Common Pediatric Disorders

Question 1

A 9-year-old boy includes genitals in a drawing of his family.

What should you consider as a possibility?

Answer 1

Sexual Abuse

It is unusual for older, grade-school children to draw genitals in figures; this requires further inquiry if this occurs. However, note that this is not diagnostic of abuse. It is normal for children 3.5-5 years to include genitals in their drawings.

Question 2

What is the most common obsessive-compulsive disorder (OCD) “ritual” in childhood?

Answer 2

Repetitive Cleaning and Washing

This includes showering, hand washing, and toothbrushing. Other common OCD rituals include include going in and out of doors; rereading; rechecking stove and appliances are off; rechecking the alarm clock; and counting, ordering, and arranging objects.

Question 3

A 7-year-old boy presents with:

• Pain in his left hip and knee
• He has been limping for several days
• Plain x-ray of the hip shows a “ratty” appearance of the left femoral head

What is the most likely diagnosis?

Answer 3

Legg-Calve-Perthes Disease

It is a partial or complete idiopathic avascular necrosis of the femoral head. It is most common in boys between 4 and 8 years of age. Make the child non-weightbearing and refer to an orthopedist. Generally, it resolves with time and does not require specific therapy.

Question 4

Do nightmares occur during REM or non-REM sleep?

Answer 4

REM Sleep

Nightmares tend to occur after several hours of sleep and do not usually cause a child to get out of bed. Parental reassurance is best response.

Question 5

A 10-year-old presents with the following:

• BMI > 97^th percentile
• Triglycerides: 160 mg/dL
• HDL cholesterol: 20 mg/dL
• Systolic BP > 90^th percentile
• Fasting glucose: 113 mg/dL
• Waist circumference: > 90^th percentile

What is the most likely diagnosis?

Answer 5

Metabolic Syndrome

It is not a disease itself, but is a cluster of related diseases that are becoming well described in adults; a “definite” definition has not been given for children. If a child has 3/6 criteria (listed in the question), then it is thought to meet the definition by most experts.

Question 6

A 15-year-old obese African American boy presents with a limp. He complains of pain in his left hip and knee. Plain x-rays show the epiphysis has moved when compared to the metaphysis.

What is the most likely diagnosis?

Answer 6

Slipped Capital Femoral Epiphysis (SCFE)

SCFE is the slipping of the epiphysis off the metaphysis. It most commonly occurs in obese, eunuchoid adolescents and is more common in African Americans. Note that, sometimes, patients are thin. Get an AP and frog-leg view. This requires surgery!

Question 7

Which mineral deficiency has been associated with late-onset trichotillomania (hair pulling)?

Answer 7

Iron Deficiency

Question 8

A 16-year-old boy presents with

• Unilateral retro-orbital pain that feels “like an ice-pick”
• Ipsilateral lacrimation, eye redness, and nasal congestion
• The headache has occurred at the same time of the day for the last 3 days.

What is the best acute treatment for this boy?

Answer 8

Oxygen

Cluster headaches respond to oxygen therapy. They commonly present with retro-orbital pain that is unilateral (like an ice-pick). Commonly, they have Ipsilateral lacrimation, eye redness, and nasal congestion.

Question 9

A 12-year-old boy presents with repetitive, persistent (9 months now) behaviors that violate the rights or property of others. He has been stealing, setting fires, and fighting. He lacks close friends and is unpopular. He does not have any guilt or remorse about his behavior. The behaviors occur at home, school, and in the community.

What is the most likely diagnosis?

Answer 9

Conduct Disorder

It is a complex, multifactorial disorder. Generally, think of it in kids who do repetitive, persistent (> 6 months) behaviors that violate others’ rights or destroy others’ property. The list here also includes using drugs and instigating sexual abuse.

Question 10

You are asked to evaluate a child with possible ADHD. After history and physical examination are completed, which of the following should you order to confirm your diagnosis: an EEG, MRI, both, or none?

Answer 10

None

Generally lab testing and, in particular, EEG and MRI are not recommended! Standardized assessment scales are most useful and should be filled out by parents, schools, afterschool providers, etc.

Question 11

A 13-year-old boy presents with severe nighttime pain in his proximal femur. It gets markedly better with nonsteroidals, but not with acetaminophen. Plain X-ray of the femur shows 1 cm sharp round lesion with a homogenous dense center and a 1-2 mm peripheral radiolucent zone.

What is the most likely diagnosis?

Answer 11

Osteod Osteoma

The key is that it responds to NSAIDs, but not acetaminophen. The plain film findings are classic! Do not think this represents a neoplastic lesion!

Question 12

In infants, what type of sleep initiates sleep?

Answer 12

REM Sleep

In infants, REM sleep occurs at the start of sleep. In older children, non-REM sleep begins before REM sleep kicks in. Infants have a higher proportion of REM sleep with older children having nearly 75% non-REM sleep.

Question 13

A 13-year-old boy who plays basketball presents with:

• Pain in his left knee
• A swollen, tender tibial tubercle
• Plain film shows fragmentary ossification of the tibial tubercle

What is the most likely diagnosis?

Answer 13

Osgood-Schlatter Disease

It is a repetitive stress injury (often a volleyball or basketball player) to the patellar tendon at its insertion into the tibial tubercle. Most commonly, it is seen in children 10-15 years of age. Apophysitis and/or fragmentary ossification of the tibial tubercle may be seen on plain films. NSAIDS are helpful, but no specific therapy is necessary.

Question 14

A mother brings in her 8-year-old child with a history of 2 prior admissions for bacteremia - one with E. coli and the 2^nd with a mixture of organisms including E. coli and Serratia. The mother is a nurse in another hospital. The child now presents with the following:

• Fever
• Hypotension and shock
• Previous work up for immune dysfunction was negative

The mother seems happy that the child is ill again and is excited to be coming into the hospital.

What diagnosis should be entertained at this point?

Answer 14

Munchausen Syndrome by Proxy

It is a bizarre disorder in which the caregiver-child relationship is “disturbed.” The mother is almost always the one involved, and, commonly, she is in the health care profession. Be suspicious on the test if a child presents with recurrent, serious illness that cannot be satisfactorily explained - recurrent E. coli bacteremia in an 8-year-old is very unusual, especially with a mixture of gram-negatives (think about mom injecting feces in the child or something similar).

Question 15

A 12-year-old boy presents with the following behaviors for the last 9 months:

• Loses temper often
• Actively defies teacher’s and parent’s rules
• Annoys people on purpose
• Blames others for his behavior
• Often angry and resentful
• His behavior has caused significant drop in his school grades, and he has lost friends.

What is the most likely diagnosis?

Answer 15

Oppositional Defiant Disorder

It occurs in school-age and adolescent children. Boys are most commonly affected. The behavior has to occur for at least 6 months, and a list of criteria (many of them listed here) have to be met.

Question 16

A 2-year-old male with no prior health problems presents with history of “head banging.” Most commonly it occurs at bedtime and occasionally in the middle of the night.

What is the EEG pattern seen in these children?

Answer 16

Normal

Numerous studies have been done on these kids, and they are all normal. Do not order an EEG or an imaging study to evaluate these children. Reassurance is best. Now, this is different from the child with mental retardation or autism who had had head banging as part of their spectrum; in this case, helmets or medications may be required to prevent/lessen the banging.

Question 17

Some children with OCD can have worsening of their symptoms with group A streptococcal infection.

What is the name of this syndrome?

Answer 17

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Sreptococci (PANDAS)

It is thought to be due to antibodies directed towards group A streptococcus that somehow cross-react with the basal ganglia and result in symptoms.

Question 18

Are term newborns farsighted, nearsighted, or have normal vision?

Answer 18

Farsighted

Most term newborns are hyperopic or farsighted at birth, while premature infants are nearsighted.

Question 19

A child with a high BMI presents with:

• Loud, frequent, disruptive snoring
• Restless sleep
• Daytime sleepiness and drowsiness
• Increased irritability
• Anxiety

What is the most likely diagnosis?

Answer 19

Obstructive Sleep Apnea

OSA correlates with increased weight and is felt to be in 1-4% of children. Gold standard for diagnosis is an overnight polysomnogram.

Question 20

Do children with Asperger syndrome usually have normal or delayed language and cognitive development skills?

Answer 20

Normal

It is similar to autism in that these children have severe and pervasive impairment in social interactions and also have restrictive, repetitive, stereotypic behaviors. The difference from autism is that children with Asperger’s have normal language and cognitive development skills.

Question 21

What is the best way to manage a sleep problem in a toddler (e.g., walking up in the middle of the night, having trouble staying in bed)?

Answer 21

Begin with a Daily Routine

It is important to begin each night the same way with a standard routine. It may be to read a book, take a bath, etc. The key is consistency and sticking with it. Verbal reassurance to the child (and to the parent) will eventually win out.

Question 22

A 1-month-old infant seems to have difficulty feeding and becomes diaphoretic with feeding. Also, he cried excessively.

What is the most likely diagnosis?

Answer 22

Anomalous Left Coronary Artery

Suspect this if they give you a “colic-sounding” picture, but it doesn’t fit right…This infant is young (although it could start this early), but the association with feeding poorly and having diaphoresis with feeding is not seen in colic, but is seen commonly with an anomalous left coronary artery. The crying is likely from the poor baby having angina!

Question 23

By what age do most children reach 20/20 vision?

Answer 23

5 years of age

Newborns begin with 20/400 vision and by age 5 years reach 20/20 vision.

Question 24

A 13-year-old boy is diagnosed with ADHD. He is placed on stimulant medication.

When children with ADHD are placed on stimulant medication, what disorder may be unmasked?

Answer 24

Tic Disorder

Approximately 15-30% of children who are treated with stimulant medications develop motor tics, most of which are transient. ADHD and tics are common comorbid conditions and use of methylphenidate usually improves the ADHD without worsening the tic disorder.

Question 25

Which endocrine abnormally is more common in children with ADHD?

Answer 25

Thyroid Abnormalities

You should not screen with a TSH, but you should look for signs/symptoms of hypo- or hyperthyroidism, and, if they occur, then you should persue a possible thyroid disorder.

Question 26

A 6-year-old is brought in by her parents because of concern of seizure disorder. Last night this was noted:

• Intense crying and screaming during her sleep last evening
• She was diaphoretic
• She did not respond to her parents and was disoriented
• She was difficult to arouse
• She does not remember the episode

What is the most likely diagnosis?

Answer 26

Night Terrors

It produces a distinct non-REM parasomnia - an abrupt arousal from Stage 4 non-REM sleep to near arousal. Most occur during the 1^st third of the night. The child appears to be awake, but is unresponsive and unaware of the patient’s presence, difficult to arouse, cries intensely, is diaphoretic, and appears disoriented. This is not remembered by the child. Parental reassurance is the best therapy.

Question 27

A 2-month-old presents with:

• Crying mainly in the late afternoon
• Crying is prolonged (3-5 hours a day in the afternoon/evening) and paroxysmal (stops and starts abruptly)
• During the episodes, the infant will have clinched fists, pained facies, and legs over the abdomen.
• Nothing soothes the baby
• Normal physical exam

What is the most likely diagnosis?

Answer 27

Colic

Colic is universal. Suspect it with crying for > 3 hours for > 3 days a week for > 3 weeks. If the child is > 4 months of age, it is not colic.

Question 28

An 18-month-old can do the following:

• Sequel and babble
• Says “Mama” only
• Can point at a bottle or chair
• Cannot say more words than “Mama”
• Cannot identify body parts

Do you think this child has expressive language delay?

Answer 28

Yes

By 18 months, the child should be able to say 2-3 word phrases and use 15-20 words, identify 4 body parts, and follow simple instructions. Hearing screen is the first test to do.

Question 29

At what age is separation anxiety usually first noticeable, and when is it especially prominent?

Answer 29

6 months; 9-18 months

It usually begins to lessen by 3 years of age.

Question 30

A 3-year-old girl is brought in by her mother after she began having a temper tantrum and then held her breath until she turned blue and passed out. Her mother is worried that she had a seizure because she had some tonic-clonic movements as well.

What should be the next best step in management of this child?

Answer 30

Reassurance

Breath-holding spells are benign - there are no long-term effects or brain injury. There are 2 forms usually of breath-holding temper tantrums:

1. cyanotic form, in which the face turns blue until breathing returns
2. a pale form, in which the face turns pale due to vasovagal syncope

Question 31

What does thumb sucking that persists into adolescence possibly indicate?

Answer 31

Psychological Problems

Thumb sucking peaks between 18 and 21 months, and most children stop by 4 years of age. It occurs in anywhere from 10-35% of children. Thumb sucking that persists into adolescence may indicate underlying psychological issues, and it is more commonly seen in girls.