dys-adaptation theory: Failure of hormonal adaptation (failure of adrenal cortisol rise causing loss of lean mass protection $\to$ kwashiorkor).
   • Golden's Free Radical / Oxidative Stress theory: Deficiency of dietary antioxidants (glutathione, zinc, selenium, vitamins A/E/C) causing free radical tissue damage and edema.
4. ReSoMal Differences from standard WHO-ORS:
   • Lower sodium concentration ($45\text{ mmol/L}$ vs $75\text{ mmol/L}$)
   • Higher potassium concentration ($40\text{ mmol/L}$ vs $20\text{ mmol/L}$)
   • Higher glucose concentration ($125\text{ mmol/L}$ vs $75\text{ mmol/L}$)
   • Added minerals: Magnesium ($3\text{ mmol/L}$), Zinc ($300\mu \text{mol/L}$), and Copper ($45\mu \text{mol/L}$).

1. Nutritional values:
   • One chapatti / bread slice: $70\text{ kcal}$ and $2\text{ g}$ protein
   • One biscuit: $20\text{ kcal}$ and $0.5\text{ g}$ protein
   • One whole egg: $80\text{ kcal}$ and $6\text{ g}$ protein
   • One tsp mashed potato: $40\text{ kcal}$ and $0\text{ g}$ protein
   • One tbsp cooked dal: $20\text{--}30\text{ kcal}$ and $1\text{--}1.5\text{ g}$ protein (or 1 tsp $=10\text{ kcal}$ and $0.5\text{ g}$ protein).
2. Numerical answers:
   • Dextrose in 1 L Ringer's Lactate: $0\text{ g}$
   • ${\text{Na}}^{+}$ in $1\text{ mL}$ of $3\mathrm{\%}\text{NaCl}$: $0.513\text{ mEq}$ ($\approx 0.5\text{ mEq}$)
   • ${\text{Na}}^{+}$ in $1\text{ mL}$ of $0.9\mathrm{\%}\text{NaCl}$: $0.154\text{ mEq}$ ($\approx 0.15\text{ mEq}$)
   • Elemental Calcium in $1\text{ mL}$ of $10\mathrm{\%}$ calcium gluconate: $9.3\text{ mg}$ ($0.465\text{ mEq}$)
   • ${\text{K}}^{+}$ in 1 L Isolyte-P: $20\text{ mEq/L}$.

1. Five Radiological Findings:
   • Ground-glass osteoporosis (demineralization of shaft) with pencil-thin cortex
   • White line of Fraenkel (dense, irregular zone of provisional calcification at metaphysis)
   • Pelkan spurs (lateral metaphyseal boney spurs)
   • Trümmerfeld zone (scorbutic zone of rarefaction/radiolucency underneath the white line)
   • Wimberger's sign (thin, dense calcified ring surrounding a radiolucent center in epiphyses)
   • Subperiosteal hemorrhage and calcification.
2. Diagnosis & Management:
   • Diagnosis: Infantile Scurvy (Vitamin C / Ascorbic Acid Deficiency).
   • Management: Oral or parenteral Vitamin C (Ascorbic acid) $100\text{--}200\text{ mg/day}$ (up to $500\text{ mg/day}$ in divided doses) for 1–2 weeks followed by daily dietary maintenance and citrus fruits.

1. Nutritional status (Expected 1-year weight $\approx 10\text{ kg}$, expected length $\approx 75\text{ cm}$; Expected weight for $70\text{ cm}\approx 8.5\text{ kg}$):
   • $\mathrm{\%}\text{Weight-for-Age}=\frac{6.4}{10}\times 100=64\mathrm{\%}$
   • a. IAP Classification: Grade II PEM ($61\text{--}70\mathrm{\%}$).
   • b. Wellcome Classification: Undernutrition ($60\text{--}80\mathrm{\%}$ without edema).
   • c. Gomez Classification: Grade II (Moderate) Malnutrition ($60\text{--}75\mathrm{\%}$).
   • d. Waterlow Classification:
     • Weight-for-Height: $\frac{6.4}{8.5}\times 100\approx 75.3\mathrm{\%}$ $\to$ Grade II Wasting ($70\text{--}80\mathrm{\%}$)
     • Height-for-Age: $\frac{70}{75}\times 100\approx 93.3\mathrm{\%}$ $\to$ Grade I Stunting ($90\text{--}95\mathrm{\%}$).
2. Classification Schemes:
   • Gomez Classification (Weight-for-Age % of 50th percentile):
     • $>90\mathrm{\%}$: Normal
     • $75\text{--}90\mathrm{\%}$: Grade I (Mild)
     • $60\text{--}74\mathrm{\%}$: Grade II (Moderate)
     • $<60\mathrm{\%}$: Grade III (Severe).
   • Waterlow Classification:
     • Stunting (Height-for-Age): $>95\mathrm{\%}$ Normal, $90\text{--}95\mathrm{\%}$ Grade I, $85\text{--}89\mathrm{\%}$ Grade II, $<85\mathrm{\%}$ Grade III.
     • Wasting (Weight-for-Height): $>90\mathrm{\%}$ Normal, $80\text{--}90\mathrm{\%}$ Grade I, $70\text{--}79\mathrm{\%}$ Grade II, $<70\mathrm{\%}$ Grade III.

1. Lactose intolerance: (a) Food intolerance (enzymatic lactase deficiency)
2. Abdominal migraine: (a) Food intolerance (pharmacological/dietary amines)
3. Urticaria: (b) Food hypersensitivity (IgE-mediated)
4. Heiner syndrome: (b) Food hypersensitivity (non-IgE cow's milk pulmonary hypersensitivity)
5. Celiac disease: (b) Food hypersensitivity (cell-mediated/immune-mediated enteropathy to gluten)
6. Irritable bowel syndrome: (a) Food intolerance (functional/non-immunologic).

1. Allergen matches:
   • a - 4: Cow's milk $\to$ Casein (and $\beta$-lactoglobulin)
   • b - 3: Egg $\to$ Ovomucoid (and ovalbumin)
   • c - 2: Peanut $\to$ Vicilin (Ara h 1, Ara h 2, Ara h 3)
   • d - 1: Fish $\to$ Parvalbumin (Gad m 1).
2. Age of introduction:
   • a. Whole cow's milk: After 1 year (12 months) of age as main drink.
   • b. Egg: Around 6 months (once complementary feeds start; well-cooked).
   • c. Peanut / Seafood: Around 6 months (early introduction between 4–11 months prevents food allergy in high-risk infants).

1. Case 1:
   • a. Diagnosis: X-Linked Hypophosphatemic Rickets (Familial hypophosphatemia / Vitamin D-resistant rickets).
   • b. Inheritance: X-linked dominant.
   • c. First clinical manifestation: Progressive bowing deformity of lower extremities (genu varum/valgum) and waddling gait upon onset of weight-bearing.
2. Case 2:
   • a. Diagnosis: Vitamin D-Dependent Rickets Type 2 (VDDR-II / Hereditary 1,25-dihydroxyvitamin D-resistant rickets) with alopecia.
   • b. Inheritance: Autosomal recessive (mutations in Vitamin D Receptor [VDR] gene).
   • c. Treatment: High-dose oral Calcitriol ($1,25(\text{OH}{)}_2{\text{D}}_3$) ($5\text{--}60\mu \text{g/day}$) plus high-dose oral or intravenous Calcium infusions ($1\text{--}3\text{ g/day}$ elemental calcium).

1. Manifestations in preterms: Hemolytic anemia, thrombocytosis, peripheral edema, retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH), spinocerebellar ataxia.
2. Chemical property: Antioxidant (lipid-soluble free radical scavenger preventing lipid peroxidation of polyunsaturated fatty acids in cell membranes).
3. Daily requirement in preterms: $5\text{--}25\text{ IU/day}$ (or $0.7\text{ IU}/100\text{ kcal}$).
4. Diagnostic ratio: Serum $\alpha$-tocopherol to total serum lipid ratio $<\mathbf{0.8}\text{ mg/g}$.
5. Concentration: Evion / standard solution contains $50\text{ IU/mL}$ (or $50\text{--}100\text{ mg/mL}$).

1. Diagnosis: Nutritional Rickets.
2. Most likely etiology: Vitamin D deficiency (inadequate sunlight exposure, exclusive unsupplemented breastfeeding).
3. Earliest clinical sign: Craniotabes (ping-pong ball sensation on palpation of parietal/occipital bones, present in infants $<3\text{--}6$ months).
4. First radiological healing sign: Appearance of the dense provisional zone of calcification in the submetaphyseal radiolucent zone.
5. Prevention: Routine oral Vitamin D supplementation: $400\text{ IU/day}$ starting from birth for all breastfed infants.
6. Non-specific urinary findings (secondary to secondary hyperparathyroidism):
   • Generalized aminoaciduria
   • Phosphaturia (decreased tubular reabsorption of phosphate)
   • Hypercitraturia
   • Renal tubular acidosis / impaired renal acidification.

1. Cow's milk feeding: Iron deficiency anemia (and occult GI blood loss).
2. Goat's milk feeding: Folic acid (folate) deficiency (megaloblastic anemia).
3. Prolonged exclusive breastfeeding: Iron deficiency (and Vitamin D deficiency).

1. Severe Vitamin D deficiency: $<\mathbf{5}\text{ ng/mL}$ (or $<10\text{ ng/mL}$; insufficiency $=12\text{--}20\text{ ng/mL}$; sufficiency $>20\text{ ng/mL}$).
2. Toxicity threshold: $>\mathbf{100}\text{--}\mathbf{150}\text{ ng/mL}$ (with hypercalcemia/hypercalciuria).
3. Equivalence: $1\mu \text{g}=\mathbf{40}\text{ IU}$ ($400\text{ IU}=10\mu \text{g}$).
4. Calcium therapy: Oral elemental calcium $30\text{--}75\text{ mg/kg/day}$ in 3 divided doses for 1–2 weeks, then halved and continued until PTH and Vitamin D normalize.
5. Sequence of normalization:
   • 1st: Serum Phosphorus (normalizes within 72–96 hours)
   • 2nd: Serum Calcium
   • 3rd: Serum PTH
   • 4th (Last): Serum Alkaline Phosphatase (ALP) (takes several weeks to months to normalize; reliable marker of complete healing).

1. 5 years (60 months): Ties shoelaces, differentiates morning vs afternoon.
2. 4 years (48 months): Buttons clothes, identifies longer of two lines.
3. 3 years (36 months): Tower of 9 cubes, unbuttons clothes.
4. 2 years (24 months): Picks up ball without falling, uses 'I', 'Me', 'You'.
5. 15 months: Kneels without support, removes shoes/socks.

1. Diagnosis: Chronic Lead Poisoning (Plumbism) (radiographs show dense metaphyseal "lead lines" at knees and wrists).
2. Treatment / Chelation options:
   • Remove from lead exposure source.
   • Dimercaptosuccinic acid (DMSA / Succimer): Oral drug of choice for moderate toxicity.
   • ${\text{CaNa}}_2\text{EDTA}$ (Calcium Disodium Edetate) IV/IM.
   • BAL (Dimercaprol): Used in conjunction with ${\text{CaNa}}_2\text{EDTA}$ for severe lead encephalopathy.
3. Indication for chelation: Blood Lead Level (BLL) $\ge 45\mu \text{g/dL}$ (normal reference level $<3.5\text{--}5\mu \text{g/dL}$).
4. Urine investigation: Increased urinary $\delta$-aminolevulinic acid ($\delta$-ALA), elevated coproporphyrin, and elevated blood/urine Zinc Protoporphyrin (ZPP).

1. Hyderabad Mix (per $100\text{ g}$):
   • Ingredients: Whole wheat ($40\text{ g}$), Bengal gram ($16\text{ g}$), Groundnut ($10\text{ g}$), Jaggery ($20\text{ g}$)
   • Nutritional value: $\approx 330\text{ kcal}$ and $11.3\text{ g}$ protein per $86\text{ g}$ ($\approx 380\text{ kcal}$ and $13\text{ g}$ protein per $100\text{ g}$).
2. Shakti Ahar (per $100\text{ g}$):
   • Ingredients: Roasted wheat ($40\text{ g}$), Roasted Bengal gram ($20\text{ g}$), Roasted peanuts ($10\text{ g}$), Jaggery ($30\text{ g}$)
   • Nutritional value: $\mathbf{390}\text{ kcal}$ and $\mathbf{11.4}\text{ g}$ protein per $100\text{ g}$.

1. Gross Motor: Walks with one hand held; stands independently for a few seconds; rises to standing independently.
2. Fine Motor / Adaptive: Releases object to another person on request; neat pincer grasp (picks pellet with tip of index and thumb).
3. Language: 1 to 2 meaningful words with meaning besides 'mama' and 'dada'; jabbers with intonation.
4. Personal-Social: Plays simple interactive games (e.g., 'peek-a-boo', ball rolling); assists with dressing by extending arm or leg; waves bye-bye.

1. 5 years (60 months): Copies triangle ($5\text{ yrs}$), square ($4\text{ yrs}$), diamond ($6\text{ yrs}$).
2. 12 months (1 year): Cruising, standing alone, fine pincer grasp.
3. 3 years (36 months): Copies circle, tower of 9 cubes, climbs stairs alternating feet.
4. 9 months (or 7–9 months): Sits unsupported, transfers objects hand-to-hand, babbles.

1. Child A:
   • a. Developmental age: 24 months (2 years) (or 30 months).
   • b. Adaptive milestones: Builds tower of 6–7 cubes; imitates vertical and circular strokes; dumps pellet from bottle by imitation.
2. Child B:
   • a. Developmental age: 48 months (4 years).
   • b. Motor milestones: Hops on one foot; throws ball overhand; catches bounced ball; climbs ladders skillfully.

1. Language Red Flags at 2 Years (24 months):
   • No spoken single words by 15–18 months
   • No 2-word spontaneous meaningful phrases/combinations by 24 months
   • Inability to follow simple 1-step verbal commands without gestures
   • Speech unintelligible to parents by 24–36 months
   • Avoidance of eye contact or vocal/verbal communication
   • Any regression or loss of previously acquired language or social milestones.
2. Developmental Age: 4 months (Hand regard appears at 3–4 months; hands brought to midline and reaching for objects occurs at 4 months).

1. Diagnosis: Active Nutritional Rickets (Wrist radiograph).
2. Three radiological features:
   • Cupping of the distal metaphysis (concave distal margin)
   • Flaring / widening of the metaphyseal ends
   • Fraying (brush-like, irregular margins of the provisional zone of calcification)
   • Increased distance between the distal metaphysis and epiphysis.
3. Biochemical tests:
   • Serum Calcium (normal or low), Serum Phosphorus (low), Serum Alkaline Phosphatase (markedly elevated)
   • Serum $25(\text{OH})\text{D}$ (low, $<20\text{ ng/mL}$), Serum PTH (elevated).
4. Treatment:
   • Stoss therapy: Vitamin ${\text{D}}_3$ $300,000\text{--}600,000\text{ IU}$ orally or IM as a single dose (or daily therapy: $2000\text{--}6000\text{ IU/day}$ for 6–12 weeks).
   • Concurrent oral elemental calcium $50\text{ mg/kg/day}$ for 2–4 weeks to prevent hungry bone syndrome/hypocalcemic tetany.

1. Child A:
   • a. Age: 36 months (3 years).
   • b. Adaptive milestones: Copies circle; builds tower of 9–10 cubes; imitates 3-cube bridge.
2. Child B:
   • a. Age: 48 months (4 years).
   • b. Motor milestones: Hops on one foot; throws ball overhand; cuts paper with scissors.
3. Matching:
   • a: Palmar grasp disappears $\to$ 3–4 months
   • b: Transfers object hand-to-hand $\to$ 6–7 months
   • c: Turns pages of a book one by one $\to$ 24 months (turns multiple pages at 12–15 months)
   • d: Neat pincer grasp $\to$ 12 months (immature pincer at 9 months).

1. Most common cause: Idiopathic / Habitual toe walking (normal developmental variant).
2. Differential diagnosis:
   • Cerebral Palsy (spastic diplegia/hemiplegia)
   • Duchenne Muscular Dystrophy (Gowers sign, pseudohypertrophy)
   • Tethered cord syndrome / Spinal dysraphism
   • Congenital short Achilles tendon (tendo-Achilles contracture)
   • Developmental Dysplasia of the Hip (DDH) / Leg length discrepancy
   • Autism Spectrum Disorder.
3. Normal up to: Up to 3 years of age, provided the child can walk flat-footed when asked and has normal neurological tone and range of motion.

1. Key Principles & Targets:
   • Supplementary meal to supply at least $1/3\text{rd}$ of daily energy and $1/2$ of daily protein requirements.
   • For Primary (Classes I–V): At least $450\text{ kcal}$ and $12\text{ g}$ protein.
   • For Upper Primary (Classes VI–VIII): At least $700\text{ kcal}$ and $20\text{ g}$ protein.
   • Use locally available, cost-effective foods prepared fresh and hygienically at schools.
2. Model Menu (Primary school quantities per child per day):
   • Cereals / Millets (Rice/Wheat): $100\text{ g}$ (or $75\text{ g}$)
   • Pulses (Dal): $20\text{--}30\text{ g}$
   • Vegetables (Leafy and others): $50\text{ g}$
   • Oil and Fat: $5\text{ g}$
   • Salt and condiments: As needed.

1. Age for copying geometric figures:
   • Vertical line / stroke: 2 years (24 months)
   • Circle ($◯$): 3 years (36 months)
   • Cross ($+$): 4 years (48 months) (imitates cross at 3.5 yrs)
   • Square ($◻$): 4 to 4.5 years
   • Triangle ($\mathrm{△}$): 5 years (60 months)
   • Diamond ($\diamond$): 6 to 7 years (72 months).
2. Pervasive Developmental Disorders (PDD):
   • Autistic Disorder (Autism)
   • Asperger Syndrome
   • Rett Syndrome
   • Childhood Disintegrative Disorder (Heller syndrome)
   • Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS).