Midwife Licensure Exam Infant & Child Health (Growth, Development & IMCI) — Paediatric Respiratory & Cardiac DisordersCheat Sheet
Paediatric Respiratory & Cardiac Disorders cheat sheet — the reference card you wish you had on exam day. Condensed from the full study notes, this is the high-yield core of Paediatric Respiratory & Cardiac Disorders for Midwife Licensure Exam Infant & Child Health (Growth, Development & IMCI). Download, print, revise.
Exam context
For the Midwife Licensure Examination, Professional Regulation Commission (PRC) — Board of Midwifery tests Infant & Child Health (Growth, Development & IMCI) under a "Core" label, with Paediatric Respiratory & Cardiac Disorders in the 3rd slot across 6 chapters. Midwife Licensure Exam candidates must clear the 75% weighted average cut on the 2026 paper, which draws about a meaningful share of Infant & Child Health (Growth, Development & IMCI) questions. Date to watch: April and November 2026 (expected).
Paediatric Respiratory & Cardiac Disorders - Cheat Sheet
Your last-minute revision companion for recognising respiratory distress, mastering CHD classification, and nailing high-yield nursing interventions in paediatric respiratory and cardiac emergencies. Every item here has been tested on the NLE.
Sections
Common Values
Value
30–60 breaths/min
Symbol
RR
Quantity
Normal RR: Infant (0–6 months)
Value
25–35 breaths/min
Symbol
RR
Quantity
Normal RR: Infant (6–12 months)
Value
20–30 breaths/min
Symbol
RR
Quantity
Normal RR: Toddler (12 months–3 years)
Value
20–25 breaths/min
Symbol
RR
Quantity
Normal RR: Preschool (3–6 years)
Value
120–160 bpm
Symbol
HR
Quantity
Normal HR: Newborn
Value
100–160 bpm
Symbol
HR
Quantity
Normal HR: Infant (6 months)
Value
98–140 bpm
Symbol
HR
Quantity
Normal HR: Toddler (2–3 years)
Section Title
Recognising Respiratory Distress in Children — IMCI Fast-Breathing Thresholds
Important Facts
- EARLY SIGNS of respiratory distress = restlessness, tachypnea, tachycardia, nasal flaring, mild retractions.
- WORSENING SIGNS = intercostal/subcostal/suprasternal retractions, grunting, head-bobbing, accessory muscle use.
- LATE/OMINOUS SIGNS = cyanosis, bradycardia, decreased/absent breath sounds, lethargy/unresponsiveness (impending respiratory failure).
- IMCI Fast-Breathing Thresholds: ≥60/min if <2 months | ≥50/min if 2–12 months | ≥40/min if 12 months–5 years.
- Bradycardia in a distressed child = ALARM; indicates severe hypoxia/imminent arrest.
- Silent chest (no wheeze heard) in an asthmatic or bronchiolitic = severe obstruction, NOT improvement.
- Head-bobbing and use of accessory muscles indicate significant increased WOB.
- Nasal flaring + any retraction in an infant = automatic fast-track to care.
- Always assess RR, HR, BP, O₂ saturation, and level of consciousness TOGETHER — never isolated findings.
- Position matters: head elevation, upright posture reduces WOB; supine or head-down worsens distress.
Key Definitions
Term
Respiratory Distress (Paediatric)
Example
A 4-month-old RSV+ infant with subcostal retractions, nasal flaring, and RR 68/min = RESPIRATORY DISTRESS.
Definition
Clinical state of increased work of breathing with inadequate oxygenation/ventilation; manifested by tachypnea, retractions, and/or abnormal breath sounds.
Term
Stridor
Example
Barking cough with inspiratory stridor in a 2-year-old = croup until proven otherwise.
Definition
High-pitched, musical breathing sound; inspiratory stridor = upper airway obstruction (croup); biphasic stridor = critical obstruction.
Term
Grunting
Example
Bronchiolitis infant grunting = lungs trying to stay open; sign of increased WOB.
Definition
Expiratory sound produced by premature glottic closure; indicates attempt to maintain positive end-expiratory pressure (PEEP) and prevent alveolar collapse.
Term
Tet Spell (Hypercyanotic Spell)
Example
Infant with TOF suddenly becomes deeply cyanotic and limp after crying = tet spell; PRIORITY: knee-chest position.
Definition
Acute episode of deep cyanosis and dyspnoea in TOF due to sudden increase in right-to-left shunting, often triggered by crying, exertion, or defecation.
Diagrams To Know
- Respiratory distress progression from early to late signs
- Body sites of retractions (intercostal vs. subcostal vs. suprasternal)
- Comparison of normal vs. abnormal breath sounds (stridor, wheeze, grunting, crackles)
Section Title
Congenital Heart Defects (CHD) — Classification & Key Facts
Important Facts
- VSD = MOST COMMON CHD overall; small VSDs may close spontaneously; large VSDs cause early CHF.
- TOF = MOST COMMON CYANOTIC CHD; 4 components (Pulmonary stenosis, VSD, Overriding aorta, RV hypertrophy); boot-shaped heart.
- Acyanotic defects (VSD, ASD, PDA, coarctation) = LEFT-TO-RIGHT SHUNT; child is pink but at risk of CHF and pulmonary overcirculation.
- Cyanotic defects (TOF, TGA, tricuspid atresia, truncus arteriosus, TAPVR) = RIGHT-TO-LEFT SHUNT; cyanosis UNRELIEVED by supplemental oxygen.
- Five T's of cyanotic CHD = Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus, Total anomalous pulmonary venous return.
- PDA: IndomethACin/ibuprofen CLOSES the duct; Prostaglandin E1 KEEPS the duct OPEN (duct-dependent lesions).
- Coarctation classic sign = higher BP/pulses in ARMS, lower BP/weak femoral pulses in LEGS.
- TGA: cyanosis present from birth; egg-on-string CXR; emergency prostaglandin E1 and balloon septostomy.
- In duct-dependent lesions (PDA, some TOF, TGA, tricuspid atresia) = prostaglandin E1 is LIFE-SAVING; do NOT give indomethacin.
- CHF signs in infants = feeding difficulty/diaphoresis with feeds, tachycardia (>160 bpm), tachypnea, hepatomegaly, periorbital edema, poor weight gain.
- Tet spell = acute cyanosis episode; priority action = KNEE-CHEST POSITION (older children squat); increases SVR, reduces right-to-left shunt.
- Oxygen, morphine, and calm environment are adjuncts; the POSITION CHANGE is the primary intervention for tet spell.
Key Definitions
Term
Ventricular Septal Defect (VSD)
Example
Newborn with a continuous holosystolic murmur at the left lower sternal border = VSD likely. Many small VSDs close spontaneously.
Definition
Hole between the ventricles allowing left-to-right shunt; MOST COMMON CHD; loud holosystolic (pansystolic) murmur.
Term
Atrial Septal Defect (ASD)
Example
School-age child found to have a murmur during routine exam = ASD possible; may not present until later.
Definition
Opening between the atria; left-to-right shunt; usually asymptomatic in infancy; soft systolic ejection murmur.
Term
Patent Ductus Arteriosus (PDA)
Example
Premature infant with continuous murmur + bounding pulses + wide pulse pressure = PDA; indomethacin/ibuprofen may close it.
Definition
Failure of ductus arteriosus to close; left-to-right shunt; CLASSIC SIGN = machine-like continuous murmur, bounding pulses, widened pulse pressure.
Term
Coarctation of the Aorta
Example
Child with hypertension in arms only, absent femoral pulses, claudication = coarctation; surgical repair needed.
Definition
Narrowing of the aorta; classic triad = higher BP and bounding pulses in ARMS, lower BP and weak/absent FEMORAL pulses in LEGS.
Term
Tetralogy of Fallot (TOF)
Example
Infant with cyanosis unrelieved by O₂, boot-shaped heart on X-ray = TOF. Tet spells triggered by crying/exertion.
Definition
MOST COMMON CYANOTIC CHD; 4 defects: (1) Pulmonary stenosis, (2) VSD, (3) Overriding aorta, (4) RV hypertrophy. X-ray = BOOT-SHAPED HEART.
Term
Transposition of the Great Arteries (TGA)
Example
Severely cyanotic newborn with egg-on-string appearance on CXR = TGA; emergency prostaglandin E1 and balloon atrial septostomy (Rashkind procedure).
Definition
Aorta and pulmonary artery are reversed; cyanosis present; survival depends on shunting (ASD, VSD, PDA). Prostaglandin E1 keeps ductus open.
Term
Tricuspid Atresia
Example
Newborn with severe cyanosis, single S2, decreased pulmonary vascular markings on CXR = tricuspid atresia; prostaglandin E1 ASAP.
Definition
Complete absence of tricuspid valve; no communication between RA and RV; profound cyanosis; requires PDA/ASD for survival.
Term
Congestive Heart Failure (CHF) in Infants
Example
VSD infant at 4–6 weeks develops feeding difficulty, poor weight gain, tachycardia, hepatomegaly = CHF from left-to-right shunt.
Definition
Inability of the heart to pump blood effectively; in acyanotic left-to-right shunts, CHF develops from pulmonary overcirculation and increased workload.
Diagrams To Know
- Acyanotic vs. cyanotic CHD decision tree
- Tetralogy of Fallot: the 4 defects and how they interact
- Direction of shunting in left-to-right vs. right-to-left defects
- Tet spell progression and intervention flowchart
Common Values
Value
0.8–2.0 ng/mL
Symbol
Therapeutic
Quantity
Therapeutic Digoxin Level
Value
90–100 bpm
Symbol
Hold threshold
Quantity
Normal Apical HR: Infant (HOLD if <)
Value
70 bpm
Symbol
Hold threshold
Quantity
Normal Apical HR: Older Child (HOLD if <)
Value
3.5–5.0 mEq/L
Symbol
K⁺
Quantity
Normal Serum K⁺
Section Title
Digoxin — Paediatric Heart Failure Drug (CRITICAL)
Important Facts
- ALWAYS count the APICAL PULSE for a FULL MINUTE before administering digoxin.
- HOLD digoxin and notify physician if apical HR is <90–100 bpm in an INFANT or <70 bpm in an OLDER CHILD.
- Signs of toxicity: bradycardia, vomiting, nausea, anorexia, visual disturbances, dysrhythmias.
- HYPOKALEMIA POTENTIATES DIGOXIN TOXICITY — monitor serum K⁺ carefully, especially with concurrent diuretics (furosemide).
- If the child VOMITS, DO NOT repeat the dose; contact the physician.
- DO NOT mix digoxin with food or formula; give it at regular intervals.
- Teach parents: use a proper measuring syringe (NOT a spoon), give exact doses, keep locked away from other children.
- Adverse effects: anorexia, nausea, bradycardia, dysrhythmias (premature ventricular contractions, bigeminy).
- Digoxin has a narrow therapeutic window in children; even small overdoses are dangerous.
- Do NOT give digoxin if the child is digitalized unless specifically ordered; risk of toxicity is high.
Key Definitions
Term
Digoxin
Example
CHF infant on digoxin 0.01 mg/kg/dose; requires APICAL PULSE CHECK before EVERY dose.
Definition
Cardiac glycoside that increases cardiac contractility and slows AV nodal conduction; used in CHF and certain dysrhythmias. Narrow therapeutic index in children.
Term
Digoxin Toxicity
Example
Infant on digoxin presents with vomiting, poor feeding, apical HR 70 bpm = digoxin toxicity; HOLD dose and notify physician.
Definition
Overdose effects: bradycardia, vomiting/nausea, anorexia, visual disturbances (in older kids), dysrhythmias (ectopic beats, AV block).
Term
Therapeutic Digoxin Level
Example
Serum digoxin 1.5 ng/mL appears therapeutic, but if K⁺ is 2.8 mEq/L, toxicity may still occur.
Definition
0.8–2.0 ng/mL (narrow range); toxicity can occur within therapeutic range if hypokalemia is present.
Diagrams To Know
- Digoxin administration checklist (apical pulse count, normal ranges by age, hold parameters)
- Hypokalemia effect on digoxin toxicity risk
Section Title
Croup (Laryngotracheobronchitis)
Important Facts
- Croup is VIRAL, usually parainfluenza; most common respiratory emergency in children.
- Classic triad: BARKING/SEAL-LIKE COUGH, INSPIRATORY STRIDOR, HOARSENESS.
- Worse at night (cool night air); symptoms often improve by morning.
- Management: KEEP THE CHILD CALM (agitation worsens obstruction); cool humidified air/mist; oxygen as needed.
- COOL MIST/HUMIDIFICATION is the MAINSTAY of home treatment.
- Nebulised RACEMIC EPINEPHRINE for stridor at rest or significant distress (provides temporary relief; rebound is possible).
- DEXAMETHASONE (corticosteroid) reduces airway edema and hastens recovery.
- Most croup cases are managed at HOME with cool mist, fluids, and parental reassurance.
- Hospitalization only if severe obstruction, recurrent tet spells, or failed home management.
- Intubation rarely needed unless airway is critically compromised.
- Do NOT force the child to lie flat or agitate them; this can precipitate total obstruction.
Key Definitions
Term
Croup
Example
Toddler with barking cough, inspiratory stridor, worse at night; X-ray shows steeple sign = croup.
Definition
Viral inflammation of larynx/trachea (usually parainfluenza); classic triad = barking/seal-like cough, inspiratory stridor, hoarseness; MOST COMMON in 6 months–3 years.
Term
Steeple Sign (X-ray)
Example
Child with suspected croup + AP neck X-ray showing narrowed subglottic airway (loss of normal shoulders) = steeple sign.
Definition
Narrowing of the subglottic trachea on anteroposterior (AP) neck X-ray; pathognomonic for croup.
Diagrams To Know
- Croup management algorithm (home vs. hospital vs. ICU)
- Differentiating croup from epiglottitis and other upper airway emergencies
Section Title
Epiglottitis — AIRWAY EMERGENCY
Important Facts
- Epiglottitis is a BACTERIAL EMERGENCY (Hib); Hib vaccine has made it rare but still LIFE-THREATENING when it occurs.
- Classic presentation: High fever (>39°C), acute onset, DROOLING, DYSPHAGIA, DYSPHONIA (muffled), and SEVERE DISTRESS.
- Child is TOXIC-LOOKING and sits in TRIPOD POSITION to maintain airway.
- CRITICAL: DO NOT examine the throat with a tongue depressor or take a throat culture — this can trigger LARYNGOSPASM and TOTAL OBSTRUCTION.
- DO NOT agitate the child; keep them UPRIGHT and CALM with a parent present.
- Have EMERGENCY AIRWAY EQUIPMENT (intubation tray, tracheostomy kit, oxygen) at the BEDSIDE.
- X-ray: Lateral neck shows THUMB SIGN (enlarged, rounded epiglottis).
- Management: Keep upright, humidified oxygen, IV access, IV antibiotics (ceftriaxone or cefotaxime), prepare for possible intubation/tracheostomy.
- Intubation must be done in a controlled setting (operating room or ICU) with experienced personnel ready.
- Prognosis: With early antibiotics and airway management, survival is excellent; delay = death.
Key Definitions
Term
Epiglottitis
Example
Child with sudden high fever, drooling, muffled voice, tripod positioning, toxic appearance = epiglottitis; prepare for intubation IMMEDIATELY.
Definition
BACTERIAL inflammation of the epiglottis (classically Haemophilus influenzae type b, now rare with Hib vaccine); MEDICAL EMERGENCY; rapid onset, risk of total airway obstruction.
Term
Four D's of Epiglottitis
Example
Child presents with drooling, difficulty swallowing saliva, muffled speech, severe distress = epiglottitis until proven otherwise.
Definition
Drooling, Dysphagia (difficulty swallowing), Dysphonia (muffled/hot-potato voice), Distress.
Term
Thumb Sign (X-ray)
Example
Lateral neck X-ray showing an enlarged, rounded epiglottis (instead of normal leaf-like shape) = thumb sign.
Definition
Enlarged, rounded epiglottis on lateral neck X-ray; resembles a thumb; pathognomonic for epiglottitis.
Term
Tripod/Sniffing Position
Example
Child with epiglottitis assumes tripod position on arrival; assume patient is maintaining airway and do NOT agitate.
Definition
Child sits upright, leaning forward with chin extended; posture that maximises airway patency and reduces airway obstruction.
Diagrams To Know
- Epiglottitis vs. croup comparison (presentation, X-ray findings, management)
- Epiglottitis airway emergency protocol
Section Title
Bronchiolitis (RSV Infection)
Important Facts
- Bronchiolitis is RSV (most common); other viruses include parainfluenza, metapneumovirus, influenza.
- RSV is HIGHLY CONTAGIOUS; spreads by DROPLET and DIRECT CONTACT.
- PEAK INCIDENCE: infants <2 years, especially <6 months; more severe in premature infants and those with chronic lung disease.
- Signs: WHEEZING, TACHYPNEA, RETRACTIONS, NASAL FLARING, COUGH, COPIOUS SECRETIONS, poor feeding.
- Diagnosis: Rapid antigen test or PCR from nasal swab.
- Management is SUPPORTIVE: suctioning (bulb or nasal) to maintain airway, humidified oxygen, hydration, small feeds, head elevation.
- PRIORITY NURSING INTERVENTION: Strict CONTACT PRECAUTIONS — private room or cohorting; gloves, gown, hand hygiene.
- Palivizumab is PROPHYLAXIS (given monthly IM during RSV season), NOT treatment; it prevents RSV infection in high-risk infants.
- NO specific antiviral for most RSV; ribavirin is reserved for severely immunocompromised children.
- Most infants recover in 1–2 weeks; however, severe bronchiolitis can require ICU care and mechanical ventilation.
- Post-bronchiolitis wheezing can persist for weeks; teach parents about this and when to seek follow-up care.
Key Definitions
Term
Bronchiolitis
Example
4-month-old with wheezing, tachypnea, retractions, copious nasal secretions, poor feeding = RSV bronchiolitis.
Definition
Viral inflammation of bronchioles, most often caused by Respiratory Syncytial Virus (RSV); affects INFANTS <2 YEARS (peak 2–6 months); highly contagious.
Term
Palivizumab
Example
Premature infant born at 28 weeks; receives palivizumab IM monthly during RSV season to prevent severe RSV infection.
Definition
Monoclonal antibody against RSV; given as PROPHYLAXIS (NOT treatment) to high-risk infants during RSV season (Nov–Mar in Northern Hemisphere).
Term
Contact Precautions (RSV)
Example
RSV+ infant requires private room or cohorting with other RSV+ patients; all staff use gloves and gown; meticulous hand hygiene MANDATORY.
Definition
Infection control measure requiring gloves, gown, and hand hygiene for all direct patient contact and contact with contaminated materials; RSV spreads by droplet and contact.
Diagrams To Know
- RSV infection pathway in the lower respiratory tract (bronchioles, air trapping, hyperinflation)
- Contact precautions protocol for RSV+ patients
Common Values
Value
150–300 L/min (varies)
Symbol
PFR
Quantity
Normal Peak Flow Rate: Child (5–7 years)
Value
250–430 L/min (varies)
Symbol
PFR
Quantity
Normal Peak Flow Rate: Older Child (8–15 years)
Section Title
Asthma (Chronic Airway Inflammation with Bronchospasm)
Important Facts
- Asthma = CHRONIC reversible airway inflammation; NOT cured, but managed.
- Symptoms: WHEEZING (expiratory), COUGH (often worse at night or with exercise), CHEST TIGHTNESS, SHORTNESS OF BREATH, PROLONGED EXPIRATION.
- SILENT CHEST (no audible wheeze in a distressed child) = SEVERE OBSTRUCTION and OMINOUS SIGN; prepare for emergent airway intervention.
- Triggers: cold air, exercise, allergens (dust, pollen), infections, emotional stress, smoke.
- SABAs (salbutamol/albuterol) = RELIEVER/RESCUE drugs for acute bronchospasm; side effects = tachycardia, tremor, jitteriness.
- ICS (fluticasone, budesonide) = CONTROLLER/PREVENTER drugs for daily use in persistent asthma; RINSE MOUTH after use to prevent oral thrush.
- Ipratropium (anticholinergic) is an adjunct in acute exacerbations; combined with SABA for synergistic effect.
- Oral/IV corticosteroids (methylprednisolone, prednisone) for acute exacerbations; reduce inflammation.
- ALWAYS USE A SPACER with MDI in children; improves lung deposition and compliance.
- Teach trigger avoidance: avoid smoke, dust, cold air, allergens; maintain environmental control.
- Provide a WRITTEN ASTHMA ACTION PLAN using traffic-light system (green/yellow/red zones); ensure family understands when to use reliever vs. controller vs. seek ER.
- Peak flow monitoring in older children can help identify early worsening.
- Monitor for medication side effects: tremor, tachycardia (SABA); oral candidiasis (ICS).
Key Definitions
Term
Asthma
Example
Child with history of recurrent wheezing triggered by cold air, exercise, or allergens = asthma.
Definition
Chronic reversible airway inflammation with bronchospasm, mucosal edema, and mucus production; presents with WHEEZING (expiratory), COUGH, CHEST TIGHTNESS, PROLONGED EXPIRATION.
Term
Silent Chest
Example
Child in acute distress, using accessory muscles, but NO wheeze heard on auscultation = silent chest; EMERGENCY; prepare for intubation.
Definition
Absence of audible wheeze in a child with severe asthma exacerbation; indicates SEVERE OBSTRUCTION and impending respiratory failure — OMINOUS SIGN.
Term
Short-Acting Beta-2 Agonist (SABA)
Example
Child with acute wheezing receives nebulised salbutamol 2.5 mg; within 15–20 min, wheezing improves.
Definition
Reliever/rescue drug (e.g., salbutamol/albuterol); rapid bronchodilation in acute bronchospasm; side effects = tachycardia, tremor, jitteriness.
Term
Inhaled Corticosteroid (ICS)
Example
Asthmatic child on twice-daily fluticasone inhaler; TEACH: rinse mouth after use to prevent oral thrush.
Definition
Controller/preventer drug (e.g., fluticasone, budesonide); reduces airway inflammation; used daily in persistent asthma.
Term
Spacer (Holding Chamber)
Example
Young child with asthma uses spacer with MDI; improves medication deposition in lower airways compared to MDI alone.
Definition
Device attached to metered-dose inhaler (MDI) to improve drug delivery in children; reduces need for hand-breath coordination.
Term
Asthma Action Plan
Example
Asthmatic child given written action plan: green zone = no symptoms, use controller daily; yellow zone = occasional cough/wheeze, add reliever; red zone = severe distress, go to ER.
Definition
Written, individualised plan specifying when to use reliever, controller, and when to seek emergency care; traffic-light system (green/yellow/red).
Diagrams To Know
- Asthma classification and step-wise management algorithm
- Traffic-light asthma action plan (green/yellow/red zones)
- Normal airway vs. asthma airway (inflammation, bronchoconstriction, mucus)
Common Values
Value
1–5 weeks (peak 2–3 weeks)
Symbol
Time
Quantity
Interval: Strep throat to ARF onset
Value
1.2 million units IM monthly OR 250 mg PO daily
Symbol
Dose
Quantity
Penicillin G prophylaxis
Section Title
Rheumatic Fever (Autoimmune Sequela of Untreated GABHS)
Important Facts
- ARF follows UNTREATED or PARTIALLY TREATED Group A beta-hemolytic streptococcal pharyngitis; peak onset 2–3 weeks after strep throat.
- PREVENTION IS KEY: Treat strep throat COMPLETELY with the FULL ANTIBIOTIC COURSE (10 days penicillin) — the #1 tested prevention point.
- Major Jones Criteria manifestations: CARDITIS (most serious), POLYarthritis (migratory), CHOREA (Sydenham's), ERYTHEMA MARGINATUM (non-pruritic rash), SUBCUTANEOUS NODULES.
- Carditis is the MAJOR SIGN nurses must recognise; can lead to permanent MITRAL VALVE damage (stenosis/regurgitation) = RHD.
- Diagnosis: Jones Criteria (2 major or 1 major + 2 minor) + evidence of preceding GABHS (strep serology positive, culture positive, or recent strep exposure).
- Management: Penicillin to eradicate strep; anti-inflammatories (aspirin for arthritis/carditis under supervision; NSAIDs); rest during acute phase.
- Long-term prophylactic penicillin (monthly benzathine penicillin G IM or daily oral penicillin V) for years to PREVENT RECURRENCE.
- Sydenham's chorea may persist for months; manage with supportive care, sedatives if needed; can recur after stress.
- Erythema marginatum = non-pruritic, migratory rash with pale centre; characteristic of ARF.
- Subcutaneous nodules are rare; hard, painless nodules over bony prominences.
- Complications: permanent valve disease (RHD), heart failure, arrhythmias, emboli.
- Long-term antibiotic prophylaxis is CRITICAL to prevent recurrent ARF and further valve damage; compliance is challenging but essential.
Key Definitions
Term
Acute Rheumatic Fever (ARF)
Example
Child with untreated strep throat 3 weeks prior now presents with fever, joint pain, new murmur = ARF.
Definition
Autoimmune inflammatory disease following untreated Group A Beta-Hemolytic Streptococcal (GABHS) pharyngitis; occurs 1–5 weeks after strep throat; most common in school-age children.
Term
Rheumatic Heart Disease (RHD)
Example
Teen with history of ARF now has mitral stenosis and irregular heartbeat = RHD.
Definition
Chronic sequela of ARF; permanent valve damage (mitral valve most common) resulting in stenosis, regurgitation, or both.
Term
Jones Criteria
Example
Child with carditis + polyarthritis + strep serology positive = meets Jones criteria for ARF.
Definition
Clinical/laboratory criteria for diagnosis of ARF; requires 2 major criteria (or 1 major + 2 minor) PLUS evidence of preceding GABHS infection.
Term
Sydenham's Chorea
Example
School-age child with sudden onset of involuntary jerky movements and emotional lability = Sydenham's chorea; screen for other ARF features.
Definition
Involuntary, purposeless movements of the face, trunk, and limbs; a major criterion for ARF; may persist for months; manage symptomatically.
Diagrams To Know
- Jones Criteria (major and minor manifestations) decision tree
- Pathway from untreated strep throat → ARF → RHD
- Long-term prophylaxis protocol for ARF recurrence prevention
Common Values
Value
>5 days, unresponsive to antipyretics
Symbol
Temperature
Quantity
Fever threshold for Kawasaki
Value
2 g/kg single IV infusion
Symbol
Dose
Quantity
IVIG dose
Value
80–100 mg/kg/day in 4 divided doses
Symbol
Dose
Quantity
High-dose aspirin: acute phase
Value
3–5 mg/kg/day for antiplatelet effect
Symbol
Dose
Quantity
Low-dose aspirin: maintenance
Section Title
Kawasaki Disease (Acute Vasculitis in Young Children)
Important Facts
- Kawasaki disease = acute vasculitis of unknown cause in young children; PEAK AGE <5 years.
- LEADING CAUSE OF ACQUIRED HEART DISEASE in developed countries (has replaced rheumatic fever in many settings).
- Diagnostic clues: FEVER >5 DAYS UNRESPONSIVE TO ANTIPYRETICS, BILATERAL NON-PURULENT CONJUNCTIVITIS, STRAWBERRY TONGUE, RED CRACKED LIPS, CERVICAL LYMPHADENOPATHY, POLYMORPHOUS RASH, SWELLING/REDNESS/PEELING OF HANDS AND FEET.
- No single pathognomonic test; diagnosis is CLINICAL (criteria-based) + exclusion of other causes.
- DREADED COMPLICATION: CORONARY ARTERY ANEURYSM (risk ~25% if untreated; <5% with IVIG + aspirin).
- Management: IV immunoglobulin (IVIG) 2 g/kg single dose + HIGH-DOSE aspirin (80–100 mg/kg/day in 4 divided doses) during acute phase; continue high-dose aspirin until inflammation resolves, then switch to low-dose (3–5 mg/kg/day) for antiplatelet effect for 6–8 weeks or longer.
- ASPIRIN IN CHILDREN is normally avoided, but Kawasaki disease is a KEY EXCEPTION where high-dose aspirin is STANDARD OF CARE.
- Treatment should begin within 10 days of fever onset for optimal outcome; delay increases coronary complications risk.
- After acute phase, long-term cardiac surveillance (echocardiography, angiography) is essential to detect coronary involvement.
- Teach parents: irritability, poor feeding, and joint swelling may persist; skin peeling (especially fingers/toes) continues post-fever.
- Fever typically resolves within 48 hours of IVIG + aspirin start; if fever persists >5 days, consider retreating with IVIG or other interventions.
Key Definitions
Term
Kawasaki Disease
Example
Toddler with persistent fever (39–40°C for 7 days), red swollen hands/feet, strawberry tongue, rash = Kawasaki disease.
Definition
Acute vasculitis of unknown aetiology in young children (usually <5 years); LEADING CAUSE OF ACQUIRED HEART DISEASE in developed countries; high fever >5 days unresponsive to antipyretics.
Term
Strawberry Tongue
Example
Child with Kawasaki disease presents with swollen red papillae on tongue (strawberry appearance) + cracked red lips.
Definition
Tongue with prominent papillae and red appearance, resembling a strawberry; characteristic of Kawasaki disease.
Term
Coronary Artery Aneurysm
Example
Child with untreated Kawasaki disease develops coronary artery aneurysm; 25% untreated risk; with IVIG + aspirin, risk drops to <5%.
Definition
Dilated coronary artery; the DREADED COMPLICATION of Kawasaki disease if untreated; can lead to thrombosis, MI, and sudden cardiac death.
Diagrams To Know
- Kawasaki disease diagnostic criteria (fever + 4 of 5 additional features)
- Timeline: acute phase → convalescent phase → convalescent complications phase
- Coronary artery aneurysm risk (untreated vs. treated with IVIG + aspirin)
Common Values
Value
~10 weeks (adjusted for prematurity)
Symbol
Timing
Quantity
Cleft lip repair age
Value
~10 lb (~4.5 kg)
Symbol
Timing
Quantity
Cleft lip repair weight
Value
~10 g/dL
Symbol
Timing
Quantity
Cleft lip repair Hgb
Value
6–12 months (before speech develops)
Symbol
Timing
Quantity
Cleft palate repair age
Section Title
Cleft Lip and Cleft Palate — Feeding & Post-operative Care
Important Facts
- Cleft lip/palate are congenital malformations from failure of in-utero fusion; can occur separately or together.
- PRIORITY PROBLEMS: Feeding difficulty and risk of aspiration due to poor suction; later speech and ear (otitis media) complications.
- FEEDING (Pre-operative): Hold UPRIGHT, use WIDE/CROSS-CUT NIPPLES or SQUEEZABLE BOTTLES, feed SLOWLY, BURP FREQUENTLY (they swallow air), allow adequate time (up to 45 min), avoid frustration.
- Breastfeeding IS OFTEN STILL POSSIBLE with cleft lip/palate; encourage if mother willing; positioning is key (upright, support the jaw).
- CLEFT LIP REPAIR: By Rule of 10s — ~10 weeks old, ~10 lb (~4.5 kg), Hgb ~10 g/dL. If infant is premature, adjust for corrected age.
- CLEFT PALATE REPAIR: Usually later (~6–12 months), BEFORE SPEECH DEVELOPS; repair during optimal window for speech development.
- POST-OP CLEFT LIP CARE: PROTECT SUTURE LINE — Position SUPINE or SIDE-LYING (NEVER PRONE, to avoid rubbing sutures); apply ELBOW RESTRAINTS; keep suture line CLEAN; avoid TENSION/CRYING; NO HARD OBJECTS/UTENSILS in mouth; monitor for signs of infection.
- POST-OP CLEFT PALATE CARE: NOTHING HARD IN THE MOUTH — NO straws, pacifiers, spoons, or suction catheters near suture line; feed with CUP or SIDE OF SPOON; SOFT/LIQUID diet; ELBOW RESTRAINTS; monitor for airway patency.
- Elbow restraints: Check circulation, skin integrity regularly; remove for supervised arm movement/play but NOT during sleep.
- Pain management post-op: assess pain, use appropriate analgesia (acetaminophen, ibuprofen as ordered); comfort measures.
- Suture line care: gentle cleaning with sterile saline or as per surgeon protocol; observe for redness, drainage, dehiscence.
- Avoid suction near suture line; use bulb syringe gently for secretion removal if needed.
- Long-term follow-up: Speech therapy, dental care, hearing assessment (due to palatal involvement affecting Eustachian tube).
- Teach parents about post-op restrictions, activity limitations, when to call physician (fever, bleeding, suture separation).
Key Definitions
Term
Cleft Lip
Example
Newborn with visible opening/gap in the upper lip, unilateral or bilateral = cleft lip.
Definition
Congenital malformation from failure of fusion of maxillary and medial nasal processes; may involve lip only, lip and alveolus, or extend into nostril.
Term
Cleft Palate
Example
Infant with cleft palate has difficulty achieving suction for breastfeeding; visible opening in roof of mouth.
Definition
Congenital malformation from failure of fusion of palatal shelves; may be partial (incomplete) or complete (extends from hard to soft palate).
Term
Rule of 10s (Cleft Lip Repair Timing)
Example
Newborn with cleft lip is scheduled for surgical repair at 10–12 weeks of age, once weight and haemoglobin thresholds are met.
Definition
Traditional guideline for cleft lip repair: infant should be ~10 weeks old, weigh ~10 lb (~4.5 kg), and have Hgb ~10 g/dL.
Term
No-No Restraints (Elbow Restraints)
Example
Post-op cleft lip infant wears elbow restraints to prevent hand-to-face contact and disruption of sutures.
Definition
Soft restraints applied to elbows post-operatively to prevent infant from touching/rubbing the suture line.
Diagrams To Know
- Cleft lip and palate classification and types
- Pre-operative feeding techniques for cleft lip/palate
- Post-operative cleft lip care checklist (positioning, restraints, suture line protection)
- Post-operative cleft palate care checklist (diet, feeding, mouth care)
- Timeline: Rule of 10s for cleft lip repair
Must Remember
- **VSD = MOST COMMON CHD overall; Tetralogy of Fallot = MOST COMMON CYANOTIC CHD** (pulmonary stenosis + VSD + overriding aorta + RVH; boot-shaped heart on X-ray).
- **Tet Spell PRIORITY ACTION = KNEE-CHEST POSITION** (older child squats) + oxygen + calm environment; this increases systemic vascular resistance and reduces right-to-left shunt. Morphine as ordered.
- **PDA:** Indomethacin or ibuprofen CLOSES the ductus arteriosus; **Prostaglandin E1 KEEPS the ductus OPEN** in duct-dependent lesions (PDA, TGA, tricuspid atresia). This is a life-saving distinction.
- **Coarctation of the aorta classic sign = higher BP and BOUNDING PULSES in ARMS; LOWER BP and WEAK/ABSENT FEMORAL PULSES in LEGS.**
- **Digoxin: ALWAYS COUNT APICAL PULSE FOR A FULL MINUTE before every dose; HOLD if <90–100 bpm (infant) or <70 bpm (child).** Toxicity signs: bradycardia, vomiting, anorexia. **Hypokalemia potentiates toxicity.**
- **Epiglottitis = AIRWAY EMERGENCY;** **Four D's: Drooling, Dysphagia, Dysphonia, Distress;** classic position = tripod/sniffing; **DO NOT examine throat with tongue depressor or take throat culture** — risk of complete laryngospasm. Have emergency airway equipment at bedside.
- **Croup = viral, barking/seal-like cough, inspiratory stridor, steeple sign.** Management: cool mist, racemic epinephrine, dexamethasone; **keep child calm** — agitation worsens obstruction.
- **Bronchiolitis = RSV in infants <2 years;** **priority = strict CONTACT PRECAUTIONS (gloves, gown, hand hygiene).** **Palivizumab is PROPHYLAXIS, not treatment.** Management is supportive: suctioning, oxygen, hydration.
- **Asthma: Salbutamol/albuterol = RELIEVER/RESCUE;** **Inhaled corticosteroids = CONTROLLER/PREVENTER (rinse mouth after use).** **SILENT CHEST (no audible wheeze in distressed child) = SEVERE obstruction and OMINOUS SIGN.**
- **Cleft lip/palate: PRIORITY = feeding difficulty + aspiration risk. Rule of 10s for lip repair (10 weeks, 10 lb, Hgb 10).** Post-op care: **elbow restraints, NO prone positioning (lip repair), NO hard objects/straws/pacifiers in mouth (palate repair).** Palate repair usually 6–12 months before speech.
Last Minute Tips
- **Remember the 5 T's of cyanotic CHD for rapid recall:** Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus, Total anomalous pulmonary venous return. If a question describes cyanosis unrelieved by O₂, one of these is the answer.
- **Digoxin and prostaglandin E1 are OPPOSITE-ACTION drugs:** Digoxin strengthens contractions; prostaglandin E1 dilates (keeps ductus open). On an exam, if you see 'prostaglandin E1' with a CHD question, think 'duct-dependent lesion' and 'keep the ductus OPEN.' If you see 'indomethacin,' think 'PDA closure.'
- **Post-operative cleft palate: think NOTHING HARD IN THE MOUTH.** No straws, spoons, pacifiers, suction catheters, or feeding tubes near the palate suture line. Cup feeding or side-of-spoon feeding only.
- **RSV bronchiolitis in a question = CONTACT PRECAUTIONS MANDATORY.** Even if other management is mentioned, if the question asks about nursing priorities, contact precautions (private room, gloves, gown, hand hygiene) must be in your answer.
- **On NLE questions about heart murmurs and CHD:** Remember murmur timing — holosystolic (pansystolic) = VSD; continuous (machine-like) = PDA; systolic ejection = ASD or pulmonary stenosis. This phonetic finding can quickly narrow diagnosis.
Comparison Tables
Rows
Values
- Oxygenated blood shunts back to lungs
- Deoxygenated blood bypasses lungs → enters systemic circulation
Property
Shunt direction
Values
- Pink, not cyanotic (initially)
- Cyanotic (blue), even with supplemental O₂
Property
Appearance
Values
- CHF from pulmonary overcirculation
- Hypoxaemia, acidosis, polycythaemia
Property
Primary risk
Values
- VSD, ASD, PDA, coarctation
- TOF, TGA, tricuspid atresia, truncus, TAPVR
Property
Common types
Values
- O₂ saturation may improve slightly
- Cyanosis DOES NOT IMPROVE with supplemental O₂ (unrelieved cyanosis)
Property
Response to O₂
Values
- Not typically used; indomethacin/ibuprofen CLOSES PDA
- Used to KEEP ductus arteriosus OPEN in duct-dependent lesions
Property
Prostaglandin E1 use
Columns
- Feature
- Acyanotic (Left-to-Right Shunt)
- Cyanotic (Right-to-Left Shunt)
Table Title
Acyanotic vs. Cyanotic CHD — Quick Comparison
Rows
Values
- Viral (parainfluenza)
- Bacterial (Hib)
- Viral (RSV)
Property
Aetiology
Values
- 6 months–3 years
- Any age (often 2–6 years)
- Infants <2 years (peak 2–6 months)
Property
Age group
Values
- Barking/seal-like cough
- Drooling, dysphagia, dysphonia
- Wheezing, retractions
Property
Classic sign
Values
- Inspiratory stridor
- Stridor (usually inspiratory, may be biphasic)
- Wheeze, crackles
Property
Respiratory sound
Values
- Mild to moderately ill, not toxic
- TOXIC, high fever, tripod position, drooling
- Ill, poor feeding, tachypnoea
Property
Appearance
Values
- Steeple sign (narrowed subglottic)
- Thumb sign (enlarged epiglottis)
- Hyperinflation, air trapping
Property
X-ray finding
Values
- Cool mist, racemic epinephrine, dexamethasone
- Airway protection, antibiotics, prepare for intubation
- Suctioning, oxygen, hydration, contact precautions
Property
Management
Values
- Agitate; keep calm
- Examine throat with tongue depressor; examine throat at all
- None (examine and treat supportively)
Property
CRITICAL do NOT do
Columns
- Feature
- Croup
- Epiglottitis
- Bronchiolitis
Table Title
Croup vs. Epiglottitis vs. Bronchiolitis — Rapid Differentiator
Rows
Values
- Reliever/rescue for acute bronchospasm
- Controller/preventer — daily use for inflammation
Property
Function
Values
- Fast (15–20 min)
- Slow (days to weeks)
Property
Onset
Values
- Beta-2 agonist — bronchodilation
- Corticosteroid — reduces airway inflammation
Property
Mechanism
Values
- Tachycardia, tremor, jitteriness, headache
- Oral thrush (if mouth not rinsed), hoarseness
Property
Side effects
Values
- ONLY when wheezing occurs (PRN)
- EVERY DAY in persistent asthma (scheduled)
Property
When to use
Values
- No special care
- RINSE MOUTH to prevent thrush
Property
Post-use care
Values
- Nebuliser or MDI + spacer
- Nebuliser or MDI + spacer
Property
Device
Columns
- Feature
- SABA (Salbutamol/Albuterol)
- ICS (Fluticasone/Budesonide)
Table Title
Asthma Drugs: SABA (Reliever) vs. ICS (Controller)
Rows
Values
- SUPINE or SIDE-LYING (NEVER PRONE)
- SUPINE or SIDE-LYING (head slightly elevated)
Property
Positioning
Values
- Protect from rubbing/tension; no hand-to-face contact
- Protect from hard objects; nothing in mouth
Property
Suture line protection
Values
- ELBOW RESTRAINTS (no-no restraints) ALWAYS
- ELBOW RESTRAINTS (no-no restraints) ALWAYS
Property
Restraints
Values
- Soft diet, bottle/cup; no straws initially
- SOFT/LIQUID DIET ONLY; no hard foods, straws, pacifiers, spoons near palate
Property
Feeding
Values
- Gentle; avoid lip area
- Gentle; NEVER SUCTION or insert objects near palate
Property
Suction
Values
- Keep minimal; avoid wide yawning
- Keep minimal; avoid wide yawning or jaw strain
Property
Mouth opening
Values
- Avoid; causes tension on suture line
- Avoid; causes tension on palatal repair
Property
Crying/distress
Values
- Usually 7–10 days (sutures removed)
- Usually 2–3 weeks (palatal repairs take longer to heal)
Property
Duration of restrictions
Columns
- Feature
- Post-op Cleft Lip
- Post-op Cleft Palate
Table Title
Post-operative Care: Cleft Lip vs. Cleft Palate
Rows
Values
- YES (most serious; can cause permanent valve damage)
- No
Property
Carditis
Values
- YES (knees, ankles, elbows, wrists)
- Monoarthritis or polyarthralgia (in young children)
Property
Polyarthritis (migratory)
Values
- YES (involuntary jerky movements)
- No
Property
Chorea (Sydenham's)
Values
- YES (non-pruritic rash with pale centre)
- No
Property
Erythema Marginatum
Values
- YES (hard, painless nodules)
- No
Property
Subcutaneous Nodules
Values
- No (but usually present)
- YES (fever >38.5°C)
Property
Fever
Values
- No
- YES (ESR >60 or CRP positive)
Property
ESR/CRP elevation
Values
- No (but may occur with carditis)
- YES (on ECG)
Property
Prolonged PR interval
Values
- 2 major criteria (or 1 major + 2 minor) PLUS evidence of preceding GABHS
- Counts toward diagnosis threshold
Property
Diagnosis requirement
Columns
- Manifestation
- Major Criteria
- Minor Criteria
Table Title
ARF (Rheumatic Fever) Major vs. Minor Jones Criteria
Rows
Values
- COUNT APICAL PULSE FOR FULL MINUTE
Property
BEFORE EVERY DOSE
Values
- <90–100 bpm
Property
HOLD digoxin if HR (Infant)
Values
- <70 bpm
Property
HOLD digoxin if HR (Older child)
Values
- DO NOT REPEAT DOSE; notify physician
Property
If vomiting occurs
Values
- Give at regular intervals; DO NOT mix with food/formula; use proper syringe
Property
Drug administration
Values
- Lock away; keep out of reach of other children
Property
Storage
Values
- Bradycardia, vomiting, anorexia, dysrhythmias (PVCs, bigeminy)
Property
Monitor for toxicity
Values
- SERUM POTASSIUM (hypokalemia potentiates toxicity)
Property
Key lab to check
Values
- 0.8–2.0 ng/mL
Property
Therapeutic level
Columns
- Checkpoint
- Action / Parameter
Table Title
Digoxin Dosing & Safety Checkpoints (Paediatric)
Previous chapter
Paediatric Assessment, Hospitalization & Pain
Next chapter
Paediatric GI, Genitourinary & Neurologic Disorders
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