• a: 2 (Escherichia coli — bacteriostatic via iron chelation)
• b: 4 (Amoeba, Giardia — kills protozoa)
• c: 1 (Malaria — low PABA in breast milk protects against malaria)
• d: 3 (Bacteria — kills bacteria by generating reactive oxygen species)

• a. False (Ca:P ratio is 2:1 in human milk, whereas P:Ca ratio is < 1; in cow's milk Ca:P is 1.2:1).
• b. False (Mature human milk is 60% whey and 40% casein; colostrum is 80:20 whey:casein).
• c. False ($\beta$-lactoglobulin and $\alpha$-casein are absent in human milk; human milk contains $\alpha$-lactalbumin and $\beta$-casein).
• d. False (Safe at room temperature for 4–6 hours in clean containers).
• e. False (Thawed breast milk must be used within 24 hours).

Key nutritional points on human milk:

• $\alpha$-Lactalbumin: Rich in tryptophan, essential for brain development and neurotransmitter synthesis.
• Lactoferrin: Promotes absorption of iron and zinc; bacteriostatic.
• Bifidus factor: Promotes growth of Lactobacillus bifidus, inhibiting enteric pathogens.
• Taurine & Cysteine: Essential amino acids for neonatal retinal and brain development.

• a. Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act.
• b. Enacted in 1992 (amended in 2003).
• c. Five core provisions:
  • 1. No person/company shall use the healthcare system, hospitals, or pharmacies for display of placards, posters, or promotion of infant milk substitutes (IMS).
  • 2. Total prohibition of all advertising and commercial promotion of infant formulas, milk substitutes, and feeding bottles to the public.
  • 3. Ban on free samples or subsidized supplies of infant formulas and feeding bottles to health facilities or families.
  • 4. Marketing personnel of baby food companies are strictly prohibited from having direct contact with pregnant women or mothers.
  • 5. Healthcare professionals shall provide feeding counseling, strictly highlighting the superiority of exclusive breastfeeding and hazards of artificial feeding.

• a. Heartbeat $\to$ 4 weeks
• b. Circulation $\to$ 8 weeks
• c. Meconium formation $\to$ 16 weeks
• d. Surfactant production $\to$ 20 weeks (type II pneumocytes)
• e. Fetal movement (quickening) $\to$ 14–18 weeks
• f. External genitalia differentiation $\to$ 10–12 weeks
• g. Early sucking / swallowing $\to$ 28 weeks (mature swallow-breathe coordination at 32–34 weeks)
• h. Bile secretion $\to$ 12 weeks
• i. Phonation capability $\to$ 22 weeks
• j. Respiratory movements $\to$ 18 weeks

• a. $\text{BMI}=\frac{\text{Weight (kg)}}{[\text{Height (m)}{]}^2}=\frac{40}{(1.0{)}^2}=40{\text{ kg/m}}^2$
• b. Severe Obesity ($\text{BMI}>95\text{th percentile}/>+3\text{ Z-score}$ for age and sex).
• c. Waist circumference, waist-to-height ratio ($>0.5$), skinfold thickness (triceps, subscapular), and dual-energy X-ray absorptiometry (DEXA).
• d.
  • Constitutional (exogenous/nutritional) obesity: Advanced bone age (with tall stature).
  • Pathological (endocrine/syndromic) obesity: Delayed / retarded bone age (with short stature).
• e. Syndromes with obesity: Prader–Willi syndrome, Bardet–Biedl syndrome, Cohen syndrome, Alström syndrome, Beckwith–Wiedemann syndrome, and Cushing syndrome.

S. No.	Food Item	Calories (kcal)	Protein (g)
1.	Apple (100 g)	59 kcal	0.2 g
2.	Ragi (100 g)	320 kcal	7.2 g
3.	Groundnut (100 g)	560 kcal	25.0 g
4.	Two biscuits	40 kcal	1.0 g
5.	Sugar (3 tsp)	60 kcal	0 g
6.	Boiled egg (1 whole)	80 kcal	6.0 g
7.	Egg flip	200 kcal	10.0 g
8.	Vada (2 numbers)	100 kcal	2.0 g
9.	SAT mix (6 tsp)	125 kcal	2.5 g
10.	Chapati (1 number)	70 kcal	2.0 g

• a. WHO Classification of Xerophthalmia:
  • XN: Night blindness (Nyctalopia)
  • X1A: Conjunctival xerosis
  • X1B: Bitot's spots (foamy keratinized conjunctival plaques)
  • X2: Corneal xerosis
  • X3A: Corneal ulceration / keratomalacia involving $<1/3$ cornea
  • X3B: Corneal ulceration / keratomalacia involving $\ge 1/3$ cornea
  • XS: Corneal scarring
  • XF: Xerophthalmic fundus
• b. Daily requirement: $1,500\text{ IU}$ ($400\text{–}500\mu \text{g}$ retinol).
• c. Treatment of clinical deficiency / Xerophthalmia: Oral Vitamin A:
  • $<6\text{ months: }50,000\text{ IU}$
  • $6\text{–}12\text{ months: }100,000\text{ IU}$
  • $>1\text{ year: }200,000\text{ IU}$
  • Schedule: 3 doses — Day 0 (immediately), Day 1 (next day), and Day 14–28 (2–4 weeks later).
• d. First functional symptom: Impaired dark adaptation / night blindness (XN); earliest clinical sign is conjunctival xerosis (X1A).
• e. High-dose oral vitamin A given on Day 0, Day 1, and Day 14–28, along with topical lubricating and antibiotic eye drops.

• a. Active Nutritional Vitamin D Deficiency Rickets (hypophosphatemia, elevated ALP, low 25-OH-D).
• b. Metaphyseal cupping, fraying, widening/splaying of growth plates, cortical thinning, and rachitic rosary.
• c. Treatment: Cholecalciferol $60,000\text{ IU}$ orally weekly for 6 weeks (or fortnightly for 5 doses), along with elemental calcium $50\text{ mg/kg/day}$ for 3 months, followed by maintenance Vitamin D $400\text{–}600\text{ IU/day}$.
• d. Vitamin D-Dependent Rickets Type 2 (VDDR-2) (hereditary 1,25-dihydroxyvitamin D resistance due to Vitamin D receptor mutation).
• e. High-dose calcitriol ($2\text{–}50\mu \text{g/day}$) and mega-dose oral/IV calcium infusions ($1,000\text{–}3,000\text{ mg/day}$).

• a. Thiamine (Vitamin B1) $\to$ Wernicke encephalopathy
• b. Vitamin E (Tocopherol) $\to$ Spinocerebellar ataxia and peripheral neuropathy
• c. Biotin (Vitamin B7 / Vitamin H)
• d. Pantothenic Acid (Vitamin B5) $\to$ Gopalan's burning feet syndrome
• e. Niacin (Vitamin B3) $\to$ Pellagra (3Ds: Diarrhea, Dermatitis, Dementia)

• a. MAA: Mothers’ Absolute Affection program.
• b. Goal: Intensified nationwide program to promote, protect, and support optimal breastfeeding practices across all public healthcare facilities.
• c. Objectives: Build an enabling environment for early initiation within 1 hour, exclusive breastfeeding for 6 months, and continued breastfeeding up to 2 years with complementary feeding; reinforce lactation counseling support; and recognize health facilities delivering optimal breastfeeding services.
• d. Key components: Community awareness via ASHA/AWWs, capacity building of health personnel (nurses, ANMs, doctors), dedicated lactation support at delivery points, and monitoring/recognition of mother-baby friendly facilities.

• a. Rashtriya Bal Swasthya Karyakram (RBSK).
• b. Age group covered: Birth to 18 years (0–6 years screened at Anganwadi centers; 6–18 years screened in schools).
• c. Objective: Early identification and early intervention for 30 selected health conditions to reduce out-of-pocket expenditure and improve child survival.
• d. Ministry of Health and Family Welfare (MoHFW), Government of India.
• e. The 4 D's Category:

Category	Health Conditions Screened
1. Defects at birth	Neural tube defects, Down syndrome, Cleft lip and palate, Talipes (club foot), Developmental dysplasia of the hip (DDH), Congenital cataract, Congenital deafness, Congenital heart diseases, Retinopathy of prematurity (ROP).
2. Deficiencies	Anemia (severe), Vitamin A deficiency (Bitot's spots), Vitamin D deficiency (Rickets), Severe Acute Malnutrition (SAM), Goiter.
3. Diseases in childhood	Skin conditions (scabies, fungal, eczema), Otitis media, Rheumatic heart disease (RHD), Reactive airway disease, Dental caries.
4. Developmental delays & Disabilities	Vision impairment, Hearing impairment, Neuromotor impairment (Cerebral palsy), Motor delay, Cognitive delay, Language delay, Autism, ADHD.

• a. Launched in September 2018 by Prime Minister Narendra Modi.
• b. Two pillars:
  • 1. Ayushman Arogya Mandir (Health and Wellness Centers, HWCs).
  • 2. Pradhan Mantri Jan Arogya Yojana (PM-JAY).
• c. National Health Policy, 2017.
• d. Health and Wellness Centers (HWCs): Transformed Sub-centers and Primary Health Centers providing Comprehensive Primary Health Care (CPHC), maternal and child health services, noncommunicable disease screening, and free essential drugs and diagnostic tests.
• e. PM-JAY Benefits: Cashless secondary and tertiary health insurance coverage of up to Rs. 5 lakh per family per year for vulnerable and bottom 40% poor families across empaneled public and private hospitals nationwide.

• a. A relactation technique designed to stimulate breast milk production while ensuring the infant receives supplemental nutrition at the breast.
• b. Indications: Relactation in mothers who developed lactation failure, adoptive nursing, or weak infants unable to extract sufficient milk.
• c. Procedure:
  • A size 5–8 Fr nasogastric feeding tube is placed with its tip taped along the mother's nipple so that the infant latches onto both nipple and tube simultaneously.
  • The other end of the tube is submerged into a cup containing expressed breast milk or formula.
  • The cup is positioned $5\text{–}10\text{ cm}$ below breast level so milk flows only when the infant sucks actively (never above breast level to prevent rapid flooding and aspiration).

• a. LATCH Breastfeeding Assessment System:
  • L: Latch (infant grasping breast)
  • A: Audible swallowing
  • T: Type of nipple (inverted, flat, everted)
  • C: Comfort of breast and nipple
  • H: Hold / positioning assistance needed
• b. Used by nurses and lactation consultants to systematically assess breastfeeding effectiveness, identify problems early, and monitor lactation interventions.
• c. Each of the 5 parameters is scored from 0 to 2 (Total score: 0 to 10; score $\ge 8$ indicates successful breastfeeding).

• a. CLMC: Comprehensive Lactation Management Centre
• b. LMU: Lactation Management Unit
• c. DC: Digestibility Coefficient
• d. RDA: Recommended Dietary Allowance (daily nutrient intake meeting needs of $97\text{–}98\mathrm{\%}$ of healthy individuals)
• e. SDA: Specific Dynamic Action / Thermic Effect of Food
• f. EAR: Estimated Average Requirement (intake meeting requirement of $50\mathrm{\%}$ of healthy individuals)
• g. NPU: Net Protein Utilization ($\text{Retained Nitrogen}/\text{Dietary Nitrogen}\times 100$)
• h. BV: Biological Value ($\text{Retained Nitrogen}/\text{Absorbed Nitrogen}\times 100$)
• i. DRI: Dietary Reference Intake
• j. JUNCS:
  • J: Junk foods
  • U: Ultra-processed foods (NOVA category 4)
  • N: Nutritionally inappropriate foods
  • C: Caffeinated / colored / carbonated beverages
  • S: Sugar-sweetened beverages

• a. Scurvy (Vitamin C / Ascorbic acid deficiency).
• b. Radiological features:
  • White line of Fraenkel: Dense, irregular zone of provisional calcification at metaphysis.
  • Trümmerfeld zone: Radiotranslucent rarefied band underlying the white line.
  • Pelkan spur: Lateral bony spurring extending from the metaphysis.
  • Wimberger ring sign: Thin sclerotic cortical ring encircling a ground-glass demineralized epiphysis.
  • Subperiosteal hematoma: Elevating the periosteum.
• c. Boiled/heat-treated cow's milk without fresh fruit supplementation, selective picky eating / autism food selectivity, unfortified formulas, and prolonged total parenteral nutrition.
• d. Treatment: Oral Vitamin C $100\text{–}300\text{ mg/day}$ for 4 to 6 weeks until full symptomatic and radiographic resolution.

• a. Probiotics: Live microorganisms (e.g., Lactobacillus rhamnosus GG, Bifidobacterium lactis, Saccharomyces boulardii) which when administered in adequate amounts confer a health benefit on the host.
• b. Prebiotics: Non-digestible dietary carbohydrates (e.g., inulin, fructooligosaccharides [FOS], lactulose) that selectively stimulate the growth and activity of beneficial colonic microbiota.
• c. Synbiotics: Synergistic combinations of probiotics and prebiotics (e.g., Lactobacillus + Inulin).
• d. Type I vs. Type II Nutrients:

Feature	Type I Nutrients	Type II Nutrients
Body stores	Specific tissue stores present	No dedicated tissue stores
Serum level in deficiency	Decreases noticeably	Maintained normal at cost of tissue breakdown
Clinical signs	Specific clinical deficiency signs (e.g., Bitot spots, scurvy)	Non-specific growth arrest, wasting, anorexia
Growth faltering	Not an early feature	Early, primary cardinal feature
Examples	Iron, Iodine, Copper, Vitamin A, Vitamin C, Vitamin D	Zinc, Magnesium, Potassium, Sodium, Nitrogen/Essential Amino Acids

• Total Fluid Requirement (Day 1): $60\text{ mL/kg/day}\times 1.8\text{ kg}=108\text{ mL/day}$
• Lipid Emulsion (SMOFlipid 20%):
  • Dose: $2\text{ g/kg/day}=3.6\text{ g/day}$
  • Volume of 20% lipid: $\frac{3.6}{20}\times 100=18\text{ mL/day}=0.75\text{ mL/hour}$
• Net Aqueous IVF: $108\text{ mL}-18\text{ mL (lipids)}-5\text{ mL (antibiotic flush)}=85\text{ mL/day}$
• Amino Acids (Aminoven 10%):
  • Dose: $1.5\text{ g/kg/day}=2.7\text{ g/day}$
  • Volume of 10% AA: $\frac{2.7}{10}\times 100=27\text{ mL/day}$
• 10% Dextrose Volume: $85\text{ mL}-27\text{ mL}=58\text{ mL/day}$
• Glucose Infusion Rate (GIR):
  $\text{GIR}=\frac{\text{Total mL/kg/day}\times \mathrm{\%}\text{Dextrose}}{144}=\frac{32.2\times 10}{144}\approx 4\text{ mg/kg/min}$
• Final TPN Order:
  • SMOFlipid 20% @ $0.75\text{ mL/hour}$ via dedicated line.
  • Dextrose 10% + Aminoven 10% mixture @ $3.5\text{ mL/hour}$.

• a. General Danger Signs (IMNCI):
  • Inability to drink or breastfeed
  • Vomiting everything
  • History of convulsions during present illness
  • Lethargic or unconscious
  • Convulsing now
• b. Classification & Treatment (Very Severe Disease / Pink):
  • Urgent pre-referral stabilization: Give first dose of parenteral antibiotic (Ampicillin + Gentamicin or Ceftriaxone), nebulized rapid-acting bronchodilator for wheeze, treat/prevent hypoglycemia (oral 10% Dextrose), provide humidified oxygen, and refer urgently to hospital.
• c. Revised Grade (No danger signs, RR 52 breaths/min, chest indrawing): Classified as Pneumonia (Yellow).
• d. Treatment for Pneumonia (Yellow): Oral Amoxicillin ($40\text{–}45\text{ mg/kg/dose}$ BID for 5 days), inhaled bronchodilator if wheezing, home care advice, fever management with paracetamol, and follow-up in 2 days.

• a. Objective: Reduce anemia prevalence by 3 percentage points per year among children, adolescents, and reproductive-age women.
• b. 6 Interventions (6x6x6 strategy):
  • 1. Prophylactic Iron and Folic Acid (IFA) supplementation.
  • 2. Periodic deworming (Albendazole).
  • 3. Intensified year-round Behavior Change Communication (BCC).
  • 4. Point-of-care digital testing and treatment of anemia.
  • 5. Mandatory provision of IFA-fortified foods in public safety net programs.
  • 6. Addressing non-nutritional causes of anemia (malaria, hemoglobinopathies, fluorosis).
• c. Target Groups & IFA Doses:

Age / Target Group	IFA Regimen	Tablet / Syrup Color
6–59 months	Biweekly $20\text{ mg}$ elemental iron $+100\mu \text{g}$ folic acid ($1\text{ mL}$ syrup)	Iron syrup
5–9 years	Weekly $45\text{ mg}$ elemental iron $+400\mu \text{g}$ folic acid	Pink tablet
10–19 years (Adolescents)	Weekly $60\text{ mg}$ elemental iron $+500\mu \text{g}$ folic acid	Blue tablet
Women 20–49 years	Weekly $60\text{ mg}$ elemental iron $+500\mu \text{g}$ folic acid	Red tablet
Pregnant women	Daily $60\text{ mg}$ elemental iron $+500\mu \text{g}$ folic acid for 180 days (from 2nd trimester)	Red tablet
Lactating mothers (0–6 mo)	Daily $60\text{ mg}$ elemental iron $+500\mu \text{g}$ folic acid for 180 days post-delivery	Red tablet

• d. National Deworming Day (NDD): Biannual single-dose Albendazole ($200\text{ mg}$ for 12–24 months; $400\text{ mg}$ for $\ge 24$ months).

• a. Janani Shishu Suraksha Karyakram (JSSK).
• b. Ministry of Health and Family Welfare (MoHFW), Government of India (launched in June 2011).
• c. Objective: Completely eliminate out-of-pocket expenses for pregnant women delivering in public health institutions and sick neonates up to 1 year of age.
• d. Entitlements / Interventions:
  • Zero-expense cashless institutional delivery and C-section.
  • Free drugs, consumables, diagnostics (blood, urine, USG).
  • Free diet during hospital stay (up to 3 days for normal delivery, 7 days for C-section).
  • Free provision of blood and blood components.
  • Free transport from home to health facility, inter-facility transfer, and drop-back home.

• a. Key clinical triage test to differentiate uncomplicated SAM (eligible for outpatient therapeutic care) from complicated SAM (requiring inpatient stabilization).
• b. Conducted in a calm environment; caregiver gently offers Ready-to-Use Therapeutic Food (RUTF) with clean hands and drinking water over a 30–60 minute observation period without force-feeding.
• c. Minimum RUTF intake to Pass Appetite Test:

Weight of Child (kg)	Minimum RUTF Paste to Pass (g)
$<4.0\text{ kg}$	Inpatient care
$4.0\text{–}6.9\text{ kg}$	$\ge 25\text{ g}$ ($1/4\text{ to }1/3$ packet)
$7.0\text{–}9.9\text{ kg}$	$\ge 35\text{ g}$ ($1/3\text{ to }1/2$ packet)
$10.0\text{–}14.9\text{ kg}$	$\ge 50\text{ g}$ ($1/2\text{ to }3/4$ packet)

• d. Passed: Eager consumption $\to$ Outpatient Management. Failed: Refusal or inadequate intake $\to$ Immediate Inpatient Admission to Nutrition Rehabilitation Centre (NRC).

• a. Food Fortification: Practice of deliberately increasing the content of essential micronutrients in commonly consumed staple foods during processing to improve nutritional quality with minimal health risk.
• b. Food Supplementation: Direct administration of concentrated micronutrients (tablets, syrups, capsules) targeted to specific deficient individuals or high-risk populations.
• c. Advantages: Broad population coverage, does not require behavioral change or individual adherence, cost-effective, low risk of chronic toxicity, and utilizes existing food distribution channels.
• d. Food Vehicle Selection Criteria: Universally consumed in predictable amounts by all socioeconomic strata, stable during cooking/storage, does not alter food taste, odor, or color, and economically viable.
• e. Ultra Rice: Extruded manufactured rice grains made from rice flour enriched with Vitamin A, Iron, Zinc, and Folic Acid, blended with natural milled rice at a ratio of 1:100 to 1:200.

• a. POSHAN Abhiyaan (National Nutrition Mission): Flagship holistic multi-ministerial convergence program to improve nutritional outcomes for children, pregnant women, and lactating mothers focusing on the first 1,000 days of life.
• b. Objectives: Reduce stunting, undernutrition, and low birth weight by 2% per annum, and reduce anemia among children and women by 3% per annum.
• c. Convergent Schemes: ICDS (Anganwadi services), PMMVY, National Health Mission (JSY, JSSK, RBSK, Anemia Mukt Bharat), Swachh Bharat Mission, National Rural Drinking Water Mission, and NRLM.

• a. Launched on 7th January 2014 by MoHFW.
• b. Vision: Enable all adolescents in India to realize their full potential by making informed and responsible decisions regarding their health and well-being.
• c. Target age group: Adolescents aged 10 to 19 years (10–14 and 15–19 years, both in-school and out-of-school, married and unmarried).
• d. 6 Priority Thematic Areas:
  • 1. Improve nutrition (reduce IDA and malnutrition).
  • 2. Improve sexual and reproductive health (reduce teen pregnancies).
  • 3. Enhance mental health.
  • 4. Prevent injuries and violence (including gender-based violence).
  • 5. Prevent substance misuse.
  • 6. Address noncommunicable diseases (NCD lifestyle modifications).

• a. Kishori Shakti Yojana (KSY) / Scheme for Adolescent Girls (SAG - SABLA).
• b. Objectives: Empower adolescent girls with life skills, vocational training, literacy, and health education to facilitate transition back to schooling and improve health/nutrition.
• c. Target group: Out-of-school girls aged 11 to 14 years (expanded previously to 11–18).
• d. Ministry of Women and Child Development (MoWCD).
• e. Two components:
  • 1. Nutrition component: Take-Home Rations or Hot Cooked Meals providing 600 kcal and 18–20 g protein per day for 300 days/year.
  • 2. Non-nutrition component: Weekly IFA supplementation, health checkups, life skill education, and vocational counseling.

• a: 1 (Fluoride $\to$ Dental caries)
• b: 2 (Iodine $\to$ Hypothyroidism / Goiter)
• c: 3 (Copper $\to$ Microcytic anemia, depigmentation of hair/skin)
• d: 4 (Chromium $\to$ Impaired glucose tolerance, neuropathy)
• e: 5 (Manganese $\to$ Hypercholesterolemia, skeletal abnormalities)
• f: 6 (Selenium $\to$ Keshan disease / Kaschin-Beck disease)
• g: 7 (Zinc $\to$ Acrodermatitis enteropathica, delayed wound healing)
• h: 8 (Iron $\to$ Behavioral changes, iron deficiency anemia)
• i: 9 (Molybdenum $\to$ Tachycardia, tachypnea, night blindness)

• a. Breastfeeding jaundice (Breastfeeding failure jaundice): Onset in the 1st week of life due to inadequate milk intake, mild dehydration, and increased enterohepatic circulation of bilirubin.
• b. Breast milk jaundice: Onset in the 2nd week of life (peaks at 10–14 days) in a thriving, well-fed infant with prolonged unconjugated hyperbilirubinemia.
• c. $\beta$-Glucuronidase and high concentrations of non-esterified fatty acids / pregnane-3$\alpha$,20$\beta$-diol in breast milk.
• d. Cholestatic / Obstructive jaundice (due to complete biliary obstruction preventing bilirubin entry into gut).
• e. Dubin–Johnson syndrome and Rotor syndrome.
• f. Severe unconjugated hyperbilirubinemia (Type 1: absent UDPGT; Type 2: severe UDPGT deficiency).

• a. Triangular cord sign (thick triangular echogenic fibrous band anterior to portal vein bifurcations $>4\text{ mm}$).
• b. Biliary Atresia.
• c. Progressive conjugated jaundice after 2 weeks of life, acholic (clay-colored / pale) stools, dark high-colored urine, and firm hepatosplenomegaly.
• d. Conjugated (direct) hyperbilirubinemia.
• e. BASM: Biliary Atresia Splenic Malformation syndrome (associated with polysplenia/asplenia, situs inversus, and preduodenal portal vein).
• f. Kasai Portoenterostomy (ideally performed before 60 days of life).

• a. Portal venous pressure $>10\text{ mm Hg}$ (or hepatic venous pressure gradient $\text{HVPG}>5\text{ mm Hg}$).
• b. Formed by union of Superior Mesenteric Vein and Splenic Vein behind the neck of the pancreas at the level of L2 vertebra.
• c. Extrahepatic Portal Venous Obstruction (portal cavernoma transformation).
• d. Neonatal umbilical vein catheterization / umbilical sepsis (omphalitis).
• e. Recurrent upper gastrointestinal bleeding (hematemesis/melena from esophageal varices) with massive splenomegaly and normal liver function.
• f. Continuous venous hum heard over the epigastrium/umbilicus due to turbulent collateral flow in recanalized paraumbilical veins.
• g. Obstruction of hepatic venous outflow (hepatic veins to IVC junction).

• a.
  • Single toxic dose: $\ge 150\text{–}200\text{ mg/kg}$
  • Cumulative supratherapeutic dose: $>90\text{–}100\text{ mg/kg/day}$ over several days
• b. Metabolism by CYP2E1 generates N-acetyl-p-benzoquinone imine (NAPQI), which exhausts hepatocellular glutathione stores and causes covalent binding to mitochondrial proteins leading to centrilobular hepatic necrosis.
• c. Rumack–Matthew nomogram (evaluating 4-hour to 24-hour post-ingestion serum paracetamol concentrations).
• d. Intravenous or oral N-acetylcysteine (NAC).
• e. Acute onset of severe liver injury with coagulopathy ($\text{INR}>1.5\text{–}2.0$) and encephalopathy within 8 weeks in a patient without prior liver disease.
• f. King's College / O'Grady criteria for liver transplant:
  • Arterial $\text{pH}<7.30$ after fluid resuscitation (regardless of encephalopathy stage), OR
  • All 3 of: Grade III/IV encephalopathy, Prothrombin Time $>100\text{ seconds}$ ($\text{INR}>6.5$), and Serum Creatinine $>300\mu \text{mol/L}$ ($>3.4\text{ mg/dL}$).

• a. Classic Galactosemia (fulminant neonatal liver disease with E. coli sepsis).
• b. Galactose-1-phosphate uridylyltransferase (GALT).
• c. Galactose-1-phosphate and Galactitol.
• d. Oil-drop cataract (nuclear cataract due to galactitol accumulation in the lens).
• e. Immediate cessation of all lactose/galactose-containing feeds (breast milk, standard cow's milk formula) and substitution with soy-based or elemental formula.
• f. Primary ovarian insufficiency / Hypergonadotropic hypogonadism.

• a. Autosomal recessive.
• b. Chromosome 13q14.3; ATP7B gene.
• c. Kayser–Fleischer (KF) ring (copper deposition in Descemet's membrane) and Sunflower cataract (anterior subcapsular copper deposition).
• d. Low serum ceruloplasmin ($<20\text{ mg/dL}$), elevated 24-hour urinary copper, high non-ceruloplasmin bound copper, and hepatic copper concentration $>250\mu \text{g/g}$ dry weight on biopsy.
• e. 24-hour urinary copper excretion $>40\text{–}100\mu \text{g/day}$ ($>1.6\mu \text{mol/day}$).
• f. Chelators (D-Penicillamine, Trientine) and intestinal absorption blockers (Zinc acetate/gluconate, Ammonium tetrathiomolybdate).

• a. Dermatitis herpetiformis (pruritic vesiculopapular eruption on extensor surfaces).
• b. Intraepithelial lymphocytosis ($>25\text{ IELs}/100\text{ enterocytes}$), crypt hyperplasia, and villous atrophy/blunting.
• c. Enteropathy-associated T-cell lymphoma (EATL).
• d. Selective IgA deficiency.
• e. Modified Marsh Classification:
  • Marsh 0: Normal mucosal architecture
  • Marsh 1 (Infiltrative): $>25\text{ IELs}/100\text{ enterocytes}$
  • Marsh 2 (Hyperplastic): Marsh 1 $+$ crypt hyperplasia
  • Marsh 3 (Destructive): Crypt hyperplasia $+$ villous atrophy (3a: partial; 3b: subtotal; 3c: total)
• f.
  • Safe (Gluten-free): Rice, maize/corn, ragi, bajra, jowar, soya, potato, sago.
  • Avoid (Gluten-containing): Wheat, barley, rye, and oats (contaminated).
• g. Serum IgA tissue transglutaminase (anti-tTG IgA) antibody with total serum IgA.

• a: 1 (Lead pipe colon $\to$ Ulcerative colitis)
• b: 2 (ASCA positive $\to$ Crohn’s disease)
• c: 3 (PAS-positive foamy macrophages $\to$ Whipple disease)
• d: 4 (Target sign on USG $\to$ Intussusception)
• e: 5 (Coffee bean sign on X-ray $\to$ Sigmoid volvulus)
• f: 6 (Absence of ganglion cells $\to$ Hirschsprung’s disease)

• a. Infantile Hypertrophic Pyloric Stenosis.
• b. Non-bilious, projectile vomiting in an eager-feeding infant aged 3–6 weeks.
• c. Hypochloremic, hypokalemic metabolic alkalosis with paradoxical aciduria.
• d. Immediate resuscitation: Correct dehydration and acid-base derangement with IV 0.45% or 0.9% Normal Saline with 5% Dextrose and potassium chloride until $\text{serum chloride}>100\text{ mEq/L}$, ${\text{HCO}}_3<28\text{ mEq/L}$, and urine output is established.
• e. Ramstedt’s extramucosal pyloromyotomy.
• f. Oral / IV Atropine sulfate (rarely used for non-surgical medical trial).

• a. Ileocolic Intussusception.
• b. Abdominal Ultrasonography (detects target / doughnut sign on transverse view and pseudo-kidney sign on longitudinal view).
• c.
  • Classic triad: Paroxysmal colicky abdominal pain (inconsolable crying with knee drawing), palpable sausage-shaped abdominal mass, and "red currant jelly" stools.
  • Pathological lead points: Meckel's diverticulum, intestinal polyp, duplication cyst, Henoch–Schönlein purpura (IgA vasculitis) intramural hematoma, and lymphoma.
• d. Coiled-spring sign on contrast enema.
• e. Non-operative hydrostatic (saline) or pneumatic (air) enema reduction under real-time ultrasound or fluoroscopic guidance.
• f. Bowel perforation (requiring emergency laparotomy) and recurrence of intussusception ($5\text{–}10\mathrm{\%}$).

• a. Ventral and dorsal pancreatic buds of the primitive foregut endoderm.
• b. Annular pancreas: Failure of proper rotation of the bifid ventral pancreatic bud, forming a ring of pancreatic tissue encircling the 2nd part of the duodenum and causing duodenal obstruction.
• c. Pancreas divisum: Failure of fusion of the dorsal and ventral pancreatic duct systems, causing the majority of pancreatic secretion to drain through the narrow minor papilla (Santorini duct).
• d. Endocrine islets and exocrine acini differentiate around the 12th to 14th week of gestation.
• e. Shwachman–Diamond syndrome (and Cystic Fibrosis).

• a. Functional constipation (Rome IV / NASPGHAN criteria): Presence of $\ge 2$ of the following for $\ge 1$ month:
  • $\le 2$ defecations in the toilet per week
  • $\ge 1$ episode of fecal incontinence per week (in toilet-trained child)
  • History of retentive posturing or excessive stool withholding
  • History of painful or hard bowel movements
  • Presence of a large fecal mass in the rectum
  • History of large-diameter stools that may obstruct the toilet
• b. Constipation lasting for $>1\text{ to }3\text{ months}$.
• c. Constipation that fails to respond to optimal conventional medical and behavioral therapy for $\ge 3$ months.
• d. Rule of 1 for toilet training:
  • One routine (fixed time after meals)
  • One place (designated toilet/potty)
  • One word (consistent encouragement and terminology)
• e. Polyethylene Glycol (PEG 3350/4000) and Lactulose.

• a. Acute Pancreatitis.
• b. INSPPIRE diagnostic criteria (requires $\ge 2$ of the following 3):
  • 1. Characteristic abdominal pain (epigastric/periumbilical radiating to back).
  • 2. Serum amylase or lipase $\ge 3\times$ upper limit of normal.
  • 3. Imaging findings characteristic of acute pancreatitis (USG, CT, MRI).
• c.
  • Cullen’s sign: Bluish periumbilical ecchymosis indicating retroperitoneal / intraperitoneal hemorrhage.
  • Grey Turner’s sign: Flank / loin ecchymosis from retroperitoneal blood tracking.
• d. Serum Lipase (more sensitive and specific than amylase, remains elevated for 8–14 days).
• e. PRSS1 (Cationic trypsinogen), SPINK1 (Serine protease inhibitor Kazal-type 1), CFTR (Cystic fibrosis), and CTRC (Chymotrypsin C).
• f. Pancreatic pseudocyst, necrotizing pancreatitis / infected necrosis, splenic vein thrombosis, and systemic shock / multi-organ failure.
• g. Management: Early aggressive fluid resuscitation with balanced crystalloids (Ringer's Lactate), adequate multi-modal analgesia (opioids/paracetamol), early enteral nutrition as tolerated, and avoiding prophylactic antibiotics in uncomplicated pancreatitis.

• a. Standard WHO ORS osmolarity: $311\text{ mOsm/L}$.
• b. WHO Reduced / Low-Osmolarity ORS: $245\text{ mOsm/L}$.
• c. ReSoMal: Rehydration Solution for Malnutrition (specially formulated for children with Severe Acute Malnutrition, SAM).
• d. ReSoMal has lower sodium ($45\text{ mmol/L}$ vs $75\text{ mmol/L}$), higher potassium ($40\text{ mmol/L}$ vs $20\text{ mmol/L}$), higher sugar/sucrose content ($125\text{ mmol/L}$), and added magnesium and zinc to prevent hypernatremic fluid overload and heart failure in SAM.
• e. WHO Low-Osmolarity ORS Composition (per Liter):

Component	Grams per Liter ($\text{g/L}$)	Molar Concentration ($\text{mmol/L}$)
Sodium Chloride	$2.6\text{ g}$	$\text{Sodium: }75\text{ mmol/L}$
Anhydrous Glucose	$13.5\text{ g}$	$\text{Glucose: }75\text{ mmol/L}$
Potassium Chloride	$1.5\text{ g}$	$\text{Potassium: }20\text{ mmol/L}$, $\text{Chloride: }65\text{ mmol/L}$
Trisodium Citrate Dihydrate	$2.9\text{ g}$	$\text{Citrate: }10\text{ mmol/L}$
Total	$20.5\text{ g/L}$	Total Osmolarity: $245\text{ mOsm/L}$