ABFM KSA - Care of Children

Question 1

Question: 1 of 60

A 6-year-old female is brought to your office by her father for follow-up of an urgent care visit 2 days ago for uncontrolled epistaxis after minor trauma to her nose. She has not had another nosebleed since the urgent care visit but her mother has noted some bleeding of the child’s gums after she brushes her teeth. A review of her chart reveals that she has been healthy, apart from occasional childhood infections and mild allergies. Her growth and development have been normal. Her family history is benign except for Hashimoto’s thyroiditis in her mother. You saw the child 10 days ago for a febrile upper respiratory infection that resolved without complications.

On examination today the only significant finding is petechiae around her eyes. A CBC shows a WBC count of 7200/mm3 (N 4500–11,000), a hemoglobin level of 14.0 g/dL (N 12.0–16.0), a hematocrit of 40.7% (N 36.0–46.0), and a platelet count of 32,000/mm3 (N 150,000–300,000).

Which one of the following is true regarding this case?

1. She has likely had thrombocytopenia for a long time
2. The test of choice in this situation is serum antiplatelet antibodies
3. The test of choice in this situation is a bone marrow biopsy
4. The recent infection is the most likely cause of these findings
5. Child abuse is the most likely cause of these findings

Answer 1

1. She has likely had thrombocytopenia for a long time
2. The test of choice in this situation is serum antiplatelet antibodies
3. The test of choice in this situation is a bone marrow biopsy
4. The recent infection is the most likely cause of these findings
5. Child abuse is the most likely cause of these findings

Critique:

Childhood immune thrombocytopenia (ITP) typically presents with the sudden appearance of a petechial rash, bruising, and/or bleeding in an otherwise healthy-appearing child. Most children with ITP have a history of a preceding viral illness. ITP may also infrequently occur following administration of MMR vaccine. ITP can present at any age, but the peak incidence in childhood is between 2 and 5 years of age.

If thrombocytopenia is detected on a CBC, other causes of thrombocytopenia must be excluded before making a diagnosis of ITP. The three key diagnostic criteria for ITP are isolated thrombocytopenia with an otherwise normal peripheral CBC and smear, an absence of hepatosplenomegaly and lymphadenopathy on physical examination, and a platelet response to classic ITP therapy (usually intravenous anti-D immunoglobulin and possibly corticosteroids).

The usefulness of antiplatelet antibody measurement is an ongoing issue. The antibody is detectable in less than 70% of patients who have ITP. Platelet-associated antibodies to specific glycoproteins may also be detected in other disorders, and thus are inadequately sensitive or specific to be of diagnostic usefulness. In patients who have apparent ITP, measurement of antiplatelet antibodies is not recommended as a routine test and does not have prognostic significance with currently available tests. The absence of detectable autoantibodies in 30%–40% of patients suggests that additional mechanisms of platelet destruction may be important (SOR C). Direct T cell–mediated cytotoxicity against megakaryocytes and platelets may be the primary mechanism of thrombocytopenia in some patients.

Bone marrow aspiration and biopsy are no longer routinely performed in ITP. They can be performed in selected patients with atypical clinical or laboratory features that suggest malignancy or bone marrow failure, if there is failure to respond to ITP treatment, or new findings at a follow-up visit are inconsistent with ITP.

Child abuse would not cause low platelets.

Question 2

Question: 2 of 60

A 15-year-old male sees you for a routine health maintenance visit. He is 173 cm (68 in) tall and weighs 82 kg (181 lb), with a BMI of 27 kg/m2. After initially recording a blood pressure of 136/88 mm Hg, you perform three consecutive measurements and calculate his average blood pressure to be 128/78 mm Hg.

Based on the 2017 American Academy of Pediatrics guideline for screening and management of high blood pressure in children and adolescents, which one of the following is most accurate?

1. You should begin a workup for stage 1 hypertension
2. His blood pressure should be assessed using standardized tables based on height, weight, and sex
3. A blood pressure >140/90 mm Hg would be categorized as stage 2 hypertension
4. Lifestyle interventions should be recommended at this visit and his blood pressure should be evaluated again in 6 months

Answer 2

1. You should begin a workup for stage 1 hypertension
2. His blood pressure should be assessed using standardized tables based on height, weight, and sex
3. A blood pressure >140/90 mm Hg would be categorized as stage 2 hypertension
4. Lifestyle interventions should be recommended at this visit and his blood pressure should be evaluated again in 6 months

Critique:

The 2017 American Academy of Pediatrics guidelines for screening and managing high blood pressure for children and adolescents has categorized blood pressure readings and definitions for two different age groups: children 1–12 years of age and adolescents age 13 and older.

Normal and elevated blood pressures for children 1–12 years of age are based on the normative distribution of blood pressures in healthy children and should be interpreted on the basis of sex, age, and height.

The definitions for adolescents 13 years and older were simplified to align with blood pressure readings used in adults:

Elevated blood pressure (previously referred to as prehypertension) – systolic blood pressure 120–129 mm Hg with a diastolic blood pressure <80 mm Hg

Stage 1 hypertension – blood pressure 130–139/80–89 mm Hg

Stage 2 hypertension – blood pressure ≥140/90 mm Hg

With respect to frequency of testing, evidence-based recommendations relevant for this group include measuring blood pressure annually in children ≥3 years of age and in adolescents (SOR C). Blood pressures should be checked at every clinical encounter in all children ≥3 years of age, including adolescents, if they are obese, take medications known to increase blood pressure, or have renal disease, a history of aortic arch obstruction or coarctation of the aorta, or diabetes mellitus (SOR C).

Question 3

Question: 3 of 60

The mother of a 6-year-old male has recently noticed fecal soiling evident in the child’s underwear once or twice weekly. When she asks her son about this problem he quickly changes the subject to avoid the discussion. She fears that this sudden change might indicate a serious physical or psychological problem, which concerns her because the child’s father was recently diagnosed with bipolar disorder. She is married to the father but they are currently separated.

The child started first grade 4 months ago and appears to be doing well in school. His teacher reports no behavioral problems. Specifically, she said she has not noticed any behavior or odor that might suggest fecal soiling during the school day.

The mother had a normal prenatal course and delivery, and the child’s infancy and early childhood have been unremarkable. Developmental milestones were met in a timely fashion. He was exclusively breastfed until 6 months of age and continued partial breastfeeding until 18 months of age. He was fully toilet trained at 2½ years of age. There has been no recent change in his diet.

Which one of the following is true regarding this problem?

1. A referral for psychological assessment and counseling should be made at this visit
2. The most effective treatment plans include both dietary and behavioral components
3. A low-residue diet has been shown to reduce the frequency and amount of stool leakage
4. Biofeedback bowel training has been proven to reduce the frequency of fecal soiling in children over the age of 5 years

Answer 3

1. A referral for psychological assessment and counseling should be made at this visit
2. The most effective treatment plans include both dietary and behavioral components
3. A low-residue diet has been shown to reduce the frequency and amount of stool leakage
4. Biofeedback bowel training has been proven to reduce the frequency of fecal soiling in children over the age of 5 years

Critique:

After the age of 5 years, encopresis is three times as common in males as in females (SOR A). Although psychological causes are possible and parents often fear this is the case, fecal soiling is the result of functional constipation over 80% of the time (SOR B). Functional fecal incontinence, the most common cause of fecal soiling, tends to resolve spontaneously by adolescence, but treatment should not be deferred for this reason (SOR C).

Psychosocial stressors may trigger the onset of encopresis, especially when there is a history of separation or change in a relationship with an important person in a child’s life. It can also be associated with certain places such as school restrooms or events such as divorce. Studies show that children with functional constipation and fecal soiling who receive treatment that includes both medical and behavioral components experience a higher rate of remission than those treated only with drugs (SOR A).

The most effective dietary treatment for encopresis is one that incorporates high-fiber foods and/or supplemental fiber (SOR A). The use of mineral oil, stimulant laxatives, and enemas are not recommended for functional constipation in children because of the risk of complications. There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional fecal incontinence in children (SOR C).

Question 4

Question: 4 of 60

A 5-year-old female is brought to an emergency department in Oregon with a 3-day history of intermittent fever, headache, mild nausea, and a sore throat. There is no history of recent travel. On examination the child has a fever of 40.6°C (105.1°F), appears uncomfortable, and has a maculopapular rash on her legs and the soles of her feet.

Which one of the following would be most appropriate at this point?

1. Order titers for Lyme disease
2. Administer ceftriaxone in the office
3. Order a CBC to see if the WBC count is elevated
4. Begin treatment with doxycycline now

Answer 4

1. Order titers for Lyme disease
2. Administer ceftriaxone in the office
3. Order a CBC to see if the WBC count is elevated
4. Begin treatment with doxycycline now

Critique:

Rocky Mountain spotted fever (RMSF) is most common in the south central and south Atlantic states, although cases have been reported from all contiguous 48 states and the District of Columbia.

Most people present with RMSF before the rash develops (SOR B). The initial symptoms typically appear 3–12 days after a bite from an infected tick and include a sudden onset of fever, headache, chills, myalgias, and fatigue. The classic triad of fever, rash, and a report of a tick bite is present in only a minority of cases. Only 55%–60% of patients with RMSF are aware of any tick bite within 2 weeks of the illness (level of evidence 2). RMSF is included in the differential diagnosis of rash on the palms and soles (level of evidence 3).

RMSF remains associated with a mortality rate of 5%–10%, and both a delay in diagnosis beyond the fifth day of symptoms and age <10 years are associated with higher mortality rates. Since blood tests are often not positive during the first 2 weeks of the illness and diagnostic serum antibody tests are usually not present during the first week of illness, treatment should be empirically started as soon as RMSF is suspected (SOR C).

Doxycycline, not ceftriaxone, is the effective treatment. It remains the drug of choice for all tickborne diseases, regardless of the patient’s age. For children, the recommended dosage is 2.2 mg/kg twice daily, with oral therapy being effective for those who can be treated as outpatients. The risk of tooth staining is not high after only one course of treatment for RMSF (SOR A).

Question 5

Question: 5 of 60

A 30-year-old female who is hepatitis B surface antigen (HBsAg) positive gives birth to a 2800-g (6 lb 3 oz) male. Which one of the following is essential in the care of this infant during its first 12–24 hours of life?

1. A hepatitis profile
2. Adefovir dipivoxil (Hepsera)
3. Hepatitis B immune globulin and hepatitis B vaccine
4. Hepatitis A vaccine

Answer 5

1. A hepatitis profile
2. Adefovir dipivoxil (Hepsera)
3. Hepatitis B immune globulin and hepatitis B vaccine
4. Hepatitis A vaccine

Critique:

Approximately 1000 new cases of perinatal hepatitis B infection are identified in the United States each year. Mother-to-child transmission is responsible for more than one-third of chronic hepatitis B virus infections worldwide. Prevention of perinatal hepatitis B depends on the timely identification of infants born to mothers who are HBsAg-positive or whose hepatitis B status is unknown, in order to ensure administration of appropriate postexposure immunoprophylaxis. The risk of perinatal transmission among infants born to HBsAg-positive mothers is as high as 90% without immunoprophylaxis, which has been shown to be 85%–95% efficacious for preventing mother-to-child transmission.

The American Academy of Pediatrics endorses the recommendation of the CDC’s Advisory Committee on Immunization Practices (ACIP) that all newborn infants with a birth weight of ≥2000 g receive hepatitis B vaccine by 12–24 hours of age. Infants born to mothers who are HBsAg-positive or whose HBsAg status is unknown should also be given hepatitis B immune globulin, with the timing dependent on birth weight and the mother’s status. The dosing and administration of these do not require adjustment for birth weight or for maternal antiviral therapy for high hepatitis B viral loads during pregnancy. Infants who receive appropriate immunoprophylaxis may breastfeed immediately after birth.

The schedule for subsequent doses of the vaccine depends upon the infant’s birth weight. If the birth weight is ≥2000 g (4 lb 7 oz), the second and third doses should be given at 1 and 6 months of age, respectively. For infants who weigh <2000 kg (4 lb 7 oz), three additional doses are required and should be given at 1, 2–3, and 6 months of age, or at 2, 4, and 6 months of age.

Since this is prophylaxis, treatment of the infant for an active infection with an antiviral medication such as adefovir dipivoxil is unnecessary. A hepatitis profile to check for HBsAg and antibody to HBsAg is indicated between the ages of 9 months and 18 months. This profile is recommended after completion of the hepatitis B vaccine series, not in the newborn period. The ACIP recommends the initiation of routine hepatitis A immunization between the ages of 1 and 2 years. This is a two-dose series that can be integrated into the routine childhood vaccination schedule.

Question 6

Question: 6 of 60

A couple expecting their first child asks for your advice about how to choose a safe and healthy day care center. Which one of the following criteria is endorsed by the National Resource Center for Health and Safety in Child Care to guide parents in choosing a child care program?

1. The day care center director has a bachelor’s degree in a child-related field
2. There is at least one caregiver for every four infants
3. The staff individualizes discipline according to the parents’ requests
4. The center conducts fire drills at least every 3 months

Answer 6

1. The day care center director has a bachelor’s degree in a child-related field
2. There is at least one caregiver for every four infants
3. The staff individualizes discipline according to the parents’ requests
4. The center conducts fire drills at least every 3 months

Critique:

Family physicians who are asked for information about how to identify a safe and healthy day care center should know about the indicators of quality child care produced by the National Resource Center for Health and Safety in Child Care and supported by the U.S. Department of Health and Human Services and its Maternal and Child Health Bureau. There are several areas that should be evaluated when selecting a child care center, including staffing and supervision, programs and activities, food and nutrition, health concerns such as infectious disease prevention and first aid training, and licensing.

Safe and healthy child care centers should have a director with a bachelor’s degree in a child-related field such as child development, early childhood education, or elementary education; have one caregiver for every two infants; provide discipline that is positive, clear, consistent, and fair; assure that no child is ever alone with one caregiver; and practice fire drills once every month. The staff should also have appropriate training and plans regarding medication safety; first aid, including rescue breathing; hand washing and diapering; and poison prevention.

Question 7

Question: 7 of 60

A 17-year-old male who is on the high school football team sees you for a preparticipation evaluation. He asks you about the risk of using androgenic steroids, which he has been using to build muscle for the upcoming season on the advice of a teammate.

You tell him that he may experience which one of the following side effects?

1. A decrease in libido
2. Permanent elevation of his blood pressure
3. A permanently decreased sperm count
4. Testicular atrophy

Answer 7

1. A decrease in libido
2. Permanent elevation of his blood pressure
3. A permanently decreased sperm count
4. Testicular atrophy

Critique:

Androgenic steroids and steroid precursors are increasingly used by adolescents as a way to increase lean body mass and decrease fat mass, with a goal of improving the muscle definition of their bodies and their ability to enhance their performance in sports. While the drugs do produce these effects, their use should be discouraged because of potential health risks, which should be reviewed with the adolescent who is either using or at risk for using these drugs.

The CDC has reported that the use of androgenic steroids without a doctor’s prescription by high school students has a lifetime prevalence of 4%. In a longitudinal study of adolescent health, nonmedical use of androgens was associated with greater involvement in violent behaviors such as physical fighting, after controlling for other variables. Abuse of androgens should be suspected in adolescents with a history of problem behavior such as fighting, other substance abuse, and risky sexual behaviors.

The risks to a male user include permanent growth of breasts and permanent hair loss. Reversible effects include an increase in libido and aggressive behavior, a decreased sperm count, testicular atrophy, elevation of blood pressure, acne, liver abnormalities, clotting, elevation of LDL-cholesterol, and reduction of HDL-cholesterol.

Question 8

Question: 8 of 60

Which one of the following should receive further evaluation for developmental problems, assuming they are persistent?

1. A 10-month-old who cannot make a mark on a piece of paper with a crayon
2. A 15-month-old who does not point to an object he wants
3. A 24-month-old who cannot thread a shoelace into the eyelet of a shoe or into a bead
4. A 30-month-old who cannot balance on one foot for 1 second
5. A 36-month-old who cannot throw a ball overhand while standing

Answer 8

1. A 10-month-old who cannot make a mark on a piece of paper with a crayon
2. A 15-month-old who does not point to an object he wants
3. A 24-month-old who cannot thread a shoelace into the eyelet of a shoe or into a bead
4. A 30-month-old who cannot balance on one foot for 1 second
5. A 36-month-old who cannot throw a ball overhand while standing

Critique:

A 10-month-old infant should be able to hold a crayon but would not be expected to make a mark on a piece of paper until 15 months of age. A 15-month-old child who does not point to an object he wants clearly is behind in abilities and needs to be evaluated further. This failure may be a cardinal sign of a difficulty such as pervasive developmental delay or autism, especially when accompanied by other suggestive findings.

The ability to thread a shoelace into the eyelet of a shoe or into a bead would normally be expected of a 30-month-old child. A 36-month-old child should be able to balance on one foot for 1 second. This task may be too difficult for a 30-month-old. Throwing a ball overhand while standing is an ability that should be achieved by the age of 42 months. Failure to perform this at age 36 months would not raise an alarm. The ability of children to perform these various tasks is outlined in the Denver II Developmental Assessment and the Ages and Stages Questionnaire.

Question 9

Question: 9 of 60

A 17-year-old female comes to your office accompanied by her mother. The patient tells you that she had unprotected intercourse the night before. She describes this as a one-time, consensual encounter and says that she is not in an established relationship. She is requesting emergency contraception only and does not wish to start long-term contraception.

Which one of the following would be most appropriate?

1. Provide a prescription and instructions for single or split-dose levonorgestrel
2. Tell the patient she will need to return for evaluation if she needs emergency contraception in the future
3. Explain that she will need to have a pelvic examination at this visit prior to receiving the prescription
4. Order a pregnancy test

Answer 9

1. Provide a prescription and instructions for single or split-dose levonorgestrel
2. Tell the patient she will need to return for evaluation if she needs emergency contraception in the future
3. Explain that she will need to have a pelvic examination at this visit prior to receiving the prescription
4. Order a pregnancy test

Critique:

The majority of adolescents begin sexual activity during their teenage years. Provision of emergency contraception before it is needed has been demonstrated to increase the rate and timeliness of use in adolescents, with 2–7 times greater use among those who had received an advanced supply. The use of emergency contraceptives by adolescents does not result in higher rates of STDs or unprotected intercourse and does not change patterns of routine contraceptive use (SOR C). However, the rates of pregnancy in patients receiving an advanced supply have not seemed to decline despite timely use.

A pelvic examination is not required prior to prescribing oral contraceptives and should not be a barrier to receiving emergency contraception. While it is reasonable to attempt to determine if she is pregnant, a negative pregnancy test is insufficient to rule out this possibility and is not required.

Adolescents should be educated about the availability of, and indications for, emergency contraception in the event of a gap in contraceptive use or a method failure, or if they are not using another form of contraception.

Question 10

Question: 10 of 60

A 5-year-old female has recently been wetting the bed 3–4 nights weekly. Before this she had wet the bed 2–3 nights weekly and she has never been dry through the night for a long period of time. She has no recent history of daytime enuresis. Her mother asks if you can prescribe something to treat the enuresis because she expects there will be sleepover invitations once the child begins school.

Further history reveals that the mother has recently remarried, and that her husband has two children of his own. The mother reports that her daughter seems to be generally adjusting well to her new family but is a bit more clingy than in the past. A review of systems is otherwise unremarkable. The child’s growth and development are appropriate for her age.

Which one of the following is true regarding the management of this problem?

1. The bed wetting will eventually resolve even without treatment
2. The local child protective services agency should be contacted to report presumptive sexual abuse
3. Tricyclic antidepressants are the first-line choice for drug treatment of enuresis
4. Enuresis alarms are no more effective than placebo treatments

Answer 10

1. The bed wetting will eventually resolve even without treatment
2. The local child protective services agency should be contacted to report presumptive sexual abuse
3. Tricyclic antidepressants are the first-line choice for drug treatment of enuresis
4. Enuresis alarms are no more effective than placebo treatments

Critique:

Enuresis in children is most commonly primary, or monosymptomatic, which is defined as never having achieved 6 months of continuously dry nights. Secondary, or nonmonosymptomatic, enuresis refers to enuresis in children who have previously achieved 6 months or more of dry nights and have a recurrence of nighttime bedwetting. Studies have shown that up to 20% of 5-year-old children, and 5%–10% of all 7-year-olds experience some degree of nocturnal enuresis (SOR C). Spontaneous resolution of primary enuresis is common, occurring at an annual rate of approximately 15%. Less than 2% of the population experiences nocturnal enuresis by the age of 15 years (SOR A).

A normal physical examination is most likely in cases of primary enuresis and the only laboratory test that is indicated in children with a history consistent with this diagnosis and a normal physical examination is a urinalysis to rule out occult infection, glucosuria, or proteinuria that may signal an underlying cause. Concurrent daytime and nocturnal enuresis is more suggestive of a congenital structural or functional etiology for the enuresis, and should prompt appropriate medical evaluation before a treatment plan is formulated (SOR C). Physical findings that may indicate this type of enuresis include delayed growth, evidence of hard stool on the abdominal examination suggesting constipation, enlarged tonsils or adenoids signaling potential sleep apnea, any signs of neurologic abnormality, and signs of sexual abuse in the perineal or perianal area.

The most effective treatment option for primary enuresis is the use of bed alarms, which should be considered first-line therapy for this condition (SOR A). In considering this option with families, establishment of motivation in both the parents and the child is important. Parents must commit to a 3-month trial of therapy and be able to purchase the alarm, which is often not covered by insurance. Bed alarm use should continue until the child has achieved 14 consecutive dry nights.

The use of medication for treating enuresis should be reserved for children 7 years of age or older. While medication is more convenient to use, the return of symptoms after discontinuation of pharmacotherapy is more common than with bed alarms. Desmopressin is the first-line drug therapy for this condition (SOR A) and has been demonstrated to have a success rate of 70%. It is now available as an oral tablet, which reduces the potential risks associated with intranasal therapy, such as hyponatremia and water intoxication.

Enuresis may be a presenting sign of sexual abuse, and it is appropriate to consider this possibility when evaluating this patient. However, an isolated finding of nocturnal enuresis does not provide sufficient evidence of sexual abuse to necessitate reporting every case (SOR C).

Question 11

Question: 11 of 60

A 13-year-old male sees you for a well child visit. He is healthy and is an avid soccer player. On examination you auscultate a soft 2/6 systolic ejection murmur at the left upper sternal border. The second heart sound exhibits splitting with inspiration. The murmur becomes louder when the patient is supine and softens when he stands or performs a Valsalva maneuver. Palpation of the precordium is normal, and all pulses are equal in the upper and lower extremities.

The most likely diagnosis is

1. atrial septal defect
2. hypertrophic cardiomyopathy
3. pulmonary flow murmur
4. venous hum
5. ventricular septal defect

Answer 11

1. atrial septal defect
2. hypertrophic cardiomyopathy
3. pulmonary flow murmur
4. venous hum
5. ventricular septal defect

Critique:

The pulmonary ejection murmur is the most common innocent murmur in older children. It is a soft, grade 1–2 systolic ejection murmur heard at the left upper sternal border. It is louder in the supine position and softens with standing or the Valsalva maneuver. It is sometimes confused with the murmur of hypertrophic cardiomyopathy, which is best heard at the left lower sternal border and increases with standing or the Valsalva maneuver.

Most innocent murmurs in children are systolic and grade 3 or less. They typically soften with standing or during the Valsalva maneuver. They do not cause changes in precordial impulses or unequal pulses.

Characteristics that increase the likelihood of cardiac pathology include a grade of 3 or higher, a diastolic murmur, an increase in intensity while standing, increases in the precordial apical impulse, the presence of clicks, and cardiac symptoms such as chest pain or syncope.

Atrial septal defects are best heard in the left upper sternal border, do not change with standing, and cause an increase in precordial activity. They can also cause a diastolic rumble. They are often confused with innocent murmurs. The second heart sound may be fixedly split.

Venous hums are innocent diastolic sounds in the upper right sternal border that are heard continuously during sitting and disappear in the supine position or with light pressure over the jugular vein.

A ventricular septal defect causes a systolic murmur at the left lower sternal border that does not change with standing. The murmur of hypertrophic cardiomyopathy is best heard at the left lower sternal border and increases with standing.

Question 12

Question: 12 of 60

A 6-year-old child sustained a dog bite on his left hand about 24 hours ago. The bite was provoked, and the dog is his family’s pet and is up to date on its immunizations. The child has received all indicated well care, including immunizations, and has no known drug allergies.

An examination reveals two tender, erythematous puncture wounds on the dorsal aspect of the hand. There is some regional lymphangitis.

Which one of the following is considered first-line treatment for this patient?

1. Amoxicillin/clavulanate (Augmentin)
2. High-dose amoxicillin
3. Clindamycin (Cleocin) plus ciprofloxacin (Cipro)
4. Doxycycline

Answer 12

1. Amoxicillin/clavulanate (Augmentin)
2. High-dose amoxicillin
3. Clindamycin (Cleocin) plus ciprofloxacin (Cipro)
4. Doxycycline

Critique:

Only 15%–20% of dog bite wounds become infected, with crush injuries, puncture wounds, and hand wounds more likely to do so than scratches or tears. Most infected wounds contain multiple organisms, with Pasteurella multocida and Staphylococcus aureus being the most common. Other pathogens include Streptococcus species, Corynebacterium species, Eikenella corrodens, and Capnocytophaga canimorsus. Anaerobic organisms, including Bacteroides fragilis, Fusobacterium species, and Veillonella parvula, have also been implicated.

Prophylactic antibiotics should be prescribed for any high-risk bite wound, which includes those on the extremities or hand, crush injuries, puncture wounds, and wounds with delayed presentation (SOR B). Amoxicillin/clavulanate is the antibiotic of choice for a dog bite (SOR C) and doxycycline is an acceptable alternative for children allergic to penicillin (SOR C). Acceptable combinations include clindamycin and a fluoroquinolone in adults, or clindamycin and trimethoprim/sulfamethoxazole in children (SOR C).

Question 13

Question: 13 of 60

A 12-month-old healthy male is brought to your office for a routine well care visit. His past medical history is negative for any significant acute or chronic illnesses. His growth has progressed normally since birth and he is at the 50th percentile for height and weight.

The American Academy of Pediatrics recommends which of the following routine screening tests at this visit?

1. A serum TSH level
2. A lipid panel
3. Hemoglobin or hematocrit
4. A urinalysis

Answer 13

1. A serum TSH level
2. A lipid panel
3. Hemoglobin or hematocrit
4. A urinalysis

Critique:

The only laboratory test recommended by the American Academy of Pediatrics for routine screening from 6 to 12 months of age is a hemoglobin or hematocrit (SOR C). Either of these tests may be performed, but only one is needed. A urinalysis is no longer recommended at any age. Metabolic screening is recommended shortly after birth to detect phenylketonuria, hypothyroidism, and many other inherited diseases. A blood lead level is recommended at 2 years of age for most children, and at 1 year of age for those in whom exposure is likely. Routine assessment for lead exposure is recommended beginning at 6 months of age, with periodic reassessment through 6 years of age, and a blood lead level if the history is positive. Screening for dyslipidemia is recommended once between 9 and 11 years of age and once between 17 and 21 years of age.

Question 14

Question: 14 of 60

You see a 13-year-old female for a routine health maintenance visit. She has no concerns. She is an only child and a good student. She does not participate in any sports or other activities, and says she spends most of her free time on the computer. She had her first menstrual period the previous month. She is at the 25th percentile for height, the 90th percentile for weight, and the 95th percentile for BMI for her age. Her blood pressure is normal.

Which one of the following would be most appropriate at this visit?

1. Schedule a follow-up visit in 6 months, and if the patient is still overweight order blood tests to screen for health consequences
2. Request that she keep a food diary to bring to her next annual visit so that you can review her nutrition habits with her and her family
3. Recommend weight loss, and have her work with her family and with a nutritionist to modify her eating and activity habits
4. Reassure her that as long as she maintains her current weight it will become normal as her height increases

Answer 14

1. Schedule a follow-up visit in 6 months, and if the patient is still overweight order blood tests to screen for health consequences
2. Request that she keep a food diary to bring to her next annual visit so that you can review her nutrition habits with her and her family
3. Recommend weight loss, and have her work with her family and with a nutritionist to modify her eating and activity habits
4. Reassure her that as long as she maintains her current weight it will become normal as her height increases

Critique:

Rates of overweight and obesity in children and adolescents have continued to rise steadily over the past several decades, with the most recent CDC data indicating that almost 32% of this population is overweight or obese. There has been some stabilizing of this overall rate in the last decade, although continued increases are noted in certain populations, including African-American females and Hispanic males. Obesity rates are inversely related to the level of household education.

According to the CDC, height and weight should be measured, and BMI calculated, at least yearly in children older than 2 years (SOR C). The U.S. Preventive Services Task Force (USPSTF) now recommends that clinicians screen for obesity in children and adolescents 6 years and older. Obesity is defined as a BMI ≥95th percentile for age and sex, and overweight is defined as a BMI ≥85th and <95th percentile for age and sex. Those at risk for being overweight require an additional visit for weight counseling later in the year, as well as laboratory tests under certain circumstances.

The USPSTF recommends weight maintenance in overweight children, as long as there are no complications such as hyperlipidemia or hypertension, or if the patient is younger than 7 years of age. If there are complications and the patient is over 7 years old (as in this case), then weight loss, rather than weight maintenance, is recommended regardless of complications. Any child or adolescent who is found to be ≥95th percentile should be offered comprehensive, intensive behavioral interventions (≥26 contact hours over 2–12 months) to work toward weight reduction (B recommendation). This includes two additional physician visits, two nutritionist visits, and screening tests, including fasting lipids, glucose, AST, ALT, and hemoglobin A1c. There is inadequate evidence regarding the effectiveness of less intensive interventions.

Evaluation to identify treatable causes and comorbidities should be considered, including a complete history and physical examination with attention to the presence of signs that might indicate genetic or endocrinologic causes. The evaluation should also be directed toward comorbidities such as polycystic ovary syndrome, obstructive sleep apnea, hypothyroidism, Cushing syndrome, and orthopedic problems. Children and adolescents may also experience teasing and bullying behaviors based on their weight. The psychological toll of pediatric obesity on the individual and family necessitates screening for mental health issues and counseling as indicated.

Question 15

Question: 15 of 60

During a well child visit the parents of a 4-year-old child inquire about how much time they should allow her to spend watching television or using a tablet. Which one of the following is appropriate advice to help parents develop positive habits in preschool children with regard to the use of electronic devices such as televisions, smartphones, and tablets?

1. Parents should limit screen time to less than 2 hours per day for children 5–10 years of age
2. Allowing televisions in children’s bedrooms does not affect their total screen time
3. Mealtime and bedtime curfews on phone use have little effect on reducing overall screen time
4. Co-viewing of television or internet videos may not provide parents with a true picture of what the child is watching

Answer 15

1. Parents should limit screen time to less than 2 hours per day for children 5–10 years of age
2. Allowing televisions in children’s bedrooms does not affect their total screen time
3. Mealtime and bedtime curfews on phone use have little effect on reducing overall screen time
4. Co-viewing of television or internet videos may not provide parents with a true picture of what the child is watching

Critique:

Screen time has been associated with adverse health outcomes for children, most notably with increasing childhood obesity. Children in the United States watch about 4 hours of television every day on average. However, recognizing that playing, reading, and spending time with friends and family are much healthier than sitting in front of a screen, the American Academy of Pediatrics recommends that a child’s use of television, movies, and video and computer games be limited to <2 hours per day. Curfews on media use at mealtimes and bedtimes reduce overall use. Televisions should not be placed in children’s bedrooms.

Videos on television or the internet can inform, entertain, and teach, but not everything shown is healthy or desirable. Programs and commercials often show violence, alcohol or drug use, and sexual content that may not be suitable for children. Many younger children cannot discriminate between what they see on a screen and what is real. Research has shown primarily negative effects on violence and aggressive behavior, sexuality, academic performance, body concept and self-image, nutrition, dieting and obesity, and substance use and abuse patterns. In the scientific literature on media violence, the connection between media violence and real-life aggressive behavior and violence has been substantiated. This is why it is important for the family physician to address the topic of television viewing with parents beginning around age 3. Parents should watch television and other electronic materials with the child on a regular basis and as often as possible.

Question 16

Question: 16 of 60

A 2-year-old male is brought to your office in October with a 2-day history of low-grade fever, runny nose, and a barking cough. He has a rectal temperature of 38.9°C (102.0°F) and does not appear toxic. He has a respiratory rate of 35/min and you hear occasional stridor but he is not wheezing. His oxygen saturation is 95% on room air.

Which one of the following has the strongest evidence of benefit in this situation?

1. Inhalation of supplemental oxygen
2. Treatment with nebulized racemic epinephrine
3. Oral glucocorticoids
4. Oral amoxicillin

Answer 16

1. Inhalation of supplemental oxygen
2. Treatment with nebulized racemic epinephrine
3. Oral glucocorticoids
4. Oral amoxicillin

Critique:

Croup, or inflammation of the larynx and trachea, is common in children. It is a viral infection that causes hoarseness, a barking cough, and noisy breathing. Croup is usually self-limited, but children who are hypoxic or have stridor at rest should be hospitalized.

Corticosteroids should be administered to children with croup, regardless of the severity of disease (SOR A). A Cochrane review of randomized, controlled trials has shown that glucocorticoids can improve croup within 6 hours and that the effect lasts for 12 hours, decreasing the need for other interventions and/or hospitalization (SOR A). Antibiotics are not indicated.

This child does not manifest any symptoms or signs of hypoxemia, so oxygen therapy is not indicated. Nebulized epinephrine is not indicated for mild croup, although it should be used in moderate to severe croup (SOR A). The effect lasts only 2 hours and the final outcome of disease is not altered. It has many adverse side effects, including tachycardia and restlessness (SOR C).

Question 17

Question: 17 of 60

A 9-year-old female is brought to the office for a well child visit. Her mother mentions that a family friend is being treated for scoliosis and she wants to have her daughter screened for this condition.

Which one of the following is true regarding this condition?

1. The U.S. Preventive Services Task Force recommends screening adolescents for idiopathic scoliosis
2. Screening for scoliosis is most important in females who have reached skeletal maturity
3. Using a scoliometer in the school setting improves detection of clinically significant scoliosis
4. Idiopathic scoliosis is most commonly seen in females between the ages of 10 and 13
5. Approximately 3% of patients with idiopathic scoliosis will eventually require treatment

Answer 17

1. The U.S. Preventive Services Task Force recommends screening adolescents for idiopathic scoliosis
2. Screening for scoliosis is most important in females who have reached skeletal maturity
3. Using a scoliometer in the school setting improves detection of clinically significant scoliosis
4. Idiopathic scoliosis is most commonly seen in females between the ages of 10 and 13
5. Approximately 3% of patients with idiopathic scoliosis will eventually require treatment

Critique:

The U.S. Preventive Services Task Force’s 2018 update on screening for idiopathic scoliosis in adolescents gives it an I recommendation, indicating that current evidence is insufficient to assess the balance of benefits and harms of screening. This is based on its findings that although there is adequate evidence that currently available screening tests can accurately detect adolescent idiopathic scoliosis, there is no direct evidence regarding the effect of screening for adolescent idiopathic scoliosis on patient-centered health outcomes, and no studies on the direct harms of screening, such as psychological harms or harms associated with confirmatory radiography.

Scoliosis is most commonly seen in females between the ages of 10 and 13 years and progresses most severely during the growth phase before the patient has reached skeletal maturity. Ninety percent of cases are idiopathic, and the prevalence of scoliosis that eventually requires treatment is very small (<0.5%). This means that there is much unnecessary testing and referral. Use of a scoliometer does not increase the rate of discovery of clinically significant scoliosis, which usually comes to light without the aid of screening tests.

Question 18

Question: 18 of 60

A 5-month-old male born at term has a 4-month history of random, nonprojectile vomiting 2–4 times daily. Because of his mother’s work schedule the child breastfeeds only twice a day and ingests appropriate amounts of bottled breast milk or formula for other feedings. He also eats 2 small jars of baby food every day. His development has been appropriate and he is growing well and smiles or giggles frequently. A physical examination is normal, including the abdominal and neurologic examinations.

To reduce these vomiting episodes you advise the parents to

1. elevate his head when he sleeps
2. place him in a prone position for sleep
3. start him on metoclopramide (Reglan)
4. thicken his feedings with rice cereal
5. give him a dose of antacid following each meal

Answer 18

1. elevate his head when he sleeps
2. place him in a prone position for sleep
3. start him on metoclopramide (Reglan)
4. thicken his feedings with rice cereal
5. give him a dose of antacid following each meal

Critique:

This child most likely has uncomplicated gastroesophageal reflux (GER), which is bothersome but not critical in this case. GER is a normal physiologic event and is not the same as gastroesophageal reflux disease (GERD). GERD is an abnormal reflux of stomach contents and acid into the esophagus. The treatment of GER in an infant includes a stepwise progression from adjustments in feeding techniques to medication. Positioning studies have shown that elevation of the head increases reflux (SOR A) and increases the chance that a child of this age would slide into a position that poses a greater safety risk. Despite the fact that prone positioning reduces reflux, this should not be recommended, as the risk of sudden infant death syndrome is higher in any position other than supine. An infant can be kept in the prone position while awake and being observed by a caretaker and may vomit less frequently (SOR A).

Numerous studies have documented the benefits of formula thickening (SOR A). Rice cereal has been shown to be an adequate food thickener and is likely to help in this case.

Pharmacotherapy is not indicated for infants with uncomplicated reflux, based on a lack of efficacy and modest safety concerns and because the symptoms typically resolve without treatment in many infants. Because this infant is growing well and developing normally, and because GER usually improves by age 12–18 months, drug treatment is best avoided, at least initially. Metoclopramide is a prokinetic agent with some data to support its use in GERD, but it does not consistently improve GER and it has major side effects. Antacids provide only temporary relief and are unlikely to be consistently given, so are no longer advised.

Question 19

Question: 19 of 60

A 13-year-old female is brought to your office by her parents. They tell you that since she started seventh grade 2 months ago she has not been sleeping well, and they often find her awake at 2 a.m. or later using social media on her phone. They also report that her teachers have been concerned because her behavior at school has been somewhat erratic. The mother, who has bipolar disorder, worries that her daughter might have the same diagnosis.

Which one of the following is most accurate with regard to assessing this patient for bipolar disorder?

1. Given the family history, there is sufficient information provided at this visit to make a diagnosis of bipolar disorder
2. The symptom complex of irritability, reckless behaviors, and increased energy has a high specificity for making a diagnosis of bipolar disorder
3. Genetic testing will help to establish a diagnosis of bipolar disorder
4. DSM-5 criteria should be followed when making a diagnosis of mania or hypomania in children and adolescents

Answer 19

1. Given the family history, there is sufficient information provided at this visit to make a diagnosis of bipolar disorder
2. The symptom complex of irritability, reckless behaviors, and increased energy has a high specificity for making a diagnosis of bipolar disorder
3. Genetic testing will help to establish a diagnosis of bipolar disorder
4. DSM-5 criteria should be followed when making a diagnosis of mania or hypomania in children and adolescents

Critique:

Assessment of symptoms for mania, hypomania, or depression in adolescents requires a series of observations. DSM-5 criteria should be followed when making a diagnosis of mania or hypomania in children and adolescents (SOR C). The assessment should incorporate both current and past history, noting the frequency, intensity, and duration of symptoms, as well as looking for specific findings that cluster together, including symptoms, treatment response, psychosocial stressors, and family psychiatric history.

This patient does not meet all of the criteria required to make the diagnosis. Symptoms of irritability, reckless behaviors, or increased energy are important to assess, but they occur in a number of conditions and therefore lack specificity. Manic-like symptoms of irritability and emotional reactivity may also be seen with a number of conditions, including disruptive behavior disorders, posttraumatic stress disorder, major depression, and pervasive developmental disorders. For these reasons, identification of the illness and initiation of treatment occurs, on average, 10 years after its initial manifestation.

There are no biologic tests, including genetic studies, that are helpful in making the diagnosis of bipolar disorder.

Question 20

Question: 20 of 60

A family with two children, ages 2 and 4, has just moved into the community. The home they moved into has a backyard pool and the parents ask you about keeping the children safe from drowning.

Which one of the following would be accurate advice regarding childhood drowning deaths?

1. Air-filled swimming aids such as water wings are appropriate for use by toddlers
2. Installation of a 4-ft high, four-sided fence that isolates the pool from the house decreases drowning by 50%
3. A pool cover with alarm is as effective as fencing in protecting children from accidental drowning
4. Toddlers are more likely to drown in a bathtub than in the backyard pool

Answer 20

1. Air-filled swimming aids such as water wings are appropriate for use by toddlers
2. Installation of a 4-ft high, four-sided fence that isolates the pool from the house decreases drowning by 50%
3. A pool cover with alarm is as effective as fencing in protecting children from accidental drowning
4. Toddlers are more likely to drown in a bathtub than in the backyard pool

Critique:

Drowning and near-drowning cause significant morbidity and mortality in children of all ages. Drowning is responsible for more deaths among children aged 1–4 years than any other cause except congenital anomalies. Young children can drown in as little as 1–2 inches of water. While most parents expect to hear a child scream for help, drowning more often happens quickly and silently.

Infants are most likely to drown in bathtubs or buckets at home, while children 1–4 years of age are most likely to die in swimming pools.

Evidence-based strategies for reducing drowning include pool fencing, use of approved flotational devices, active supervision or lifeguarding, and swimming and water safety lessons. Installation of a four-sided fence that isolates a swimming pool from a house or a backyard decreases drowning injuries by 50% (SOR A). The fence should be at least 4 feet high and have no openings at the bottom or between slats that are more than 4 inches wide, should completely separate the pool from the house, and should have a self-closing and self-latching gate that opens away from the pool, with the latch at least 54 inches from the ground.

Air-filled swimming aids such as water wings are not appropriate substitutes for approved personal flotation devices. Pool alarms and covers, which theoretically provide protection from drowning, should not be used in place of four-sided fences. Alarms and covers have not been shown to decrease drowning injuries and may actually increase the risk of drowning because of inappropriate use.

Bathroom risks should still be considered with toddlers, as they can topple headfirst into toilet bowls or a filled tub. Safety measures to consider for bathrooms include safety latches or doorknob covers to keep bathrooms closed, installation of latches on toilet seat lids, and removal of the bathtub drain plug when it is not in use so that the tub does not fill if a child turns on the faucet.

Question 21

Question: 21 of 60

A 7-year-old male is brought to your office by his parents because of his poor performance in school. His teacher reports that he often does not pay attention to details, has difficulty concentrating on tasks, does not seem to listen when spoken to, is forgetful, loses school supplies, and is easily distracted. His developmental and medical histories are unremarkable. A physical examination is normal. You suspect that he has attention-deficit/hyperactivity disorder (ADHD).

Which one of the following is true regarding the evaluation of this problem?

1. A direct report of symptoms from the parents alone is sufficient to make the diagnosis
2. ADHD-specific instruments, such as the Conners Parent Rating scale or the Vanderbilt scales, are reliable for establishing the diagnosis
3. Global teacher rating scales are reliable instruments for establishing the diagnosis
4. Children suspected of having ADHD should undergo a routine laboratory workup

Answer 21

1. A direct report of symptoms from the parents alone is sufficient to make the diagnosis
2. ADHD-specific instruments, such as the Conners Parent Rating scale or the Vanderbilt scales, are reliable for establishing the diagnosis
3. Global teacher rating scales are reliable instruments for establishing the diagnosis
4. Children suspected of having ADHD should undergo a routine laboratory workup

Critique:

When diagnosing attention-deficit/hyperactivity disorder (ADHD), a direct report of symptoms should be obtained from the parents and a teacher. According to American Academy of Pediatrics guidelines, the diagnosis requires confirmation of symptoms in more than one setting, usually the home and school (SOR C).

The use of broad rating scales is not recommended to establish the diagnosis of ADHD, as they are not reliable. The Conners Abbreviated Symptom Questionnaire and the Vanderbilt ADHD Diagnostic Parent/Teacher Rating Scales are ADHD-specific scales that have the best efficacy for making this diagnosis (SOR B). In the absence of a history or physical findings suggesting a physical problem, laboratory tests are not routinely indicated (SOR C).

Question 22

Question: 22 of 60

You see a 7-year-old female for a well child visit. She is 127 cm (50 in) tall. Her father asks about the most appropriate seating for his daughter when she is riding in an automobile.

You tell him she should sit in the

1. rear seat, using the lap and shoulder belt alone
2. rear seat on a belt-positioning booster seat, using the lap and shoulder belt
3. center of the rear seat on a belt-positioning booster seat, using the lap belt only
4. rear seat in a forward-facing child seat, using the seat’s five-point belts
5. front passenger seat on a belt-positioning booster seat, using the lap and shoulder belt

Answer 22

1. rear seat, using the lap and shoulder belt alone
2. rear seat on a belt-positioning booster seat, using the lap and shoulder belt
3. center of the rear seat on a belt-positioning booster seat, using the lap belt only
4. rear seat in a forward-facing child seat, using the seat’s five-point belts
5. front passenger seat on a belt-positioning booster seat, using the lap and shoulder belt

Critique:

Safety advocates have dubbed the age group between 4 and 8 years the “forgotten child” when it comes to car safety restraints. While child seat use is mandated for infants and children, many states do not require the use of child-appropriate safety restraint devices for the upper end of this age group. All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the lap and shoulder belt of the car fits properly.

Seat belts are designed for use by adults. In children, lap belts normally fall over the abdomen instead of the pelvis, and shoulder straps normally fit over the neck or face instead of the mid-sternum and shoulder. Because seat belts don’t fit children correctly, their use can result in significant injuries, referred to as “seat belt syndrome.”

Belt-positioning booster seats are designed to ensure that a vehicle’s standard lap and shoulder belts will fit an older child properly. In fact, their use has been shown to result in a 59% decrease in crash-related injuries, compared to the use of seat belts alone. These boosters are designed to work with both the lap and shoulder belt and should never be used with the lap belt alone. They function by positioning the child so that both the lap and shoulder portions of the vehicle fit properly. The lap portion should fit low across the hips and pelvis and the shoulder portion should fit across the middle of the shoulder and chest. The use of belt-positioning booster seats is recommended for all children until they are tall enough for an adult seat belt to fit them properly, usually 4 ft 9 in in height.

The rear seat is always the safest place for children, who can be seriously injured even in minor accidents when an airbag is deployed. Rear-facing infant seats should never be placed in the front seat of a car with a passenger-side airbag. If a child must ride in the front seat in a forward-facing child seat or a belt-positioning booster, and the vehicle has a passenger-side airbag, the seat should be positioned as far back as possible.

Question 23

Question: 23 of 60

According to the CDC’s Advisory Committee on Immunization Practices, the live attenuated influenza vaccine is safe for which one of the following?

1. A 15-month-old who has severe combined immunodeficiency
2. A 3-year-old child living in the same household as a pregnant woman
3. A 4-year-old with a history of wheezing in the past 12 months
4. An 8-year-old taking medication containing aspirin

Answer 23

1. A 15-month-old who has severe combined immunodeficiency
2. A 3-year-old child living in the same household as a pregnant woman
3. A 4-year-old with a history of wheezing in the past 12 months
4. An 8-year-old taking medication containing aspirin

Critique:

The Advisory Committee on Immunization Practices recommends annual influenza vaccination for everyone 6 months of age and older. Any licensed age-appropriate flu vaccine may be used, including the inactivated influenza vaccines, recombinant influenza vaccine, or live attenuated influenza vaccine (LAIV4), with no preference expressed for one vaccine over another.

The LAIV4 nasal spray is approved for use in nonpregnant individuals age 2–49 years. According to the CDC, the nasal spray vaccine is not recommended for the following groups:

children under the age of 2 years

adults age 50 or older

pregnant women

people with a history of a severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine

children 2–17 years of age who are taking medications containing aspirin or salicylates

children 2–4 years of age who have asthma or who have a history of wheezing in the past 12 months

people who have taken influenza antiviral drugs within the previous 48 hours

people who are immunosuppressed

people who care for severely immunocompromised persons who require a protected environment, unless they can avoid contact with those persons for 7 days after getting the nasal spray vaccine

The CDC also states that LAIV4 may not be appropriate for patients age 5 or older with asthma, those with other underlying medical conditions that increase the risk of influenza-related complications, those with moderate or severe acute illnesses, or those with a history of Guillain-Barré syndrome within 6 weeks after a previous dose of influenza vaccine.

Question 24

Question: 24 of 60

A 3-year-old toddler grabbed a hot waffle iron and has a second degree burn on the fingers and palm of his left hand. Which one of the following commonly used burn treatments has been associated with delayed healing and increased pain?

1. Aloe vera
2. Hydrocolloid dressing
3. Silver sulfadiazine cream (Silvadene)
4. Topical honey
5. Vaseline gauze

Answer 24

1. Aloe vera
2. Hydrocolloid dressing
3. Silver sulfadiazine cream (Silvadene)
4. Topical honey
5. Vaseline gauze

Critique:

Superficial partial-thickness burns can be successfully treated with topical application of lotion, honey, aloe vera, or antibiotic ointment (SOR B). Burns treated with honey are more likely to heal over time and have a reduced time to healing when compared with topical antibiotics and non-antibacterial treatments. Topical antibiotics are not necessary in the treatment of superficial burns and show no evidence of improved outcomes.

Although randomized studies are few and offer little support for any particular burn treatment, silver sulfadiazine cream may be associated with delayed wound healing and increased pain (SOR B). Newer occlusive dressings require fewer dressing changes and are associated with greater patient satisfaction.

Question 25

Question: 25 of 60

On a routine examination an otherwise healthy 4-month-old male is found to have a flattened right occiput, with the right ear slightly anterior to the left ear. The child’s posterior fontanelle is closed; the anterior fontanelle is open, measuring 2.5 × 2.0 cm.

The most common cause of this deformity is

1. craniosynostosis
2. sleeping on his back
3. hypothyroidism
4. torticollis, or “wry neck”
5. esotropia

Answer 25

1. craniosynostosis
2. sleeping on his back
3. hypothyroidism
4. torticollis, or “wry neck”
5. esotropia

Critique:

The prevalence of deformational plagiocephaly, or positional head flattening, has been increasing steadily since the early 1990s when the “Back to Sleep” campaign began recommending that infants be placed on their backs for sleep to prevent sudden infant death syndrome. Positional skull deformities are generally benign and reversible, decreasing in frequency in proportion to increasing age. These do not require surgical intervention, as opposed to craniosynostosis, which can result in neurologic damage and progressive craniofacial distortion.

Routine evaluation of the skull in newborns and infants includes palpation of the sutures, evaluation of the posterior and anterior fontanelles, and palpation of the sternocleidomastoid muscles to detect torticollis. Failure of the sutures to move indicates the possibility of craniosynostosis, a relatively rare condition. The posterior fontanelle may be closed at birth and is usually closed by 2–4 months of age. The anterior fontanelle usually is open until at least the fourth month, and commonly until 2–2½ years of age.

A lump in the sternocleidomastoid muscle may indicate that the child has had either hemorrhage or scarring into that muscle, which can result in torticollis and deformity of the skull because the sternocleidomastoid muscle pulls on that side of the head.

Children may hold their head in an abnormal position if they have severe esotropia, creating either real or perceived changes in skull growth. Conditions that affect fontanelle growth, such as hyperthyroidism, may also affect the shape of the skull.

In most cases, positional plagiocephaly can be treated by change in positioning, although this can be challenging to achieve without changing to a face-down position, with a corresponding increased risk, or the use of positioning pillows, which are also not consistent with the American Academy of Pediatrics (AAP) recommendations about not using soft pillows in the crib. The Congress of Neurological Surgeons published a systematic review of two randomized, controlled trials and one prospective study on the management of positional plagiocephaly. Their findings were consistent with those of the AAP, with one primary exception: the data they reviewed promoted the use of physical therapy in addition to repositioning education as being more effective than repositioning alone. They concluded that a combined treatment approach is best.

A custom-fitted cranial molding orthosis (helmet) designed to relieve pressure on the flattened side should only be used in the rare case of a severe deformity that does not respond to conservative treatment, or a deformity that presents later in infancy.

Question 26

Question: 26 of 60

A 15-month-old male who is a new patient is brought to your office by his mother, who states that his 4-year-old brother was recently diagnosed with autism. The mother tells you that the infant is up to date on his immunizations and that developmental screens performed by his previous physician were all normal. Despite a lack of signs of any behavioral or developmental problems, she is concerned about whether he might also have autism spectrum disorder.

Which one of the following would be appropriate advice?

1. Siblings of autistic children have no greater likelihood of having autism than the general population
2. The U.S. Preventive Services Task Force has concluded that there is insufficient evidence to screen children for autism in the absence of clinical concerns
3. Autism can be diagnosed as early as 1 year of age
4. Autism is roughly four times more common among girls than boys
5. Genetic testing is indicated

Answer 26

1. Siblings of autistic children have no greater likelihood of having autism than the general population
2. The U.S. Preventive Services Task Force has concluded that there is insufficient evidence to screen children for autism in the absence of clinical concerns
3. Autism can be diagnosed as early as 1 year of age
4. Autism is roughly four times more common among girls than boys
5. Genetic testing is indicated

Critique:

Autism spectrum disorder (ASD) is a biologically based neurodevelopmental disorder in children that is manifested by difficulty with social communication and socialization, and by repetitive patterns of behavior or activities. It affects roughly 1 in 59 children according to the CDC monitoring network, with a male to female ratio of 4.5:1. The latest DSM-5 diagnosis encompasses disorders previously known as separate conditions: childhood disintegrative disorder, atypical autism, pervasive developmental disorder not otherwise specified, and Asperger syndrome.

Although its cause is unknown, ASD is thought to be a heritable disorder brought about through a diverse set of mutational mechanisms. Parents who have a child with autism spectrum disorder have a 2%–18% chance of having a second child who is also affected.

The U.S. Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) have different guidelines for autism screening. The USPSTF has determined that there is insufficient evidence to screen for autism if neither the parents nor clinicians have concerns about ASD. The USPSTF suggests that clinicians listen to parents’ concerns, use clinical judgment, and use validated tools to assess whether additional evaluation or services are needed. In the child described in this case, the parent raised a concern and there was an increased risk based on the sibling’s diagnosis. The AAP recommends standardized screening in primary care practices at 18 and 24 months of age, with ongoing developmental surveillance, because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function.

A diagnosis of autism can reliably be made at age 2, and early diagnosis results in earlier effective interventions for parents and children (SOR C). Children who fail a routine developmental screen should be screened for autism using an appropriate screening instrument. The Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) is a is a two-stage parent-reported validated screening instrument that assesses the risk of ASD with 85% sensitivity and 99% specificity. It should be administered at 18 and 30 months of age.

Genetic testing is indicated only for autistic children with mental retardation (SOR B).

Question 27

Question: 27 of 60

The mother of a 1-year-old African-American male is concerned that her child’s umbilical hernia has not decreased in size after she treated it by taping a half-dollar coin over it, as suggested by the child’s grandmother. The hernia measures approximately 1.5–2.0 cm at the abdominal muscle layer. She asks your opinion about surgical correction of the hernia.

With regard to surgery, you advise her that it should be

1. performed as soon as possible
2. deferred until the age of 2
3. deferred until 3–5 years of age
4. deferred until puberty

Answer 27

1. performed as soon as possible
2. deferred until the age of 2
3. deferred until 3–5 years of age
4. deferred until puberty

Critique:

Congenital umbilical hernias are very common, especially in African-American infants. After birth the fascial opening at the umbilicus spontaneously closes in most infants, with continued growth of the rectus abdominis muscles toward one another. These hernias can be detected during the newborn abdominal examination by palpating the borders of the fascial defects through the skin. They are more prominent when abdominal pressure is increased from crying.

Asymptomatic children with an umbilical ring that is progressively closing typically can be observed without concerns about incarceration, regardless of their age. Closure of the umbilical ring is complete in almost all children by 5 years of age, although the frequency of closure may be lower in African-American children. Surgery should not be considered until at least 3–5 years of age (SOR C). Conditions that increase the likelihood of surgery include a fascial opening that is greater than ≥1.5 cm, a significant amount of protruding skin, an older child, or an underlying predisposing condition that makes spontaneous closure less likely.

Although there is folklore about taping or strapping the umbilical hernia to promote closure, this practice can lead to skin maceration and infection and should be discouraged.

Question 28

Question: 28 of 60

An 18-month-old female is brought to your office because of a chronic red, dry, itchy rash over her neck and cheeks. The mother has been cleaning the affected area with alcohol but she thinks this has only made the rash worse.

Which one of the following is true regarding the management of this condition?

1. Effective skin hydration is the most important component of managing this condition
2. Lotions with higher water content are more effective than thick creams or ointments with low water content
3. Assessment and management of food allergies is important for children with this condition
4. Systemic treatments are more effective than topical treatments

Answer 28

1. Effective skin hydration is the most important component of managing this condition
2. Lotions with higher water content are more effective than thick creams or ointments with low water content
3. Assessment and management of food allergies is important for children with this condition
4. Systemic treatments are more effective than topical treatments

Critique:

This patient has eczema, which is a chronic, pruritic, inflammatory skin disease that occurs more commonly in children, with a prevalence of up to 20% in the United States. Up to 70% of affected patients have a positive family history of atopic diseases.

In infants and children up to the age of 2, atopic dermatitis typically presents with pruritic, red, scaly, and crusted lesions on the extensor surfaces and cheeks or scalp, with sparing of the diaper area. In a small child it often presents with scratching or rubbing (SOR C).

While acute lesions can include vesicles, there can be serous exudates and crusting in severe cases. An exudate or crusting suggests secondary bacterial infection and topical antibiotics should be started, with consideration of local resistance. A food allergy may be related in a subset of patients, but the role of food allergy in eczema is controversial.

Effective skin hydration is the major focus of management of atopic dermatitis in children. Returning moisture to the skin will allow it to heal and will reduce redness, itching, and scaling (SOR C). Thick creams with a low water content such as Cetaphil or Eucerin, or ointments such as petroleum jelly or Aquaphor that have zero water content, provide better protection against dry skin. Emollients should be applied liberally at least once a day and immediately after bathing or hand washing. A randomized, controlled trial of infants with moderate to severe atopic dermatitis demonstrated that regular emollient use resulted in improved symptoms and reduced the need for topical corticosteroid use. Eczematous skin is very dry and inflamed. Alcohol is a drying agent and exacerbates the rash. Lotions which have a high water and low oil content can accelerate evaporation and trigger a flare of the disease.

Question 29

Question: 29 of 60

A 14-year-old male presents with low mood and difficulty concentrating for the past 4 months. His mother says that he is more withdrawn and that his symptoms seem to be worsening. During the visit the patient says he does not have any suicidal ideation. His Patient Health Questionnaire-9 (PHQ-9) score is 17.

Which one of the following statements is most accurate regarding treatment of this condition?

1. Clinical trials have shown an increase in completed suicides among children and adolescents treated for depression with SSRIs
2. Fluoxetine (Prozac) is an approved first-line treatment
3. Cognitive-behavioral therapy alone has been shown to be equally effective in achieving remission or recovery, compared to SSRIs alone or combined therapy
4. All SSRIs have been shown to be equally effective

Answer 29

1. Clinical trials have shown an increase in completed suicides among children and adolescents treated for depression with SSRIs
2. Fluoxetine (Prozac) is an approved first-line treatment
3. Cognitive-behavioral therapy alone has been shown to be equally effective in achieving remission or recovery, compared to SSRIs alone or combined therapy
4. All SSRIs have been shown to be equally effective

Critique:

Fluoxetine and escitalopram are the only two antidepressants that are FDA-approved for pediatric patients. While either can be used as first-line therapy, three systematic reviews of randomized, controlled trials have concluded that fluoxetine has the highest efficacy for treatment of depression in children and adolescents. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and other SRRIs have not been demonstrated to be effective in this population.

Cognitive-behavioral therapy (CBT) alone has not shown consistent benefits for symptom reduction, remission, or recovery. High-quality evidence from randomized, controlled trials has demonstrated greater efficacy for combined therapy with fluoxetine and CBT (SOR A). With combined therapy, the likelihood of achieving remission within 12 weeks was greater than either therapy alone (37%, NNT = 4). When either is declined by patients or their family members, monotherapy alone with either is still recommended, even with the likelihood of lower efficacy (SOR A).

Some clinical trials have shown an increase in suicidal thoughts and behaviors among patients taking antidepressants. However, completed suicide rates are not increased with treatment, and rates actually declined with an increased duration of therapy.

Question 30

Question: 30 of 60

Over the past 3 months a 5-year-old male has had three episodes of muteness accompanied by drooling and what he describes as a “funny taste” in his mouth. The episodes all occurred when he first woke up in the morning, lasted 3–5 minutes, and were not associated with a loss of consciousness or postictal state. His father had similar episodes when he was a child.

The most likely diagnosis is

1. benign focal epilepsy
2. complex partial epilepsy
3. febrile seizures
4. juvenile myoclonic epilepsy
5. video game–related epilepsy

Answer 30

1. benign focal epilepsy
2. complex partial epilepsy
3. febrile seizures
4. juvenile myoclonic epilepsy
5. video game–related epilepsy

Critique:

Benign focal epilepsy of childhood has its onset between 3 and 13 years of age and is one of the most common focal epilepsies in children. It is genetically inherited as an autosomal dominant trait with an age-dependent penetrance. The typical focal seizure lasts seconds to minutes, and manifestations include sensory symptoms or focal twitching involving the mouth, possibly accompanied by a sudden inability to speak and/or drooling. There is no loss or alteration of consciousness, and no postictal phase. The child may not mention these episodes to parents. A single bedtime dose of carbamazepine may be all that is needed to control recurrences (SOR C). The seizures generally stop by about 14–16 years of age.

Febrile seizures are benign seizure episodes that occur in approximately 3% of children between the ages of 6 months and 6 years, with a peak incidence at 18–24 months of age. Most occur only once and last for 15 minutes or less, although in approximately one-third of cases there will be multiple occurrences within 24 hours.

Complex partial epilepsy can occur at any age. The frequency of seizures is highly variable. Symptoms tend to include alterations of consciousness, an unfocused gaze, movements of the mouth such as lip-smacking and drooling, and abdominal symptoms such as nausea or vomiting. Most seizures last for several minutes and are associated with a postictal phase of confusion, sleep, or headache.

Juvenile myoclonic epilepsy typically has its onset between 12 and 18 years of age. An associated family history is common. It is believed to be genetically transmitted. Patients have a seizure triad of generalized, absence, and myoclonic seizures. Generalized seizures are common. Absence episodes mimic petit mal seizures and are characterized by sudden brief lapses in awareness, and myoclonus may cause repetitive flexion of the neck and shoulders.

The precipitation of seizures by the flicker frequency of video games is uncommon but can occur with both full-screen and handheld monitors. Seizure types include generalized seizures, simple or complex partial seizures, and absence seizures. The most effective treatment is abstinence from playing video games, but anticonvulsant medical therapy should be strongly considered in those who have had other unprovoked seizures. Factors that may contribute to these seizures include screen brightness, sleep deprivation, fatigue, fever, and short distance from the screen (SOR C).

Question 31

Question: 31 of 60

A healthy 5-year-old male is brought to your office by his mother for a well child visit. His birth history and past medical history are unremarkable and his immunizations are up to date. The mother has no specific concerns.

For a patient such as this one, the U.S. Preventive Services Task Force recommends routine screening for

1. developmental dysplasia of the hip
2. visual disturbance
3. hearing loss
4. proteinuria

Answer 31

1. developmental dysplasia of the hip
2. visual disturbance
3. hearing loss
4. proteinuria

Critique:

Although there is no direct evidence demonstrating that vision screening in children leads to an improvement in ultimate visual acuity, various screening tests are known to be effective in detecting common childhood visual problems, including strabismus, amblyopia, and refractive errors. Addressing these problems does improve vision. Therefore, the U.S. Preventive Services Task Force (USPSTF) recommends that age-appropriate screening be offered at least once in all children 3–5 years of age to detect amblyopia or its risk factors (B recommendation). Age-appropriate screening tools, such as the Snellen, Lea Symbols, and HOTV charts, may be used in children older than 3 years of age. Additional tests that can be considered in the primary care office include the red reflex test, the cover-uncover test for strabismus, and the corneal light reflex test.

Screening for developmental dysplasia of the hip is recommended by many groups, including the American Academy of Pediatrics and the Canadian Task Force on Preventive Care, but only in the first year of life. In 2006 the USPSTF cited insufficient evidence to make a recommendation either for or against screening at any age. The USPSTF later decided not to update this topic and has made it inactive.

Universal hearing screening using evoked auditory potential has become common for newborns, but the American Academy of Pediatrics also recommends periodic objective screening for all children at the 4- and 5-year-old well child visits. This should consist of behavioral tests of auditory thresholds in response to speech and frequency-specific stimuli presented through earphones and/or a bone vibrator. In 2008 the USPSTF cited insufficient evidence to recommend hearing screening, even in newborns, and has more recently made this topic inactive.

Urinalysis is not recommended by the USPSTF as a screening test for children.

Question 32

Question: 32 of 60

A 5-year-old female has a 12-day history of nighttime and daytime cough, low-grade fever, and nasal drainage that has substantially increased in amount and gradually changed from yellow to greenish. Her growth and development have been appropriate, and she has no chronic illnesses.

Which one of the following would be most helpful for making a diagnosis?

1. The increase in the amount of nasal drainage
2. The change in color of the nasal drainage
3. A symptom duration of more than 10 days without improvement
4. The presence of mucosal thickening in a paranasal sinus on a radiograph

Answer 32

1. The increase in the amount of nasal drainage
2. The change in color of the nasal drainage
3. A symptom duration of more than 10 days without improvement
4. The presence of mucosal thickening in a paranasal sinus on a radiograph

Critique:

In most children with uncomplicated upper respiratory infections (URIs), improvement is seen in 10 days or less. A child with persistence of any one of the typical URI symptoms for more than 10 days with no improvement makes the likelihood of sinusitis >90% (SOR C). The quantity, quality, and color of nasal discharge are not helpful in differentiating acute bacterial sinusitis from other upper respiratory illnesses such as the common cold or allergic rhinitis (SOR B, C).

The presence of a URI alone, without sinusitis, can result in mucosal thickening and abnormal findings in the paranasal sinuses on plain radiographs and CT, and these findings may persist for up to 2 weeks after symptomatic improvement. This finding is therefore not useful in evaluating children for acute bacterial sinusitis.

Question 33

Question: 33 of 60

During a well child visit, the parents of a 4-year-old male tell you that he has had a recent gradual onset of snoring, nighttime awakenings, mouth breathing, and irritability. The physical examination is normal except for tonsillar hypertrophy.

Which one of the following is the most likely diagnosis?

1. Aspiration
2. Asthma
3. Epiglottitis
4. Laryngomalacia
5. Obstructive sleep apnea

Answer 33

1. Aspiration
2. Asthma
3. Epiglottitis
4. Laryngomalacia
5. Obstructive sleep apnea

Critique:

The presenting problem in children with obstructive sleep apnea (OSA) depends on the child’s age. The prevalence of OSA in children is 1%–5% and the onset is typically between 2 and 8 years of age, with males and females affected equally. In children younger than 5 years snoring is the most common symptom. Other nighttime symptoms frequently reported by parents include mouth breathing, restlessness, unusual sleep positions, nighttime enuresis or diaphoresis, paradoxical breathing, frequent awakenings, and witnessed apneic episodes (SOR C). Excessive daytime sleepiness, morning headaches, poor concentration or decreased attention, behavior problems, shortened attention spans, and failure to thrive may also be seen in addition to snoring.

The history and physical examination findings are not sufficiently sensitive for making the diagnosis, and children with suspected OSA should be referred for polysomnography. Children with high-risk features such as attention-deficit/hyperactivity disorder, cardiorespiratory failure, craniofacial abnormalities, congenital defects, or Down syndrome should be referred to a sleep medicine specialist. Most of the symptoms exhibited by this patient resolve with successful treatment.

Question 34

Question: 34 of 60

As part of a well child visit for a 3-year-old, you talk with the mother about effective dental care. Which one of the following would be appropriate to include in this conversation?

1. The use of fluoride toothpaste has been shown to reduce the risk of dental caries in children
2. The child should have her teeth brushed once daily
3. A 1-inch application of fluoride-containing toothpaste should be used to brush her teeth
4. The U.S. Preventive Services Task Force recommends oral fluoride supplementation beginning at age 2 if the water supply is deficient in fluoride

Answer 34

1. The use of fluoride toothpaste has been shown to reduce the risk of dental caries in children
2. The child should have her teeth brushed once daily
3. A 1-inch application of fluoride-containing toothpaste should be used to brush her teeth
4. The U.S. Preventive Services Task Force recommends oral fluoride supplementation beginning at age 2 if the water supply is deficient in fluoride

Critique:

Oral health is an important part of childhood development. The American Academy of Pediatric Dentistry, the American Dental Association, the American Public Health Association, and the American Academy of Pediatrics (AAP) recommend that the first dental visit occur at or near 1 year of age, with evidence demonstrating that early initiation of dental care is associated with improved outcomes. These visits should include dental risk assessment, evaluation of fluoride needs, anticipatory guidance regarding appropriate cleaning methods, and discussion of dietary oral habits such as non-nutritive sucking.

All of the 20 primary teeth should erupt by age 3. Children with any teeth should have their teeth brushed twice daily for 2 minutes with small amounts of fluoride-containing toothpaste. Use of fluoride toothpaste has been shown to reduce the risk of dental caries in children. For infants and children younger than age 3, a very thin layer of toothpaste the size of a grain of rice is most appropriate. At age 3, the amount is increased to no more than a “pea-sized” amount. A 1-inch long application would increase the risk of fluorosis (SOR C). Parents should supervise their child’s dental care until they are approximately 8 years of age and are able to effectively brush on their own, spreading fluoride-containing toothpaste on all surfaces of the teeth.

Supplemental fluoride is recommended to help prevent caries when the household water is not fluoridated. For a 3-year-old child the dosage should be 0.5 mg daily. Children living in areas with inadequate fluoride in the water supply (0.6 ppm or less) should take a daily fluoride supplement. The U.S. Preventive Services Task Force (USPSTF) recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride (B recommendation). Regular use of fluoride mouth rinse under supervision results in a large reduction in tooth decay in children’s permanent teeth.

The USPSTF and the AAP recommend universal application of fluoride varnish once primary tooth eruption begins (B recommendation) and continuing through 5 years of age to avoid missed opportunities to prevent caries. For children less than 6 years of age, 2.26% fluoride varnish should be applied every 3–6 months.

In addition to a history of insufficient fluoride exposure, children with the following risk factors should be referred for a more formal dental evaluation: a mother or primary caregiver with active cavities, breast or bottle feeding beyond 1 year of age, frequent consumption of sugary snacks and beverages, prolonged or excessive use of a training cup, having a bottle with sugary beverages at bedtime, exposure to passive tobacco smoke, visible plaque on upper front teeth and enamel defects, special health care needs, and low socioeconomic status.

Question 35

Question: 35 of 60

A 7-year-old male presents with a rapid onset of a red, swollen right shin. He is on a youth football team, and two teammates recently had boils on their legs that were culture-positive for methicillin-resistant Staphylococcus aureus (MRSA). The boy has a hot, tender, 5×5-cm area of erythema on the right lateral shin where his football pants rub the skin.

Which one of the following would be the most appropriate treatment?

1. Amoxicillin/clavulanate (Augmentin)
2. Cephalexin (Keflex)
3. Trimethoprim/sulfamethoxazole (Bactrim)
4. Vancomycin (Vancocin)

Answer 35

1. Amoxicillin/clavulanate (Augmentin)
2. Cephalexin (Keflex)
3. Trimethoprim/sulfamethoxazole (Bactrim)
4. Vancomycin (Vancocin)

Critique:

This child has a cellulitis that is most likely due to methicillin-resistant Staphylococcus aureus (MRSA). Cephalexin and amoxicillin/clavulanate are ineffective against MRSA. Vancomycin must be given intravenously and is not cost effective in this situation. Levofloxacin is contraindicated in persons under the age of 19 years because of the risk of joint malformation. The best antibiotic for this patient is trimethoprim/sulfamethoxazole. It is bactericidal and there is clinical data to support its use (SOR A).

Question 36

Question: 36 of 60

The mother of a 2-year-old male brings him to your office for the first time. He is an only child, and the mother says his growth and development have been appropriate. However, the mother reports that he recently started having temper tantrums in the afternoons. She says he is “out of control” and at times gets so worked up that he holds his breath and “turns blue,” which frightens her.

Which one of the following would be appropriate advice for this mother?

1. Most toddlers outgrow temper tantrums before the age of 3
2. Breath-holding spells can result in epilepsy or hypoxic brain damage
3. Parental calm is a key strategy in addressing temper tantrums
4. Time-out is an ineffective strategy for reducing temper tantrums at this age

Answer 36

1. Most toddlers outgrow temper tantrums before the age of 3
2. Breath-holding spells can result in epilepsy or hypoxic brain damage
3. Parental calm is a key strategy in addressing temper tantrums
4. Time-out is an ineffective strategy for reducing temper tantrums at this age

Critique:

Temper tantrums are disruptive behaviors reported by the parents of most 2- to 4-year-old children. They are much less frequent after age 4. Tantrums are more likely when the child is tired, hungry, frustrated, or faced with a new or overwhelming situation. On average tantrums last for 30 seconds to 1 minute, and the child’s behavior returns to normal afterwards. Breath-holding spells can be a component of a temper tantrum and can lead to cyanosis or syncope. They do not lead to epilepsy or hypoxic brain damage and do not need to be treated medically, although iron therapy has been shown to decrease their frequency.

Dealing with temper tantrums begins with understanding that they are part of a child’s normal psychological growth. Key strategies for preventing tantrums include understanding and predicting situations that provoke tantrums, such as hunger, fatigue, and stranger anxiety; giving children clear and simple choices; and limiting saying no only to issues that really matter such as safety issues. When tantrums occur they should be controlled as much as possible by the parent remaining calm and gently removing the child to a quiet place, distracting the child toward a more positive or enjoyable situation, and using time-outs in a clear and consistent way.

Time-outs and removing privileges can be effective strategies. Initially they may exacerbate the child’s negative behavior as he or she tries to test the new limit. Parents should accept this as normal behavior and not respond to it. With consistent use time-outs lead to a decrease in negative behavior, but they can lose their effectiveness if used too often.

Question 37

Question: 37 of 60

A healthy 2-month-old female is brought to your office for a well child visit. Which one of the following immunizations should be administered at this visit?

1. Meningococcal conjugate
2. MMR
3. Oral poliovirus
4. Rotavirus

Answer 37

1. Meningococcal conjugate
2. MMR
3. Oral poliovirus
4. Rotavirus

Critique:

Childhood immunizations have prevented many previously common communicable diseases, and the CDC’s Advisory Committee on Immunization Practices regularly updates its recommendations.

Because of the risk of inducing clinical polio with the live oral poliovirus vaccine, it is no longer recommended for routine childhood immunizations. Since 1999, parenteral inactivated poliovirus vaccine has been recommended instead.

MMR has been found to be efficacious only when given after 1 year of age and is not indicated in this child.

Meningococcal vaccine is not recommended at this age, but rather a first dose is recommended at 11–12 years of age, with a second dose at age 16.

Rotavirus immunization is accomplished in a three-dose series at 2, 4, and 6 months of age, so it is the only one on this list that is appropriate for the 2-month-old child described.

Question 38

Question: 38 of 60

A 6-year-old female is brought to your office by her parents because she has become clumsy and has a poor appetite. They report that occasionally she seems to have abdominal pain and constipation. Her weight is at the 25th percentile and was previously at the 50th percentile for her age. The remainder of the examination is normal. Further testing reveals a blood lead level of 60 µg/dL.

Which one of the following is true regarding this situation?

1. Eliminating environmental sources of lead contact for this patient is sufficient and her symptoms will improve over time
2. If lead-containing paint is identified in the home, the parents should remove or neutralize as much of it as they can
3. She should prophylactically receive whole bowel irrigation in the event that lead is still present
4. She should be admitted to the hospital emergently for chelation therapy

Answer 38

1. Eliminating environmental sources of lead contact for this patient is sufficient and her symptoms will improve over time
2. If lead-containing paint is identified in the home, the parents should remove or neutralize as much of it as they can
3. She should prophylactically receive whole bowel irrigation in the event that lead is still present
4. She should be admitted to the hospital emergently for chelation therapy

Critique:

Environmental exposure to lead is the source of most lead poisoning, with more than 500,000 children in the United States estimated to have blood lead levels >5 µg/dL. Exposure to lead paint from chips and dust on surfaces or in the soil is the most common source. Additional risk factors include age less than 5 years, living in homes built prior to 1978, having a low socioeconomic status, living in a community with lead-containing water lines, and exposure to imported foods, pottery, or herbal remedies.

Lead poisoning is often asymptomatic, even when blood lead levels are ≥45 µg/dL. The U.S. Preventive Services Task Force 2019 recommendation cites insufficient evidence for universal screening in pregnant women and asymptomatic children. However, targeted screening guidelines from the CDC by states and cities may help guide screening decisions. When local or state guidelines are not available, the CDC recommends screening all Medicaid-eligible children at 12 and 24 months of age, as well as universal screening in areas where more than 27% of housing was built before 1950, or where data shows that ≥12% of children between 12 and 36 months of age have blood lead levels >10 µg/dL.

Symptomatic lead toxicity should be treated as an emergency and the child should be admitted to the hospital for chelation therapy (SOR C). Symptoms of central nervous system toxicity include headaches, loss of appetite, clumsiness, agitation, decreased activity, and somnolence. These symptoms can rapidly deteriorate into convulsions and stupor, and prompt recognition and treatment are required. A plain abdominal radiograph is warranted in patients who have blood lead levels of 15–44 µg/dL and pica behaviors, and in all patients with a blood lead level ≥45 µg/dL. If leaded foreign bodies or flecks are identified in the small bowel, patients should undergo gastrointestinal decontamination with whole bowel irrigation (SOR C).

Anticipatory guidance for parents in at-risk environments may include recommendations to have older homes and their water sources tested for lead, regular hand washing and cleaning of toys to reduce exposure to lead-containing dust, wet mopping of floors and windowsills every 2 weeks or less, and removal of shoes before entering the home in areas where soil levels of lead may be high. Despite this, a recent Cochrane study showed household education interventions to be ineffective overall in reducing blood levels in children. Removal of lead hazards such as lead-containing paint requires expert training for safe removal. It is not advisable for parents to attempt to remove the lead hazard (SOR C). The environment needs to be tested for lead prior to the child’s return home.

Question 39

Question: 39 of 60

An 18-month-old male is brought to your office for a well child examination. He and his mother just moved to your community from a large city. She has an eighth-grade education and is on medical assistance. As part of your anticipatory guidance you mention the Reach Out and Read program.

Which one of the following is true regarding this program?

1. 18 months of age is too early to begin
2. It improves language development in young high-risk children
3. It is strictly a home-based intervention
4. Positive outcomes depend on the parent’s language proficiency

Answer 39

1. 18 months of age is too early to begin
2. It improves language development in young high-risk children
3. It is strictly a home-based intervention
4. Positive outcomes depend on the parent’s language proficiency

Critique:

Reading regularly with young children stimulates brain development and strengthens parent-child interactions during a critical period for the development of language, literacy, and social-emotional skills. The American Academy of Pediatrics (AAP) recommends that regular literacy promotion begin during infancy and continue until entry into school.

Reach Out and Read is an evidence-based literacy program that was originally designed to provide at-risk preschoolers and their families with the materials, education, and support needed to make reading part of their lives. Participating practices provide a developmentally and culturally appropriate book to take home at each pediatric visit for children age 6 months to 5 years. The clinician also provides advice about the importance of reading and the benefits of reading aloud. Studies indicate that Reach Out and Read affects parents’ reading frequency, behaviors, and attitudes, and improves language development in young high-risk children.

Reach Out and Read has been an evidence-based program from its inception, and its outcomes have been carefully documented. It was originally introduced in pediatricians’ offices, but it has much broader applications in clinical practice, especially to family physicians who care for children.

Bright Futures and the AAP have developed anticipatory guidelines incorporating Reach Out and Read. Bright Futures recommends that intervention begin at 2 months of age, and the AAP recommends beginning at 6 months of age. The program has shown that storybook reading started as early as infancy contributes significantly to the development of emergent literary skills in early childhood and to success in learning to read in school. Reach Out and Read is not just a home-based intervention, however. It is a multifaceted approach to literacy, including volunteers in physicians’ waiting rooms who read to children. However, studies have shown a nearly linear association between children’s expressive language ability at 3 years of age and the number of words the child is exposed to in the home environment. Thus, an emphasis on reading to the child at home is a very important component of Reach Out and Read. After parent education, foreign birth, and language proficiency were statistically controlled, the intervention remained significantly associated with higher language outcomes in older toddlers.

Question 40

Question: 40 of 60

Which one of the following is most accurate regarding screening and counseling adolescents about safety?

1. Evidence from high-quality randomized trials has shown that in adolescents who receive screening and counseling, safety behaviors have changed significantly 6 months later compared to the unscreened group
2. Fee-for-service reimbursement models incentivize taking time for this type of screening and counseling for adolescents
3. The use of screening tools and forms in the chart has been shown to improve screening more than training programs for health care providers
4. Accidents and unintentional injuries rank third on the list of contributors to adolescent deaths

Answer 40

1. Evidence from high-quality randomized trials has shown that in adolescents who receive screening and counseling, safety behaviors have changed significantly 6 months later compared to the unscreened group
2. Fee-for-service reimbursement models incentivize taking time for this type of screening and counseling for adolescents
3. The use of screening tools and forms in the chart has been shown to improve screening more than training programs for health care providers
4. Accidents and unintentional injuries rank third on the list of contributors to adolescent deaths

Critique:

Unintentional injuries are the leading cause of death from birth to age 18 in the United States, led by motor vehicle–related deaths. The American Academy of Pediatrics recommends that every well child visit include age-appropriate injury prevention counseling. The use of helmets and seat belts is an important topic at any visit with an adolescent, given that they are no longer seen annually for well child visits.

Barriers to performing this type of screening include lack of training, time, and reimbursement, as well as a lack of knowledge regarding the efficacy of doing so. A randomized, controlled trial found that brief safety screening and counseling was associated with a greater likelihood of positive behavior change in the adolescent’s seat belt and bicycle helmet use 6 months after the intervention. The average screening rate increased from 58% to 83%, and counseling rates increased from 52% to 78%. Training programs for practitioners, which include role playing with adolescent actors, have been shown to improve the percentage of adolescents screened at subsequent visits in the provider’s practice. These training sessions have a more important impact than just the provision of screening tools and forms in the charts.

Question 41

Question: 41 of 60

You see a 15-year-old male for a well child visit. His father is worried that the boy seems withdrawn and his grades are slipping. On questioning the patient you find out that he is increasingly afraid of going to school because he is being threatened by a boy in his class.

Which one of the following is true regarding this problem?

1. The prevalence of bullying increases during middle school and peaks in the high school years
2. Direct bullying is more prevalent than cyberbullying among high school students
3. Children who experience bullying should be asked about thoughts of suicide
4. Interviewing children with their parents present is most effective for obtaining needed information

Answer 41

1. The prevalence of bullying increases during middle school and peaks in the high school years
2. Direct bullying is more prevalent than cyberbullying among high school students
3. Children who experience bullying should be asked about thoughts of suicide
4. Interviewing children with their parents present is most effective for obtaining needed information

Critique:

Bullying and its impact have become more recognized as contributing to both short- and long-term adverse psychosocial and physical problems in young people. Defined as unwanted attacks or intimidation on another person that are intended to create fear, distress, or harm, these behaviors are repetitive and either create, or result from, an imbalance of power between the bully and the victim. The attacks can be direct, in the case of physical or verbal abuse, or indirect in the case of rumors being spread or being excluded socially. Cyberbullying uses digital platforms for either direct or indirect attacks.

Bullying at school affects 1 in 5 students according to data from the Youth Risk Behavior Surveillance survey. Rates are highest in middle school (28%), followed by high school (16%). Cyberbullying has been on the rise, with some reports indicating a prevalence of 16%–33% in middle and high school.

Young people can be victims of bullying, perpetrators, or in some cases, both. Bullying affects everyone involved, including bystanders who witness bullying behavior. Children who are bullied may present with symptoms of depression or anxiety, school refusal, social isolation, or substance use, as well as somatic complaints such as headaches, abdominal pain, or sleep disturbance. Victims have higher rates of self-harm and suicidal thoughts and attempts, with the highest rates related to cyberbullying. If bullying is suspected or confirmed, screening for suicidality is essential.

Bullies and the children that are bullied are more likely to carry weapons to school than are other children. Attackers in school shootings often cite revenge for bullying by others as a motive for their actions.

Bullying should be addressed in well child visits, both for prevention and case finding. The American Academy of Pediatrics recommends including anticipatory guidance about bullying beginning at the 6-year well child visit. Physicians should also ask about bullying when somatic complaints, school avoidance, or self-harm are identified at office visits (SOR C). Children found to be bullies should be screened for conduct disorder and other psychiatric comorbidities (SOR C).

Children are often reluctant to open up about bullying, especially with parents in the room. Ensuring some time to talk with them alone during the visit is important, and there are now electronic assessment tools that can be sent prior to well child visits that allow the child to disclose this problem without fear of a face-to-face discussion. Questions about a child or adolescent’s online activities should be included (SOR C), with recognition that they may be reluctant to disclose bullying because of fears that electronic devices will be confiscated by parents, or that their use will be severely limited.

Question 42

Question: 42 of 60

A 9-year-old male presents with a 1-week history of fever, anorexia, malaise, and axillary and supraclavicular adenopathy. He had previously been well and thriving. No one else in his home is sick. He brought home a stray cat about 6 weeks ago but recalls no scratches or skin sores. The cat was noted to have fleas. An examination confirms the presenting symptoms. He has no skin lesions, there is no hepatosplenomegaly, and a neurologic examination is within normal limits.

Which one of the following would be most appropriate at this point?

1. An erythrocyte sedimentation rate
2. Tuberculin testing
3. An indirect immunofluorescent antibody assay
4. A lymph node biopsy

Answer 42

1. An erythrocyte sedimentation rate
2. Tuberculin testing
3. An indirect immunofluorescent antibody assay
4. A lymph node biopsy

Critique:

This child has a history and physical findings that suggest cat scratch disease (CSD). CSD can result from a scratch or bite from an infected cat. Multiple lines of evidence have directly linked CSD to exposure to cats, especially young cats and cats with fleas. More than 90% of patients with CSD have a history of exposure to cats, and 75% of patients have a history of a cat scratch or bite, usually from a healthy kitten. A history of being scratched is not mandatory for the diagnosis, since transmission can occur by petting a cat, with subsequent self-inoculation via a mucous membrane, a skin break, or the conjunctivae.

The most common presenting symptom in patients seeking medical care is tender regional lymphadenopathy, typically of the cervical, axillary, or epitrochlear nodes. Approximately 50% of patients experience systemic symptoms such as fever, headache, malaise, myalgias, arthralgias, or exanthems. A careful examination may reveal an inoculation papule, usually on the head or upper extremities. The scalp, finger web spaces, eyelids, and conjunctivae should be thoroughly inspected. Multiple sites may be infected. The initial lesion evolves from a small, 2- to 5-mm reddish brown macule or vesicle to a papule or pustule over the course of several days. Patients may remember a self-healing lesion resembling an insect bite on the hand, arm, face, or neck. Lesions typically are nonpruritic and heal in days to months without scarring.

Lymphadenitis involving one or more nodes in the proximal drainage area of regional lymphatics occurs in all CSD cases approximately 2 weeks after the initial inoculation (range 5–50 days). Nodes are tender and range in size from 1–5 cm, occasionally exceeding 10 cm. The overlying skin may be erythematous, but only rarely is an associated cellulitis present. The lymphadenitis typically resolves over 2–4 months.

Although the erythrocyte sedimentation rate may be slightly elevated in CSD, this finding is not specific for the disease and will not help determine the diagnosis (SOR C). There is no crossreactivity between tuberculosis and CSD, so tuberculin skin testing is not warranted.

Immunofluorescent antibody testing to antigens of Bartonella species is useful for making the diagnosis (SOR A). However, a negative serologic test should not rule out CSD if there is a high clinical suspicion for disease. A lymph node biopsy generally is not indicated in typical cases of CSD, given the invasiveness and expense (SOR C). It should be considered only when the diagnosis is in doubt.

Question 43

Question: 43 of 60

A 14-year-old female sees you for an athletic preparticipation examination. She has played soccer since childhood and is moving up from the junior varsity to the varsity team this season.

Which one of the following should be included in the evaluation?

1. A baseline CBC and metabolic profile
2. A standardized set of questions to screen for cardiovascular disease
3. An in-office urinalysis
4. A focused physical examination to look for signs of exercise-induced asthma

Answer 43

1. A baseline CBC and metabolic profile
2. A standardized set of questions to screen for cardiovascular disease
3. An in-office urinalysis
4. A focused physical examination to look for signs of exercise-induced asthma

Critique:

Athletic preparticipation examinations are required by most states and recommended by several organizations, including the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Heart Association. Available evidence, however, indicates that they detect only a small percentage of cardiovascular abnormalities that result in sudden death during exercise. Furthermore, they have not been shown to decrease cardiovascular morbidity or mortality during athletic participation (SOR C).

Nevertheless, it is prudent to perform preparticipation examinations. The most important part of these evaluations is the history. A standardized set of screening cardiovascular questions is recommended and can help reveal more than 50% of cardiac anomalies that may prohibit or modify athletic participation. In the absence of a clear personal or family history, however, this screening does not reliably detect hypertrophic cardiomyopathy, which is the most common cause of sudden death in young athletes. This condition is often asymptomatic.

The physical examination, which should include careful auscultation of the heart and palpation of the cardiac impulse and peripheral pulses, may help in identifying hypertrophic cardiomyopathy. Physical abnormalities associated with this condition include a midsystolic murmur in the second right intercostal space or left sternal border that sometimes radiates to the neck. It increases with standing and decreases with squatting. The cardiac apical impulse is often displaced laterally. There could also be a holosystolic murmur of mitral regurgitation best heard at the apex and radiating to the axilla. Another rare cardiac anomaly that can be detected on examination is coarctation of the aorta, which results in reduced femoral pulses.

Exercise-induced asthma cannot be reliably detected during the preparticipation examination. Routine laboratory tests are not indicated as part of the preparticipation evaluation.

Question 44

Question: 44 of 60

During a routine evaluation you identify a 4-year-old male as being overweight, with a BMI of 28 kg/m2 (>95th percentile). After conducting a brief dietary assessment, you find that he drinks an 8-oz glass of juice with every meal he eats at home. His mother is careful to buy only “100% juice.” You also learn that the family relies on eating take-out restaurant meals an average of 3 nights per week. The child eats a prepared lunch at his preschool program.

Which one of the following is true in this situation?

1. Taking time to obtain a detailed dietary recall is important before initiating dietary counseling with this family
2. Excessive juice consumption is contributing to this child’s excess weight
3. The dietary habits of the rest of the family will have little to no impact on the child’s weight now or in the future
4. This child is too young for using the “MyPlate” approach to healthier nutritional planning

Answer 44

1. Taking time to obtain a detailed dietary recall is important before initiating dietary counseling with this family
2. Excessive juice consumption is contributing to this child’s excess weight
3. The dietary habits of the rest of the family will have little to no impact on the child’s weight now or in the future
4. This child is too young for using the “MyPlate” approach to healthier nutritional planning

Critique:

A detailed dietary recall with caloric intake assessment is difficult to accomplish in a busy office practice and is not typically necessary to support a brief counseling intervention. Instead, a brief dietary assessment can identify a few key nutritional habits most likely to be associated with obesity and provide some early indicators of behaviors that can initially be addressed. Important aspects to inquire about include the frequency of meals prepared in restaurants; how many high-calorie beverages, such as juice and soft drinks, are consumed daily; snacking patterns, including the frequency and portion size of high-calorie and high-sugar foods such as cookies, baked goods, ice cream and chips; whether lunch is prepared at home or purchased at school; the balance of vegetables, protein, and fruits at regular mealtimes; and any history of skipping meals.

Being able to contextualize the child’s nutritional patterns with those of the rest of the family will also help with counseling. Questions that could be asked include the following:

Does the family eat together?

If so, do they eat at the table or in front of the television?

Do they serve meals family style?

Who does the cooking and how are meals typically prepared?

How and where is grocery shopping done?

Does the shopper read food labels, use coupons, and select various types of dairy and grains?

Does the child have unlimited or monitored access to food after school?

Studies show that overconsumption of juice (and the resultant underconsumption of more nutritious drinks such as milk) contributes to obesity, malnutrition, short stature, and dental caries. Caries is especially likely if juice is drunk from a bottle rather than a cup. The American Academy of Pediatrics recommends limiting fruit juice to a maximum of 4–6 oz (½–¾ cup) per day and not allowing the child to carry a cup or box of juice throughout the day. This overweight 4-year-old is drinking three times the recommended amount of juice for his age, and because it is a relatively high-calorie beverage, it contributes to his weight problem.

U.S. dietary guidance using the MyPlate program uses tableware to convey messages about healthy eating, and resources are available for parents of preschoolers.

Question 45

Question: 45 of 60

A 7-year-old male with a history of asthma is brought to your office for routine follow-up. He is currently using a short-acting β-agonist as needed for symptom control. His mother reports that he uses his inhaler about 1–2 times a week and has nighttime symptoms 3 times a month. On examination his lungs are clear.

Which one of the following is true regarding the management of this patient’s asthma?

1. No changes are needed in his asthma treatment at this time
2. His β-agonist should be replaced with a leukotriene-receptor agonist such as montelukast (Singulair)
3. A daily inhaled corticosteroid should be started to help control his symptoms
4. A daily inhaled corticosteroid should be started to slow the progression of his asthma

Answer 45

1. No changes are needed in his asthma treatment at this time
2. His β-agonist should be replaced with a leukotriene-receptor agonist such as montelukast (Singulair)
3. A daily inhaled corticosteroid should be started to help control his symptoms
4. A daily inhaled corticosteroid should be started to slow the progression of his asthma

Critique:

The National Asthma Education and Prevention Program (NAEPP) defines asthma control as the extent to which therapy reduces or eliminates the manifestations of asthma. The classification of asthma severity is based on current impairment and future risk. Impairment is assessed by the following:

• The frequency of symptoms, nighttime awakenings, and use of short-acting β-agonists for symptom control in the past 2–4 weeks, based on patient and/or caregiver recall
• The degree to which symptoms have interfered with normal activity in the past 2–4 weeks, based on patient and/or caregiver recall
• Spirometry results in children who are able to perform the test

Risk assessment is primarily based on recall of the number of exacerbations in the past year that have required treatment with oral glucocorticoids, as well as the severity of each exacerbation and the interval since the last exacerbation. The NAEPP recommends the initiation of controller medications for all children ages 5–11 years who have persistent asthma of any severity, defined by symptom frequency, short-acting β-agonist use, impairment of normal activity, and risk for development of future exacerbations (SOR B).

The use of standardized questionnaires can aid in the assessment of asthma control in clinical practice. The Childhood ACT is validated for use in children aged 4–11 years, and the Test for Respiratory and Asthma Control in Kids (TRACK) questionnaire is validated for preschool-aged children. TRACK assesses impairment of asthma control (symptom burden, activity limitations, and rescue use of bronchodilators) and also assesses risk (oral glucocorticoid use in the past 12 months). The Asthma APGAR system (Activities, Persistent triGgers, Asthma medications, Response to therapy) system includes a patient/parent-completed questionnaire and an algorithm that uses the questionnaire answers to guide asthma care.

This patient has mild persistent asthma. He is using his inhaler on a weekly basis and having nighttime symptoms. For a patient with persistent asthma a daily inhaled corticosteroid is the preferred agent to control symptoms (SOR A). A leukotriene-receptor agonist such as montelukast could be added instead, but would be a second choice, would be more expensive, and should not be used to replace his current medication (SOR B). Adding an inhaled corticosteroid does not alter the progression of disease in asthma. These agents help control symptoms, prevent exacerbations, and improve the quality of life (SOR A).

Question 46

Question: 46 of 60

A 5-year-old female is brought to your office with a 36-hour history of vomiting and nonbloody diarrhea. Her temperature has been around 101°F, she has had 7 watery stools daily, and she has not had a cough or nasal congestion. The mother has given her oral rehydration solution but she has not been able to keep it down consistently. The child has urinated twice today.

On examination the patient is alert and fussy but is easily calmed by her mother. She is thirsty and eager to drink but vomits after attempting to do so. Her axillary temperature is 37.7°C (99.9°F), and her pulse rate, respiratory rate, and blood pressure are appropriate for her age. Her mouth is dry and her skinfold recoil is less than 2 seconds.

Which one of the following would be most appropriate at this time?

1. Advising the mother to offer a flat soft drink as desired
2. Bismuth subsalicylate (Pepto-Bismol)
3. A serum electrolyte panel
4. Ondansetron (Zofran)

Answer 46

1. Advising the mother to offer a flat soft drink as desired
2. Bismuth subsalicylate (Pepto-Bismol)
3. A serum electrolyte panel
4. Ondansetron (Zofran)

Critique:

There is ample high-quality evidence that oral rehydration is essentially as effective as intravenous rehydration for dehydrated children (SOR B). This is supported by evidence-based guidelines endorsed by the CDC and the American Academy of Pediatrics. The most-studied solution for oral rehydration is the World Health Organization Oral Rehydration Solution (WHO ORS). WHO now recommends rehydration with a reduced osmolarity ORS. The official WHO ORS or a solution composed of ½ teaspoon salt and 6 teaspoons sugar per 1 L water may be used. While other preparations resemble WHO ORS, they are not exactly the same.

Evidence-based guidelines agree that antidiarrheal medications should not be used, but some guidelines recommend the antiemetic ondansetron as an option to improve success rates of oral rehydration. Ondansetron can reduce vomiting to allow resumption of oral intake.

Laboratory studies are usually not necessary in the assessment of acute uncomplicated diarrhea due to viral gastroenteritis, and the results would not change the treatment plan (SOR C). Withholding the regular diet is not supported by current recommendations or evidence. Gut rest is not indicated and returning to an age-appropriate unrestricted diet (including breast milk or full-strength formula for infants) is recommended as soon as possible (SOR C). Because their carbohydrate-to-sodium ratio is vastly different from WHO ORS, flat soft drinks are a distinctly inappropriate rehydration fluid (SOR C). Antidiarrheal medications are not recommended for infants and children, do not change the outcome of treatment, and have potential adverse side effects (SOR C).

Question 47

Question: 47 of 60

A 9-month-old previously healthy male is brought to the emergency department by his mother. She tells you that approximately 5 hours ago the child suddenly began to cry inconsolably. Since then he has experienced paroxysms of screaming in apparent pain and pulls his legs up to his abdomen. These episodes are interspersed with periods of lethargy. He has had vomiting and diarrhea, and in the past hour has passed stool with dark blood in it. On examination you feel a cylindrical mass in the right lower quadrant.

Which one of the following tests would be most appropriate at this point?

1. CT of the abdomen
2. Hydrostatic or air enema
3. Rigid sigmoidoscopy
4. Flexible sigmoidoscopy
5. Surgery

Answer 47

1. CT of the abdomen
2. Hydrostatic or air enema
3. Rigid sigmoidoscopy
4. Flexible sigmoidoscopy
5. Surgery

Critique:

Intussusception is the most common abdominal emergency in early childhood, typically presenting between 6 and 36 months of age. In the majority of cases the cause is unknown. However, viruses, tumors, cystic fibrosis, Henoch-Schönlein purpura, Meckel’s diverticulum, and parasites have all been associated with this condition.

The most common presentation of intussusception is a sudden onset of intermittent, severe, crampy abdominal pain accompanied by inconsolable crying and drawing up of the legs toward the abdomen. The classic triad of abdominal pain, currant jelly stools, and a palpable cylindrical mass in the abdomen is seen only in a minority of patients. If the diagnosis is clear or highly suspected, as in this case, a hydrostatic (contrast or saline) or pneumatic (air) enema, performed under either sonographic or fluoroscopic guidance may be both diagnostic and therapeutic (SOR C). Pneumatic reduction in experienced hands is likely to be more successful in reducing the intussusception. If the diagnosis is uncertain, ultrasonography or plain films may be useful if readily available.

Although sigmoidoscopy is used in the management of sigmoid volvulus, it has no role in the management of intussusception. Surgical management is generally reserved for patients who have an incomplete nonoperative reduction.

Question 48

Question: 48 of 60

A 5-year-old female is brought to your office because of a recent onset of intense perineal and perianal itching, especially at night. You examine the area and see nothing unusual.

Which one of the following would be most appropriate in the evaluation and management of the child at this visit?

1. A stool sample for ova and parasites to make a definitive diagnosis
2. A CBC to check for anemia
3. Making a diagnosis based on the history of perineal and perianal itching
4. Using transparent adhesive tape applied to the anus or perianal skin to confirm the diagnosis

Answer 48

1. A stool sample for ova and parasites to make a definitive diagnosis
2. A CBC to check for anemia
3. Making a diagnosis based on the history of perineal and perianal itching
4. Using transparent adhesive tape applied to the anus or perianal skin to confirm the diagnosis

Critique:

Enterobiasis (pinworm) infection is frequently asymptomatic. The most common symptom, when present, is localized pruritus, probably caused by either an allergic response to the migrating adult pinworm or to mechanical irritation that occurs as it migrates to lay its eggs on the perianal skin. Aberrant migration to ectopic sites occasionally leads to appendicitis, chronic salpingitis, peritonitis, hepatitis, or ulcerative lesions in the large or small bowel.

The diagnosis may be made by demonstrating eggs or worms in the stool, but it is more easily established by examination of a piece of transparent adhesive tape after the adhesive side has been applied to the anus and perianal skin (SOR C). Adult female worms will be captured on the tape, with the highest yield obtained at night or early in the morning. Pinworms live in the colon, do not invade tissue, and do not take a blood meal, so they do not cause anemia as hookworms do (SOR C).

Antihelminthic drugs should be administered to infected individuals and their family members. Two 100-mg oral doses of mebendazole given 2 weeks apart results in cure rates of 90%–100% in patients of all ages. Alternative regimens include two 400-mg doses of albendazole given 2 weeks apart, or a single dose of pyrantel, 11 mg/kg, with a maximum dose of 1 g. Clinicians should be aware that the efficacy of mebendazole can be affected by such factors as preexisting diarrhea and gastrointestinal transit time, the degree of infection, and the strain of the particular helminth.

Because pinworm eggs can survive for days outside the host, all clothes and bed linens should be washed at the time of treatment. Family members should be examined and treated if they are found to harbor pinworms, to reduce the likelihood of reinfection (SOR B).

Question 49

Question: 49 of 60

You see a healthy 9-month-old infant for a well child examination. Which one of the following do you expect to find in the history that is typical for a child of this age?

1. He has temper tantrums
2. He participates cooperatively in dressing
3. He uses his fingers to point at things
4. He has a 3-word vocabulary, not including “mama” and “dada”

Answer 49

1. He has temper tantrums
2. He participates cooperatively in dressing
3. He uses his fingers to point at things
4. He has a 3-word vocabulary, not including “mama” and “dada”

Critique:

Temper tantrums generally do not occur in children under the age of 15–18 months. Participating cooperatively in dressing does not typically occur before 12 months of age. Using of their fingers to point at things is consistent with a 9-month-old milestone. A 3-word vocabulary is typical of a 15-month-old child, not a 9-month-old child.

Question 50

Question: 50 of 60

The mother of an 8-year-old female calls your office because her daughter was found to have head lice several days ago, which she treated with permethrin (Nix). However, she still sees some nits present when she examines her daughter. She wants to know when her daughter can return to school.

Which one of the following would you advise?

1. All children in the child’s class should be screened for lice
2. Information about this child’s infestation should be provided to her classmates
3. The child should be kept out of school as long as there are nits in her hair
4. The child should not be excluded from school because of head lice

Answer 50

1. All children in the child’s class should be screened for lice
2. Information about this child’s infestation should be provided to her classmates
3. The child should be kept out of school as long as there are nits in her hair
4. The child should not be excluded from school because of head lice

Critique:

The problem of head lice causes a lot of anxiety but little morbidity in school-age children and their families (SOR C). Unnecessary treatments are performed, school days are lost, and the economic loss owing to missed workdays by parents who have to stay home with their children is estimated at $4 billion to $8 billion.

Given that the likelihood of transmission is low, children should not be kept out of school even before treatment, as lice are not easily passed from one child to another in the activities of the classroom (SOR C). Screening programs have not been shown to be effective in the management of louse outbreaks (SOR B). This child poses little risk to classmates once effectively treated. Nits can remain even after successful treatment, so a policy of holding a child out of school until no nits are seen is not recommended and results in unnecessary school absences (SOR C). Nits do not necessarily pose a risk to other children, and only a small number of children with nits also have live lice.

Question 51

Question: 51 of 60

A 2-year-old male with Down syndrome is brought to your office for a well child visit. He has received appropriate screening and preventive care to this point, with normal results.

At this visit the most appropriate age-specific screening for this child would be

1. screening for refractive errors
2. a CBC to screen for leukemia
3. cervical spine radiographs to detect atlantoaxial instability or subluxation
4. echocardiography to screen for congenital heart defects

Answer 51

1. screening for refractive errors
2. a CBC to screen for leukemia
3. cervical spine radiographs to detect atlantoaxial instability or subluxation
4. echocardiography to screen for congenital heart defects

Critique:

The Committee on Genetics of the American Academy of Pediatrics has provided recommendations to assist primary care clinicians in the care of children with Down syndrome, given their increased risk for many health problems. Health supervision for the 1- to 5-year-old with Down syndrome includes annual vision screening, hearing screening, and laboratory studies for subclinical thyroid disease and blood disorders.

During the newborn period an ophthalmologic examination is needed to detect strabismus, nystagmus, and cataracts. The risk of refractive errors is approximately 50% between 3 and 5 years of age. Annual refractive screening is recommended until age 5, with screening every other year after that.

These children are also at risk for the development of both congenital and acquired hypothyroidism. After a normal newborn thyroid screen, screening should be repeated at 6 and 12 months of life, and then annually thereafter, with levels of both total thyroxine and TSH.

While the risks of atlantoaxial instability and subluxation are increased, there is some controversy regarding screening. Clinical screening should occur at every well child visit, but current evidence does not support routine cervical spine films to screen for atlantoaxial instability in asymptomatic children. A screening physical evaluation to detect atlantoaxial instability is probably prudent prior to clearance for sports and is required prior to participation in Special Olympics.

Children with Down syndrome are also at increased risk for leukemia. Screening with a CBC is recommended at birth, and then annually once the child reaches adolescence, but it is not required at this age. Echocardiography to screen for congenital heart defects, which occur in 50% of these children, should be performed in the neonatal period. If this has been done and was normal, it does not need to be repeated.

Question 52

Question: 52 of 60

A 4-year-old male is brought to your office for a well child evaluation. His family recently moved across town, so you are seeing him for the first time. He has a history of mild lower limb weakness beginning at age 3, which has been increasing over the past 6 months. During that time he has developed shortness of breath and difficulty with daily activities such as climbing stairs. The parents note that he is easily fatigued.

His last visit with his previous physician was 6 months ago and did not reveal any cause for his problems. Since that time he has lost 1 kg (2 lb) and developed a chronic nonproductive cough that is now accompanied by occasional nausea and vomiting, and he has also developed orthopnea. His bowel movements are regular.

On examination his blood pressure is 95/60 mm Hg, his pulse rate is 100 beats/min, and his respiratory rate is 20/min. He is not cyanotic. His lungs are clear to auscultation and no murmur or arrhythmia is evident. His muscle strength is reduced to 4/5 diffusely and he has hyporeflexia in his lower extremities. When he stands up he pushes his hands against his thighs and has a lordotic posture. His calf muscles are proportionately hypertrophied in relation to his thighs.

The recent escalation of this patient’s symptoms is most likely a consequence of which one of the following?

1. Cardiomyopathy
2. Gastroenteropathy
3. Peripheral neuropathy
4. Renal failure
5. Reversible airway disease

Answer 52

1. Cardiomyopathy
2. Gastroenteropathy
3. Peripheral neuropathy
4. Renal failure
5. Reversible airway disease

Critique:

This presentation is typical of Duchenne’s muscular dystrophy (DMD), which causes cardiomyopathy in 50%–70% of affected boys. Weight loss, cough, nausea, vomiting, orthopnea, and fatigue are common symptoms of heart failure in childhood. In patients with DMD, these symptoms are particularly associated with cardiomyopathy, which does not always correlate with the severity of the musculoskeletal symptoms. In addition to a careful history and physical examination, noninvasive imaging with either echocardiography or cardiac MRI is recommended, based on the child’s age and ability to cooperate. More recent studies have shown that cardiac MRI is superior to echocardiography for diagnosing DMD-related ventricular dysfunction because it is less affected by body habitus and has lower rates of suboptimal imaging. Consultation with a cardiologist is important for ongoing surveillance.

Renal failure, gastroenteropathy, reversible airway disorders, and peripheral neuropathy do not present with hypertrophied musculature or the symptom complex seen in this patient, and they are not typical complications of DMD. Diuretics, ACE inhibitors, and/or β-blockers can be used to manage cardiac symptoms.

Question 53

Question: 53 of 60

A 6-month-old male is brought to your office by his mother because she was told that two staff members at his day care center have hepatitis. He has been attending the day care center for 3 months. You call the center and confirm that two adult staff members were diagnosed with acute hepatitis A.

The child is healthy and a physical examination is completely normal. He lives with his mother, father, 18-month-old sister, and 6-year-old brother.

The most appropriate action at this point would be to

1. order a hepatitis A IgM antibody titer for the infant now, and repeat in 6 weeks
2. administer the first dose of hepatitis A vaccine to the infant now
3. administer immune globulin (IG) at a dose of 0.1 mL/kg to the infant as soon as possible
4. recommend that all household family members receive IG

Answer 53

1. order a hepatitis A IgM antibody titer for the infant now, and repeat in 6 weeks
2. administer the first dose of hepatitis A vaccine to the infant now
3. administer immune globulin (IG) at a dose of 0.1 mL/kg to the infant as soon as possible
4. recommend that all household family members receive IG

Critique:

There is no indication for ordering a hepatitis A IgM antibody titer in this patient. It has no bearing on treatment or outcome (SOR C). While hepatitis A vaccine is effective as postexposure prophylaxis in adults and children older than 1 year, it is not indicated for children younger than 1 year of age (SOR C). The CDC recommends postexposure prophylaxis with immune globulin (IG) for attendees of child care centers if one or more cases of hepatitis A are diagnosed in children or staff at the center (SOR C). IG is not indicated for family members in this situation, as the cases were reported only at the day care center.

While there is no need for the siblings to receive postexposure prophylaxis in this case, the latest recommendations call for universal hepatitis A vaccination for children between the ages of 12 and 23 months, and consideration of catch-up vaccinations for older unvaccinated children (SOR C). If there is a community outbreak (hepatitis A cases in three or more families), IG should be considered for unvaccinated household members with children in the day care center who use diapers, since the disease is spread by the fecal-oral route (SOR C).

Question 54

Question: 54 of 60

A 6-week-old male is brought to your office with a 3-day history of projectile, nonbilious vomiting at every feeding. He appears healthy and an abdominal examination is normal. A CBC and electrolyte panel are normal.

Which one of the following should be ordered initially?

1. A plain film of the abdomen
2. An upper GI series
3. Ultrasonography
4. CT of the abdomen
5. Nuclear scintigraphy

Answer 54

1. A plain film of the abdomen
2. An upper GI series
3. Ultrasonography
4. CT of the abdomen
5. Nuclear scintigraphy

Critique:

Projectile nonbilious vomiting in a 6-week-old infant should raise the suspicion of hypertrophic pyloric stenosis (HPS). Other possible diagnoses include gastroesophageal reflux, acute viral gastroenteritis, and pylorospasm. The classic hypertrophied pylorus, or “olive sign,” is found on physical examination in only 23% of infants with pyloric stenosis. HPS is more common in males and in patients with a positive family history. Imaging studies are recommended in patients without the classic findings on physical examination. The ability to feel the pylorus requires prone positioning of the infant, palpating upward in the right upper quadrant just beside the rectus abdominis muscle. Most examiners have little experience with this technique and therefore rely on imaging to confirm the diagnosis.

Ultrasonography has become the standard test for HPS, with muscle thickness measurements of 4 mm considered positive (SOR C). Measurements of 3–4 mm are indeterminate and require further evaluation. A pyloric length ≥2 cm is also considered diagnostic. An experienced ultrasonographer is needed to ensure accurate measurements.

Abdominal plain films are typically not useful and nondiagnostic, with nonspecific findings (SOR C). Ultrasonography is preferred over an upper GI series for the initial evaluation of suspected HPS because it does not expose the infant to ionizing radiation. If ultrasonography is negative or inconclusive an upper GI series should be obtained (SOR C). CT exposes the infant to a large amount of ionizing radiation and should not be used in the initial evaluation of vomiting in a 6-week-old infant (SOR C). Nuclear scintigraphy can be useful as a test for stomach motility when all other tests are normal (SOR C).

Question 55

Question: 55 of 60

You see a 15-month-old male because the parents have noted that his left foot and toes point inward when he walks. He began walking when he was 13 months old, and occasionally seems to trip because of his foot problem. When he stands or walks you note that the left patella faces forward and the left foot and toes point inward. The right leg and foot are aligned normally. His developmental history and the remainder of the physical examination are within normal limits.

Which one of the following is true regarding this deformity?

1. Males are affected more than females
2. Unilateral findings are unusual
3. About 90% of cases resolve by 8 years of age
4. Shoe wedges speed resolution

Answer 55

1. Males are affected more than females
2. Unilateral findings are unusual
3. About 90% of cases resolve by 8 years of age
4. Shoe wedges speed resolution

Critique:

Parents often seek medical advice about lower extremity deformities in their children. In most cases the problem is a variation of normal growth and development and it resolves without treatment as the child grows.

Intoeing is the most common rotational condition and has three major causes: metatarsus adductus, internal tibial torsion, and femoral anteversion. Internal tibial torsion is the most common of these. It affects males and females equally. It is often asymmetric, with the left side affected more than the right. Causes are believed to include intrauterine positioning, sleeping in the prone position after birth, and sitting on the feet.

The child with internal tibial torsion walks with the patella of the affected leg facing forward and the ipsilateral foot pointing inward. In 90% of cases internal tibial torsion gradually resolves on its own by the time the child reaches 8 years of age. Treatment with night splints, shoe wedges, or orthotics is unnecessary and ineffective.

Question 56

Question: 56 of 60

A 3-year-old male presents with a 1-day history of right ear pain. He is drinking normally but has not eaten well over the previous 24 hours. On examination the child appears irritable but nontoxic, with a rectal temperature of 38.3°C (100.9°F), and a bulging, red, immobile right tympanic membrane. He has no known allergies and no past history of otitis media.

Which one of the following is true regarding the treatment of this patient?

1. Observation without use of antibacterial agents is an appropriate option
2. The initial antibiotic of choice is amoxicillin/clavulanate (Augmentin)
3. If he does not respond to 24–72 hours of therapy with amoxicillin he should be given trimethoprim/sulfamethoxazole (Bactrim)
4. Antibiotic treatment makes analgesia unnecessary

Answer 56

1. Observation without use of antibacterial agents is an appropriate option
2. The initial antibiotic of choice is amoxicillin/clavulanate (Augmentin)
3. If he does not respond to 24–72 hours of therapy with amoxicillin he should be given trimethoprim/sulfamethoxazole (Bactrim)
4. Antibiotic treatment makes analgesia unnecessary

Critique:

Acute otitis media is one of the most common conditions leading to medical office visits. It is characterized by ear pain and fever, with or without otorrhea, outside the context of otitis externa. Other symptoms may include poor appetite, irritability, or, in more severe cases, vomiting and lethargy.

More than 80% of children have resolution of acute otitis media without treatment with antibiotics, so deferring antibacterial treatment for 48–72 hours is an option in lower-risk children with unilateral disease and low symptom severity (SOR B). Randomized, placebo-controlled trials have shown that most children recover without adverse sequelae, with or without antibiotics, although antibiotics are associated with a slight improvement in clinical success rates.

Experts from the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend an age-stratified approach, in which all children under 6 months of age with a certain or uncertain diagnosis of otitis be treated to prevent the theoretical increased risk of complications. The option of withholding antibiotics is reserved for older children.

Lower-quality randomized, controlled trials (RCTs) have demonstrated that amoxicillin (80–90 mg/kg/d in two divided doses) is an effective first-line treatment in most situations (SOR C). Its use is encouraged because of its low cost, low rate of complications, and narrow microbiologic spectrum that covers most causative organisms. Amoxicillin/clavulanate can be used if there is a reason to strongly suspect β-lactamase–producing Haemophilus influenzae or Moraxella catarrhalis, such as concomitant conjunctivitis, or if the child has received antibiotics within the past 30 days for the same diagnosis.

A child who fails the initial choice of therapy after 24–72 hours should receive an alternative antibiotic (SOR C). Although the traditional approach in children who fail amoxicillin therapy has been a switch to trimethoprim/sulfamethoxazole, recent studies have shown substantial pneumococcal resistance to this drug. Reasonable choices include high-dose amoxicillin/clavulanate (80–90 mg/kg/d amoxicillin component), cefdinir, azithromycin, or single-dose intramuscular ceftriaxone.

AAP and AAFP practice guidelines recommend treatment for otalgia in children who appear to have pain (SOR C), but this aspect of treatment is often neglected. Limited randomized, controlled trials have shown that antibiotic therapy does not reduce otalgia within the first 24–48 hours of treatment (SOR B). Options for pain relief include oral analgesics such as ibuprofen or acetaminophen, based on low-quality evidence that shows them to be more effective than placebo. Topical anesthetic agents such as benzocaine may also help, although the evidence is insufficient to recommend them as part of routine management.

Question 57

Question: 57 of 60

You and your staff are preparing for the onset of influenza season. Which one of the following is recommended by the CDC’s Advisory Committee on Immunization Practices?

1. Annual influenza vaccine for all children age 6–59 months
2. A single dose of influenza vaccine for previously unvaccinated children age 3–8 years
3. Delaying influenza vaccination until symptoms resolve in children who have minor illnesses such as upper respiratory infections
4. Skin testing with influenza vaccine prior to administration in patients with an egg allergy
5. The use of live attenuated influenza vaccine rather than trivalent inactivated influenza vaccine in patients with a history of hypersensitivity, including anaphylaxis, to eggs

Answer 57

1. Annual influenza vaccine for all children age 6–59 months
2. A single dose of influenza vaccine for previously unvaccinated children age 3–8 years
3. Delaying influenza vaccination until symptoms resolve in children who have minor illnesses such as upper respiratory infections
4. Skin testing with influenza vaccine prior to administration in patients with an egg allergy
5. The use of live attenuated influenza vaccine rather than trivalent inactivated influenza vaccine in patients with a history of hypersensitivity, including anaphylaxis, to eggs

Critique:

The Advisory Committee on Immunization Practices of the CDC recommends annual influenza vaccine for all persons age 6 months or older. Children 6 months to 8 years of age require two doses of influenza vaccine if they have not been vaccinated before, in order to optimize immune response (doses should be separated by 4 or more weeks). Children in this age range also require two doses the second year they receive the vaccine if they received only one dose the first year. The recommendations for previously vaccinated children 6 months to 8 years of age vary from year to year depending upon changes to the viruses included in the vaccine.

Several inactivated influenza vaccines and a live attenuated influenza vaccine are licensed in the United States for use in children. Live attenuated influenza vaccine and inactivated influenza vaccine are both appropriate options in healthy children 2–8 years of age who have no contraindications (SOR B). Immunization usually should be withheld from children with moderate to severe acute febrile illness until resolution of their symptoms, but children with minor illnesses (with or without fever) should receive the vaccine, particularly if they have an upper respiratory tract infection or allergic rhinitis.

Young children with an egg allergy are at increased risk for influenza complications and therefore would benefit from vaccination. Any licensed vaccine may be administered to a child with an egg allergy.

Skin testing with influenza vaccine prior to administration in patients with an egg allergy is no longer suggested. Skin testing with the vaccine is still appropriate when evaluating a patient with a history of a reaction to the influenza vaccine itself, as opposed to a history of a reaction to egg consumption.

Question 58

Question: 58 of 60

A 3-year-old female is brought to your office holding her left elbow to her side. Her father tells you the problem began when he was playing with her and pulled her up by her left arm. On examination she looks frightened and refuses to move her left arm at all. Her elbow is held at slight flexion and her wrist is held in pronation. There is no swelling, point tenderness, or ecchymosis at the elbow joint. Radial and ulnar pulses are intact, and there is no loss of sensation in the fingers.

Which one of the following is true regarding this problem?

1. The peak incidence of this injury occurs at 5 years of age
2. The injury is more common in boys
3. The classic mechanism of this injury is a fall on an outstretched hand
4. Hyperpronation of the wrist is an effective maneuver for treating this problem
5. Radiographs should be obtained before treatment is initiated

Answer 58

1. The peak incidence of this injury occurs at 5 years of age
2. The injury is more common in boys
3. The classic mechanism of this injury is a fall on an outstretched hand
4. Hyperpronation of the wrist is an effective maneuver for treating this problem
5. Radiographs should be obtained before treatment is initiated

Critique:

The diagnosis of radial head subluxation is based on the history and examination, and this patient has the classic findings for this problem. Point tenderness, ecchymosis, or swelling of the elbow would suggest a fracture, in which case a radiograph would be helpful. Radial head subluxation is the most common arm injury in children under 6 years of age, with the incidence being highest in children 2 to 3 years of age. The injury is more common in girls.

The classic mechanism of injury is axial traction applied to an arm that is extended while the forearm is pronated, usually when the arm is pulled. The subluxation can be reduced either by hyperpronation of the wrist or by supination of the wrist followed by flexion of the elbow. The hyperpronation technique has been shown to be more successful and requires fewer attempts at reduction (SOR A).

Question 59

Question: 59 of 60

A healthy, 3350-g (7 lb 6 oz) female is born at a birthing center at 8:00 p.m. Because of the family’s financial circumstances and at the parents’ insistence, the baby is discharged with the mother the following morning at about 12 hours of life. A blood sample for mandated screening for genetic and metabolic disorders is collected before discharge.

Testing for which one of the following should be repeated in 1–2 weeks?

1. Congenital adrenal hyperplasia
2. Congenital hypothyroidism
3. Galactosemia
4. Phenylketonuria
5. Sickle cell anemia

Answer 59

1. Congenital adrenal hyperplasia
2. Congenital hypothyroidism
3. Galactosemia
4. Phenylketonuria
5. Sickle cell anemia

Critique:

There are several genetic and metabolic diseases that can be detected by a simple blood test in the newborn period. It is important for family physicians who care for children to know about the detection of these diseases and how to interpret the laboratory results. Many of these screening tests are mandatory, with the specific number and kind of tests specified by individual state laws. All U.S. states mandate testing for phenylketonuria (PKU).

However, a normal result from a PKU sample taken at or before 12 hours of age does not rule out PKU. This is because the child has not yet ingested enough dietary phenylalanine to raise the PKU level. Because some cases of PKU can be missed when the test is performed too early, the recommendation is that a repeat specimen be taken 1–2 weeks later in infants whose initial test was performed within the first 24 hours of life.

The results of testing for congenital adrenal hyperplasia, congenital hypothyroidism, galactosemia, and sickle cell disease are not time-sensitive, so repeat testing is not needed.

Question 60

Question: 60 of 60

You hear a heart murmur during the well child examination of a 3-year-old female. The child’s growth and development have been normal. The murmur is a systolic, groaning murmur best heard at the left lower sternal border and toward the apex. The intensity is grade 3/6, and it is loudest in the supine position.

This murmur is a

1. physiologic peripheral pulmonary artery stenosis murmur
2. pulmonary flow murmur
3. supraclavicular systolic murmur
4. venous hum
5. vibratory Still’s murmur

Answer 60

1. physiologic peripheral pulmonary artery stenosis murmur
2. pulmonary flow murmur
3. supraclavicular systolic murmur
4. venous hum
5. vibratory Still’s murmur

Critique:

It is important for the family physician to identify heart murmurs, especially to differentiate innocent from pathologic murmurs. Innocent murmurs do not require testing or cardiology referral. The physiologic peripheral pulmonary artery stenosis murmur, pulmonary flow murmur, supraclavicular systolic murmur, venous hum murmur, and vibratory Still’s murmur are all innocent murmurs. Innocent murmurs have some common characteristics: being systolic and of short duration; having a low-pitched, soft sound, often with varying intensity with position change and/or respiration; and sometimes becoming louder with exercise and anxiety.

The vibratory Still’s murmur has been well documented since it was first described in 1909. The most characteristic feature of the Still’s murmur is its sound, which has been described as having a low to medium pitch with a vibratory or musical quality. It is loudest in the supine position and best heard at the lower sternal border. It is typically audible in children between 2 and 6 years of age and is seldom heard beyond adolescence.

The peripheral pulmonary artery stenosis murmur is a low-pitched systolic ejection murmur best heard over the axilla or back. It usually disappears during the first year of life.

The pulmonary flow murmur is characterized by a crescendo-decrescendo quality that peaks at mid-systole. It is best heard in the second intercostal space at the left sternal border and is loudest in the supine position and decreases in the upright position or when the child holds his or her breath. This murmur may be detected at any age.

A venous hum is continuous and can vary from grade 1 to grade 6 in intensity. It has a whining, roaring, or whirring quality that resolves or changes when the child is moved to a supine position. It is best heard over the low anterior neck or below the right clavicle and is accentuated in diastole. It is typically detected between 3 and 8 years of age.

Finally, the supraclavicular systolic murmur is a crescendo-decrescendo murmur that is brief and low pitched during the first two-thirds of systole and diminishes when the child hyperextends his or her shoulders. It is best heard above the clavicles with radiation to the neck.

None of these murmurs is purely diastolic in nature. If a purely diastolic murmur is heard in a child it should be considered pathologic, and the patient should be referred to a cardiologist.