Chronic Paediatric Conditions

Chronic Paediatric Conditions UK Medical PG Question 1: A 8-year-old child presents with fever, irritability, and a widespread petechial rash that doesn't blanch with pressure. The child appears unwell and has neck stiffness. What is the most appropriate immediate management?

• A. Oral antibiotics
• B. IV benzylpenicillin (Correct Answer)
• C. Lumbar puncture
• D. Blood cultures
• E. CT head

Chronic Paediatric Conditions Explanation: ***IV benzylpenicillin***- The constellation of fever, irritability, widespread non-blanching petechial rash, unwell appearance, and neck stiffness is highly suggestive of **meningococcal disease** (meningitis with or without septicaemia), a medical emergency.- **Immediate empirical intravenous antibiotics**, such as **benzylpenicillin**, are critical to reduce mortality and morbidity in suspected meningococcal disease and should not be delayed by investigations. *Oral antibiotics*- The child presents with severe symptoms, including an **unwell appearance** and **non-blanching rash**, indicating a life-threatening infection requiring urgent intervention.- **Oral antibiotics** are inadequate for treating severe, rapidly progressing infections like meningococcal disease due to potentially slow absorption and insufficient blood-brain barrier penetration.*Lumbar puncture*- While a **lumbar puncture** is crucial for definitive diagnosis of meningitis, it must **not delay the immediate administration of IV antibiotics** in suspected meningococcal disease.- In a critically unwell child with signs of increased intracranial pressure (e.g., severe irritability, neck stiffness in context of severe illness), a lumbar puncture carries a risk of **herniation** and should be deferred until after antibiotics are given and/or a CT head rules out a space-occupying lesion.*Blood cultures*- **Blood cultures** are important for identifying the causative organism and guiding specific antibiotic therapy, but they should be taken **concurrently with or immediately after administering the first dose of IV antibiotics**.- Delaying antibiotic administration to obtain blood cultures can have severe consequences in a rapidly deteriorating patient with suspected **meningococcal septicaemia**.*CT head*- A **CT head** may be indicated to rule out complications like **cerebral edema** or **abscess** before a lumbar puncture, especially if there are signs of raised intracranial pressure.- However, like other investigations, a **CT head should not delay the immediate administration of life-saving IV antibiotics** in a child with suspected meningococcal disease, where time to treatment directly impacts prognosis.

Chronic Paediatric Conditions UK Medical PG Question 2: A 4-year-old child presents with fever, irritability, and neck stiffness. Lumbar puncture shows: opening pressure 25 cmH₂O, WCC 800/μL (90% neutrophils), protein 2.8 g/L, glucose 1.2 mmol/L (serum glucose 6.0 mmol/L). What is the most likely diagnosis?

• A. Viral meningitis
• B. Bacterial meningitis (Correct Answer)
• C. Tuberculous meningitis
• D. Fungal meningitis
• E. Normal CSF

Chronic Paediatric Conditions Explanation: ***Bacterial meningitis***- The constellation of **fever**, **neck stiffness**, severely elevated CSF **protein** (2.8 g/L), and profoundly low CSF **glucose** (ratio 0.2) is classic for acute bacterial infection.- The marked CSF pleocytosis (800/μL) with a predominant population of **neutrophils** (90%) indicates a rapidly progressive, pyogenic process.*Viral meningitis*- Characterized by **lymphocytic pleocytosis** (predominant lymphocytes) rather than the neutrophilic dominance seen here.- CSF glucose levels are typically **normal** or only mildly reduced, unlike the severe hypoglycemia reported in this patient.*Tuberculous meningitis*- While associated with low CSF glucose and high protein, it generally presents **subacutely** or chronically over weeks, not acutely.- CSF pleocytosis is usually **lymphocytic** or monocytic, not the acute neutrophilic predominance found in this sample.*Fungal meningitis*- This is rare in immunocompetent children, usually follows an indolent or **chronic** course, and typically presents with **lymphocytic** pleocytosis.- The acute presentation with fever, irritability, and prominent neutrophilia points strongly away from a fungal etiology.*Normal CSF*- Normal CSF findings include an opening pressure < 18 cmH₂O, WCC < 5/μL, and a CSF/serum glucose ratio > 0.6.- All measured parameters (pressure 25, WCC 800, glucose ratio 0.2) are significantly **abnormal**, definitively ruling out normal CSF.

Chronic Paediatric Conditions UK Medical PG Question 3: A 3-year-old child presents with a barking cough, inspiratory stridor, and hoarse voice. The symptoms are worse at night. The child is alert and playful. What is the most likely diagnosis?

• A. Epiglottitis
• B. Croup (Correct Answer)
• C. Bronchiolitis
• D. Pneumonia
• E. Foreign body aspiration

Chronic Paediatric Conditions Explanation: ***Croup*** - The presentation of a **barking cough**, **inspiratory stridor**, and **hoarse voice** in a 3-year-old is the classic triad for **Croup** (laryngotracheobronchitis), typically caused by the **Parainfluenza virus**. - Symptoms are typically worse at night due to increased **vagal tone** and decreased ambient humidity, yet the child remains alert and non-toxic, which is characteristic of mild-to-moderate croup. *Epiglottitis* - This condition presents as a medical emergency with rapid onset of **high fever**, severe **dysphagia**, drooling, and a **muffled voice**, but usually lacks the characteristic **barking cough**. - The child with epiglottitis typically appears **toxic**, apprehensive, and prefers the **tripod position**, unlike the alert and playful child described. *Bronchiolitis* - Bronchiolitis is an infection of the small airways, primarily causing **wheezing**, **tachypnea**, and signs of **lower respiratory distress**, usually without stridor or the specific barking cough. - It predominantly affects infants under 2 years of age and is most often caused by **Respiratory Syncytial Virus (RSV)**. *Pneumonia* - This is an infection of the lung parenchyma, presenting with fever, **tachypnea**, and often a productive cough accompanied by focal findings like **crackles** or **dullness** on chest exam. - Pneumonia does not typically cause prominent **inspiratory stridor** or the characteristic **barking cough** associated with upper airway swelling. *Foreign body aspiration* - This diagnosis usually involves a sudden onset of **choking** or coughing, and if the object is lodged in the larynx or trachea, it causes stridor, but the symptoms do not typically fluctuate and worsen specifically **at night**.

Chronic Paediatric Conditions UK Medical PG Question 4: A 9-year-old boy with known asthma presents to the emergency department with an acute exacerbation. Following administration of oxygen, nebulized salbutamol, ipratropium bromide, and oral prednisolone, he remains in respiratory distress with oxygen saturation 92% on high-flow oxygen, peak flow 30% of predicted, and poor respiratory effort. What is the appropriate dose and route of magnesium sulphate administration in this clinical scenario?

• A. 40 mg/kg (maximum 2 g) intravenous infusion over 20 minutes (Correct Answer)
• B. 25 mg/kg (maximum 1 g) intravenous bolus over 5 minutes
• C. 40 mg/kg nebulized with salbutamol
• D. 50 mg/kg (maximum 2.5 g) intravenous infusion over 30 minutes
• E. 150 mg nebulized with ipratropium bromide

Chronic Paediatric Conditions Explanation: ***40 mg/kg (maximum 2 g) intravenous infusion over 20 minutes*** - This patient presents with a **severe acute asthma exacerbation** (peak flow 30% predicted, poor respiratory effort, poor response to initial therapies), necessitating adjunctive intravenous magnesium sulphate. - Current guidelines recommend **intravenous magnesium sulphate** at **40 mg/kg** (maximum 2 g) administered as a slow **infusion over 20 minutes** for children with severe refractory asthma. *25 mg/kg (maximum 1 g) intravenous bolus over 5 minutes* - This **dose (25 mg/kg)** is below the recommended concentration for treating **severe pediatric asthma exacerbations**, which typically calls for 40 mg/kg. - Administering magnesium as a rapid **intravenous bolus over 5 minutes** significantly increases the risk of adverse effects like **hypotension** and cardiac arrhythmias. *40 mg/kg nebulized with salbutamol* - While **nebulized magnesium sulphate** has been studied, its efficacy for **life-threatening asthma exacerbations** is not as well-established as the intravenous route, especially after failure of initial nebulized bronchodilators. - For severe, refractory asthma, **systemic (intravenous) administration** is preferred as it ensures better absorption and clinical effect compared to nebulized delivery. *50 mg/kg (maximum 2.5 g) intravenous infusion over 30 minutes* - This dose of **50 mg/kg** exceeds the standard **maximum recommended dose of 2 g** for intravenous magnesium sulphate in pediatric asthma, raising concerns for increased toxicity without additional therapeutic benefit. - Although a slow infusion, the **recommended duration** is typically 20 minutes for managing acute asthma effectively while minimizing side effects. *150 mg nebulized with ipratropium bromide* - The dose of **150 mg** is an incorrect fixed dose for nebulized magnesium sulphate in children; dosing is typically **weight-based**, and this combination with ipratropium bromide is not standard. - In a **life-threatening asthma exacerbation** with poor respiratory effort, **systemic (intravenous) magnesium sulphate** is the indicated adjunctive treatment, as nebulized delivery is less effective in this critical scenario.

Chronic Paediatric Conditions UK Medical PG Question 5: A 6-month-old baby presents with failure to thrive, chronic diarrhea, and recurrent respiratory infections. Sweat chloride test is 70 mmol/L (normal <40). What is the most likely diagnosis?

• A. Celiac disease
• B. Cystic fibrosis (Correct Answer)
• C. Immunodeficiency
• D. Inflammatory bowel disease
• E. Lactose intolerance

Chronic Paediatric Conditions Explanation: ***Cystic fibrosis***- The constellation of **failure to thrive**, chronic **malabsorptive diarrhea** (due to **pancreatic insufficiency**), and recurrent **respiratory infections** (due to thick mucus) is classic for **Cystic fibrosis**.- A sweat chloride level of 70 mmol/L is diagnostic for **Cystic fibrosis** in an infant (cut-off is typically >60 mmol/L), confirming the defect in the **CFTR channel**.*Celiac disease*- While a cause of failure to thrive and chronic diarrhea, symptoms typically manifest after the introduction of **gluten** (usually after 6 months of age) and often involve abdominal distension.- It does not cause recurrent respiratory infections as a primary feature, nor is it associated with an elevated **sweat chloride** level.*Immunodeficiency*- This could explain **recurrent respiratory infections** and failure to thrive, but it typically does not cause the specific syndrome of chronic steatorrhea due to **pancreatic insufficiency**.- Immunodeficiency conditions do not result in an abnormally high **sweat chloride** test result.*Inflammatory bowel disease*- IBD rarely presents in early infancy (6 months) and usually causes features like **bloody diarrhea** and **abdominal pain** rather than the typical **steatorrhea** associated with pancreatic insufficiency.- IBD is not associated with an elevated **sweat chloride** test or recurrent sino-pulmonary infections driven by mucus accumulation.*Lactose intolerance*- This causes osmotic diarrhea and potentially failure to thrive, but the symptoms are strictly gastrointestinal and often improve when **lactose** is removed from the diet.- It does not explain the hallmark triad of pulmonary disease, malabsorption, and the pathognomonic **elevated sweat chloride**.

Chronic Paediatric Conditions UK Medical PG Question 6: A 16-year-old girl with type 1 diabetes for 10 years attends for transition planning to adult services. Her HbA1c has been consistently between 65-72 mmol/mol over the past 2 years. Annual screening shows persistent microalbuminuria (ACR 4.8 mg/mmol) and background diabetic retinopathy with scattered microaneurysms bilaterally. She is on appropriate therapy including an ACE inhibitor. She asks about her long-term prognosis. What is the most appropriate counselling regarding her microvascular complications?

• A. Microalbuminuria at this stage is irreversible regardless of subsequent glycaemic control
• B. With current control, progression to end-stage renal disease is inevitable within 10 years
• C. Optimizing glycaemic control now can still slow progression even with established complications (Correct Answer)
• D. Background retinopathy always progresses to proliferative retinopathy requiring laser therapy
• E. Presence of two microvascular complications indicates imminent need for renal transplantation

Chronic Paediatric Conditions Explanation: ***Optimizing glycaemic control now can still slow progression even with established complications*** - The **Diabetes Control and Complications Trial (DCCT)** and EDIC studies confirm that improving glycaemic control reduces the risk of **microvascular progression** even after complications like **microalbuminuria** or **background retinopathy** appear. - Achieving a target **HbA1c <48 mmol/mol** is critical during transition to prevent the worsening of damage through the mechanism of **metabolic memory**. *Microalbuminuria at this stage is irreversible regardless of subsequent glycaemic control* - **Microalbuminuria** (ACR 3–30 mg/mmol) is potentially **reversible** or can be stabilized with intensive glycaemic control and **ACE inhibitor** therapy. - Progression to **macroalbuminuria** is common if control remains poor, but early intervention often leads to **regression** to normoalbuminuria. *With current control, progression to end-stage renal disease is inevitable within 10 years* - While an HbA1c of 65-72 mmol/mol increases risk, **End-Stage Renal Disease (ESRD)** typically takes decades to develop, and many patients with early nephropathy remain **stable for years**. - Labelling ESRD as **inevitable** is clinically inaccurate and discouraged in transition counselling as it ignores the impact of **blood pressure** and glycaemic management. *Background retinopathy always progresses to proliferative retinopathy requiring laser therapy* - **Background retinopathy** (microaneurysms) may remain stable for long periods or even **regress** if glycaemic control and **blood pressure** are well-managed. - Progression to **proliferative diabetic retinopathy (PDR)** is not a certainty and depends heavily on the duration of **hyperglycaemia**. *Presence of two microvascular complications indicates imminent need for renal transplantation* - The presence of multiple complications indicates a **high-risk profile** requiring intensive multidisciplinary care, but does not suggest **acute organ failure**. - **Renal transplantation** is only considered for stage 5 **chronic kidney disease**, whereas this patient currently has early-stage **diabetic nephropathy**.

Chronic Paediatric Conditions UK Medical PG Question 7: A 4-year-old boy with newly diagnosed generalized epilepsy is being commenced on sodium valproate. His mother asks about potential side effects. Which of the following monitoring investigations should be performed before starting sodium valproate and at regular intervals during treatment?

• A. Full blood count, renal function, and thyroid function tests
• B. Liver function tests, full blood count, and serum ammonia (Correct Answer)
• C. Electrocardiogram, liver function tests, and lipid profile
• D. Full blood count, vitamin D levels, and bone density scan
• E. Renal function, serum drug levels, and electroencephalogram

Chronic Paediatric Conditions Explanation: ***Liver function tests, full blood count, and serum ammonia***- Sodium valproate carries a risk of idiosyncratic **hepatotoxicity**, making baseline and regular **Liver Function Tests (LFTs)** essential, especially during the first 6 months of therapy.- **Full blood count (FBC)** is required to monitor for **thrombocytopenia** and other blood dyscrasias, while **serum ammonia** helps detect valproate-induced **hyperammonemia** which can present as lethargy or confusion.*Full blood count, renal function, and thyroid function tests*- While FBC is necessary, valproate is not primarily excreted by the kidneys and does not typically cause **renal impairment** requiring routine monitoring.- **Thyroid function tests** are not standard for valproate; they are more relevant for medications like **lithium** or **amiodarone**.*Electrocardiogram, liver function tests, and lipid profile*- **ECG monitoring** is not routinely required for valproate, unlike drugs like **tricyclic antidepressants** or certain antipsychotics that affect the **QT interval**.- Although valproate can cause **weight gain**, a routine **lipid profile** is not a primary safety monitoring requirement compared to LFTs and hematology.*Full blood count, vitamin D levels, and bone density scan*- Long-term anticonvulsant use is linked to **reduced bone mineral density**, but **DEXA scans** are not part of the standard pre-treatment or early routine monitoring battery.- Monitoring **vitamin D** may be considered long-term, but it is less critical than monitoring for acute **liver failure** or **bone marrow suppression**.*Renal function, serum drug levels, and electroencephalogram*- Unlike phenytoin or carbamazepine, there is a poor correlation between **serum drug levels** and the therapeutic effect or toxicity of valproate, so routine monitoring is not indicated.- An **EEG** is used for diagnosis and classification of epilepsy rather than as a routine investigation to monitor for medication **side effects**.

Chronic Paediatric Conditions UK Medical PG Question 8: A 13-year-old boy with type 1 diabetes for 7 years presents with intermittent episodes of abdominal bloating, early satiety, nausea, and vomiting, particularly after meals. He reports that vomiting sometimes contains food eaten several hours earlier. His HbA1c is 82 mmol/mol. On examination, he has mild epigastric tenderness and a succussion splash. Screening for coeliac disease is negative. What is the most likely diagnosis?

• A. Diabetic ketoacidosis with gastric stasis
• B. Gastroparesis secondary to diabetic autonomic neuropathy (Correct Answer)
• C. Superior mesenteric artery syndrome
• D. Helicobacter pylori-associated gastritis
• E. Coeliac disease with false-negative serology

Chronic Paediatric Conditions Explanation: ***Gastroparesis secondary to diabetic autonomic neuropathy*** - This condition is a classic complication of long-standing **Type 1 Diabetes** with poor glycemic control, leading to delayed gastric emptying due to **vagal nerve damage**.- Symptoms like **early satiety**, vomiting of food consumed hours prior, and a positive **succussion splash** indicating retained gastric contents are pathognomonic.*Diabetic ketoacidosis with gastric stasis*- While **DKA** can cause acute gastroparesis, it typically presents with acute-onset abdominal pain, **uncompensated metabolic acidosis**, and ketosis, which are not described here.- The history of intermittent postprandial symptoms over time is more indicative of a **chronic autonomic neuropathy** than an acute metabolic emergency.*Superior mesenteric artery syndrome*- This occurs when the **duodenum** is compressed between the SMA and the aorta, usually following **rapid weight loss**.- Although it presents with postprandial vomiting, it is less common in this clinical context and would not be primary suspected over **diabetic neuropathy** in a long-standing diabetic.*Helicobacter pylori-associated gastritis*- **H. pylori** commonly causes chronic epigastric pain and dyspepsia, but it does not typically lead to mechanical or functional **gastric outlet obstruction**.- The presence of a **succussion splash** strongly suggests a motility or obstructive disorder rather than simple mucosal inflammation.*Coeliac disease with false-negative serology*- While **Coeliac disease** is frequently associated with Type 1 Diabetes, it usually presents with diarrhea, malabsorption, or growth failure rather than **gastric stasis**.- Serology was negative, and the specific finding of a **succussion splash** is not a feature of Coeliac disease.

Chronic Paediatric Conditions UK Medical PG Question 9: An 8-year-old girl presents with frequent brief episodes where she suddenly stops what she is doing, stares blankly for 5-10 seconds, and then resumes her activity with no recollection of the event. Her teacher reports these episodes occur up to 20 times per day and are affecting her school performance. An EEG is performed. Which EEG finding would most strongly support the diagnosis of childhood absence epilepsy?

• A. Focal spike and wave discharges in the temporal region
• B. Generalized 3 Hz spike-and-wave discharges induced by hyperventilation (Correct Answer)
• C. Hypsarrhythmia pattern with high-amplitude chaotic activity
• D. Photoparoxysmal response with generalized polyspike-and-wave complexes
• E. Centrotemporal spikes activated during drowsiness and sleep

Chronic Paediatric Conditions Explanation: ***Generalized 3 Hz spike-and-wave discharges induced by hyperventilation*** - This is the pathognomonic EEG finding for **Childhood Absence Epilepsy (CAE)**, characterized by synchronous, symmetrical discharges with abrupt onset and termination. - **Hyperventilation** is a highly effective provocation technique that triggers these generalized seizures in over 90% of untreated patients. *Focal spike and wave discharges in the temporal region* - These findings are indicative of **Focal Impaired Awareness Seizures** (formerly complex partial seizures) originating in the **temporal lobe**. - Unlike absence seizures, temporal lobe seizures usually include a **post-ictal state** and last significantly longer than 10 seconds. *Hypsarrhythmia pattern with high-amplitude chaotic activity* - This chaotic EEG pattern is the hallmark of **West Syndrome** (infantile spasms), which typically presents in infants aged 4-8 months. - It consists of high-voltage, disorganized background activity and is associated with **developmental regression**. *Photoparoxysmal response with generalized polyspike-and-wave complexes* - This pattern is most commonly associated with **Juvenile Myoclonic Epilepsy (JME)** rather than childhood absence epilepsy. - JME usually presents in **adolescents** with myoclonic jerks specifically occurring upon awakening, often triggered by **photic stimulation**. *Centrotemporal spikes activated during drowsiness and sleep* - This finding is characteristic of **Benign Epilepsy with Centrotemporal Spikes (BECTS)**, also known as Benign Rolandic Epilepsy. - BECTS typically involves nocturnal seizures with **orofacial paresthesias** and drooling, rather than frequent daytime staring spells.

Chronic Paediatric Conditions UK Medical PG Question 10: A 10-year-old girl with type 1 diabetes for 5 years uses insulin glargine 18 units once daily at bedtime and insulin aspart before meals. She participates in competitive gymnastics training 5 evenings per week from 5-7pm. Her mother reports that she frequently becomes hypoglycaemic during and after training sessions despite eating extra snacks. Pre-dinner glucose is usually 8-10 mmol/L. What is the most appropriate modification to her insulin regimen?

• A. Increase the pre-lunch insulin aspart dose to provide better afternoon glucose control
• B. Switch insulin glargine from bedtime to morning administration
• C. Add metformin to reduce insulin requirements
• D. Reduce the pre-lunch insulin aspart dose by 30-50% on training days (Correct Answer)
• E. Split insulin glargine to twice daily administration with reduced total daily dose

Chronic Paediatric Conditions Explanation: ***Reduce the pre-lunch insulin aspart dose by 30-50% on training days***- Exercise increases **insulin sensitivity** and glucose uptake by muscles, requiring less insulin to maintain euglycemia, especially during the period of physical activity.- Rapid-acting insulin administered before lunch, such as **insulin aspart**, will still have significant activity during late afternoon gymnastics, making a dose reduction crucial to prevent **exercise-induced hypoglycemia**.*Increase the pre-lunch insulin aspart dose to provide better afternoon glucose control*- Increasing the dose of **pre-lunch aspart** would heighten the risk of **hypoglycemia** during the strenuous evening gymnastics, as more insulin would be active during this period.- The reported pre-dinner glucose levels of 8-10 mmol/L are not high enough to justify an increase that would likely lead to dangerous hypoglycemia during exercise.*Switch insulin glargine from bedtime to morning administration*- Changing the timing of **basal insulin** like glargine does not directly address the peak action of **bolus insulin** (aspart) which is responsible for the hypoglycemia during late afternoon activity.- This modification could also disrupt the overall **basal insulin coverage**, potentially leading to suboptimal glycemic control at other times, including nocturnal hyperglycemia.*Add metformin to reduce insulin requirements*- **Metformin** is primarily used in **Type 2 Diabetes** or **Type 1 Diabetes** with significant insulin resistance; it is not indicated for managing acute exercise-induced hypoglycemia in a 10-year-old with uncomplicated T1DM.- Its mechanism of action doesn't directly solve the issue of excess rapid-acting insulin activity during exercise, which is the root cause of the patient's hypoglycemia.*Split insulin glargine to twice daily administration with reduced total daily dose*- While splitting the **basal insulin** dose can sometimes improve glycemic stability, it is not the most targeted intervention for hypoglycemia specifically caused by **exercise-induced increased insulin sensitivity** interacting with mealtime bolus insulin.- Reducing the total daily basal dose might compromise overall glycemic control and lead to **hyperglycemia** on non-training days or at other times.

Chronic Paediatric Conditions Flashcard 1 of 9

Question: Down's syndrome is managed by a _____ whose care is normally coordinated by a community or neurodisability paediatrician

Answer: MDT

Chronic Paediatric Conditions Flashcard 2 of 9

Question: Key risk factors for cerebral palsy include _____, low birth weight, & TORCH infections

Answer: prematurity

Chronic Paediatric Conditions Flashcard 3 of 9

Question: Down's Syndrome is suggested by _____ hCG, increased nuchal thickness, decreased PAPPA

Answer: increased

Chronic Paediatric Conditions Flashcard 4 of 9

Question: Around ~_____% of children with simple febrile seizures develop epilepsy

Answer: 1

Chronic Paediatric Conditions Flashcard 5 of 9

Question: Children with Down's Syndrome are prone to _____

Answer: snoring

Chronic Paediatric Conditions Flashcard 6 of 9

Question: _____ instability in people with Down syndrome who participate in sports that may carry an increased risk of neck disclocation

Answer: Atlanto-axial

Chronic Paediatric Conditions Flashcard 7 of 9

Question: What investigation will confirm a diagnosis in Duchenne Muscular Dystrophy? _____

Answer: Genetic Analysis

Chronic Paediatric Conditions Flashcard 8 of 9

Question: There are two types of recongised ASDs known as _____

Answer: ostium secundum & ostium primum

Chronic Paediatric Conditions Flashcard 9 of 9

Question: ASDs can present with a splitting of _____

Answer: S2