G&D

Question 1

If you suspect a language disorder, what is the first test to order?

Answer 1

Hearing screen
Explanation
Know this! A hearing screen is the most important thing to do when evaluating a language problem (receptive or expressive) in a child. Common causes of language disorders include: hearing deficits, intellectual disability, genetics, structural anomalies (lip/palate/oropharynx), and child abuse.

Question 2

A young girl can:

Run well and climb up and down stairs, 2 feet each step
Balance on one foot for 2–3 seconds
Dress herself (except buttons in the back)
Use 3-word sentences
But, she cannot:

Hop on one foot
Use 4-word sentences
Skip
Based on this level of development, what is the likely age of this girl?

Answer 2

3 years of age
Explanation
A 3-year-old child should be able to balance on one foot for 2–3 seconds, dress herself, and use 3-word sentences. A 2-year-old can run well and climb up and down stairs, 2 feet each step. A 4-year-old should be able to hop on one foot and use 4-word sentences. A 5-year-old should be able to skip. She meets the milestones of a 2-year-old and a 3-year-old, but is not able to do what a 4-year-old or 5-year-old should. Therefore, she is likely 3 years of age.

Question 3

A young girl can run well and go up and down stairs using 2 feet on each step. She will sometimes jump off the ground with 2 feet up. She has used a cup and spoon well for several months. She can stack up to 6 blocks.

Based on her level of development, how old is this child?

Answer 3

2 years of age
Explanation
Most 2-year-old children run well and are able to independently walk up and down stairs using both feet on each step. They often are just beginning to master jumping off the ground with 2 feet up. By 18 months of age, most children can use a spoon well and have been using a cup well for a few months (usually starting between 15–18 months of age). Most 2-year-olds can stack up to 6 blocks.

Question 4

At what age can most children hop on one foot?

Answer 4

4 years of age
Explanation
4-year-old children can hop on one foot, balance on one foot for 6-10 seconds, and use a fork without difficulty.

Question 5

At what age can most children walk well, build a tower of 2 cubes, and start to scribble?

Answer 5

15 months of age
Explanation
Most children are able to walk holding onto furniture at 11 months of age, walk without assistance at 13 months of age, and walk well at 15 months of age. At 13–15 months of age, most children can also build a tower of 2 cubes. Scribbling occurs from 15–18 months of age.

Question 6

A child enjoys playing “pat-a-cake” and uses her thumb to grasp a cube. She pulls to stand and stands momentarily, but has yet to take a step. She recently developed a parachute reflex.

Based on her level of development, how old is this child?

Answer 6

9 months of age
Explanation
Children are likely to understand and enjoy playing “pat-a-cake” or similar games at 9 months of age. Infants 6–8 months of age typically use the thumb to grasp a cube; a mature (fingertip and distal thumb) cube grasp develops at 9–12 months. The parachute reflex is first noted at 8–9 months. Most 9-month-old children easily pull to a stand and are able to stand momentarily before falling

Question 7

An infant female is able to lift her head only momentarily when lying down; head lag is present when pulled to sitting. She recently developed a social smile, but does not yet “coo.” She still has a palmar grasp reflex.

Based on her level of development, how old is this infant?

Answer 7

1 month of age
Explanation
A developmentally normal 1-month-old is able to lift her head when lying down only momentarily; by 2 months of age, most infants lift their head to 45°. Head lag when pulled to sitting persists for the first 4 months of life. A social smile is present by 1–2 months of age; an infant’s first “coo” is present at 2–4 months of age. The palmar grasp reflex disappears by 3-4 months of age.

Question 8

How is body mass index (BMI) calculated?

Answer 8

BMI = (weight in kilograms) / (height in meters)2
Explanation
BMI is calculated using a ratio of a person’s weight and height. The percentiles are age and gender based for children, and fixed values for adults.

Question 9

After 9 months of dietary changes and daily exercise, a 17-year-old obese male with hypertension and poorly controlled Type 2 diabetes fails to lose any weight.

At what BMI should bariatric surgery be considered an appropriate treatment option for this patient?

Answer 9

BMI ≥ 120% of the 95th percentile for age
Explanation
Bariatric surgery should be considered only in a mature adolescent dedicated to losing weight and able to give informed consent. The family must be equally committed to and supportive of the surgery. Additional criteria include:
Failure to lose weight after ≥ 6 months of organized attempts at weight loss
Physiologic maturity (i.e., late SMR 4, SMR 5)
BMI ≥ 120% of the 95th percentile for age with a severe comorbidity (e.g., poorly controlled Type 2 diabetes, hypertension, obstructive sleep apnea, hypoventilation syndrome)
BMI ≥ 140% of the 95th percentile for age with less severe comorbidities

Question 10

Name 4 primitive reflexes present at birth that typically disappear at 3–4 months of age.

Answer 10

Rooting, stepping, sucking, and hand grasp
Explanation
Other primitive reflexes include the crossed adductor (disappears by 7 months), toe grasp (disappears at 9–12 months), Moro (disappears at 3-6 months), and Babinski (disappears at 9–12 months). The abnormal persistence of primitive reflexes in developmentally delayed children reflects central nervous system dysfunction. It interferes with the development of voluntary motor movements, causing changes in muscle tone and limb position.

Perform a full history and physical examination in any child with developmental delay, including a complete review of systems, prenatal and perinatal history, family history, and psychosocial/behavioral assessment. Laboratory tests are based on history/physical findings; always obtain results of state-mandated newborn screens in infants and younger children.

Question 11

At what age does the AAP recommend initial autism screening?

Answer 11

18 months
Explanation
The AAP recommends universal screening for autism with an autism-specific tool (e.g., M-CHAT-R) at both the 18- and 24-month visits, or whenever parental concerns are raised. In addition, perform developmental surveillance at every preventive visit.

Question 12

If an infant presents with abnormally slow head growth or absolute microcephaly, what is the best diagnostic test to order to evaluate for structural abnormalities?

Answer 12

MRI of the head
Explanation
Microcephaly may be primary (e.g., due to a genetic disorder) or secondary (e.g., due to infection). Structural abnormalities are often associated with microcephaly and are best evaluated by MRI, while cerebral calcifications (e.g., due to congenital CMV, toxoplasmosis) are best evaluated by CT scan.

Question 13

A young child uses a cup well, has scribbled for several months, and can build a tower of 4 cubes. He began to walk well 2–3 months ago, but is not yet able to run well.

Based on his level of development, how old is this child?

Answer 13

18 months of age
Explanation
At 18 months of age, most children can build a tower of 4 cubes and walk well but are not yet able to run or go up stairs with 2 feet on each step. Most use a cup very well, but are not yet able to use a spoon. Most begin to scribble by 15–18 months of age.

Question 14

At what age should a child be able to sit with support? With no support?

Answer 14

6 months of age; 7 months of age
Explanation
A child should be able to sit with support by 6 months of age and with no support by 7 months of age.

Question 15

At what age do most children first develop the ability to follow rules while playing a game and begin to demonstrate operational thinking?

Answer 15

6 years of age
Explanation
By 6 years of age, memory and imagination are well ingrained. Children begin to develop operational thinking, becoming less egocentric and more aware of external events and feelings other than their own. They can follow rules while playing a simple game, skip, and tie their shoes.

Question 16

What is the most common type of craniosynostosis?

Answer 16

Scaphocephaly
Explanation
Scaphocephaly (a.k.a. dolichocephaly) is the premature closure of the midline sagittal suture and is characterized by a long, narrow skull. It has a 4:1 male predominance and is typically sporadic in occurrence.

Question 17

A premature neonate presents with possible macrocephaly.

What is the diagnostic test of choice?

Answer 17

Ultrasound of the head
Explanation
A premature neonate is at risk for hydrocephalus, often the result of an intraventricular hemorrhage. Therefore, an ultrasound of the head is indicated in all premature neonates with enlarged head circumferences. An ultrasound is the imaging study of choice while the fontanelles remain open; a CT or MRI is preferable once the sutures have fused.

Question 18

At what ages can a child copy a circle? A cross? A square? A triangle?

Answer 18

3 years of age; between 3 and 4 years of age; 4 years of age; 5 years of age
Explanation
A child should be able to copy a circle at 3 years of age, copy a cross between 3 and 4 years of age, copy a square at 4 years of age, and copy a triangle at 5 years of age. These are some of the major developmental milestones that should be memorized.

Question 19

After using polysyllabic babbling for the last 2–3 months, a child now says both “mama” and “dada” specifically. He is wary of strangers and has been for the last several months. He first waved “bye-bye” 2 months ago and enjoys showing a toy to an adult. He does not yet understand a 1-step command.

Based on his level of development, how old is this child?

Answer 19

12 months of age
Explanation
Polysyllabic babbling and the nonspecific use of “mama” and “dada” develop at 9 months of age. By 12 months of age the majority of children use “mama” and “dada” specifically. Stranger anxiety, which begins at around 6 months of age, is often still present at 12 months of age. Children first learn to wave “bye-bye” around 10 months of age and enjoy showing toys to others by 11 months of age. The ability to understand a 1-step command is usually not present prior to 15 months of age

Question 20

At what age should children be able to hold their heads up to 90° and lift their chests?

Answer 20

4 months of age
Explanation
Most infants can lift their heads to 90° and lift their chests by 4 months of age. Head lag when pulled to sitting at this age is a red flag for referral.

Question 21

How soon does an infant regain birth weight?

Answer 21

10–14 days of life
Explanation
Birth weight is regained by 10–14 days of life. Infants gain 30 grams/day in the first 3 months, 20 grams/day in months 3-6, and 10 grams/day for the remainder of the first year.

Question 22

10–14 days of life
Explanation
Birth weight is regained by 10–14 days of life. Infants gain 30 grams/day in the first 3 months, 20 grams/day in months 3-6, and 10 grams/day for the remainder of the first year.

Answer 22

5 lbs/year
Explanation
After 2 years of age, normal weight gain is about 5 lbs/year until adolescence. Calculate average weights for different ages as follows:
1–6 years: weight in pounds = (age × 5) + 17
7–12 years: weight in pounds = (age × 7) + 5

Question 23

An infant has recently started to cry whenever his mother leaves him with an unfamiliar person. He smiles when he looks in a mirror and often babbles, but with no discernible words. He can track an object to 180°; he visually tracks an object through a fall and searches for a partially hidden toy.

Based on his level of development, how old is this infant?

Answer 23

6 months of age
Explanation
Stranger anxiety begins around 6 months of age and can persist until 1 year of age (as opposed to separation anxiety, which occurs anywhere from 8 months to 2 years of age). Infants begin to smile at a mirror at 4 months of age. “Cooing” begins at 2–4 months of age; most 4-month-old infants squeal. Babbling begins at 6 months of age; polysyllabic babbling does not begin until 9 months of age. Object tracking to 180° should be present at 2 months of age. At 6 months of age, most infants are able to track an object visually through a fall and search for a partially hidden toy.

Question 24

A young child, for the last 2–3 months, cries whenever he is left with an unfamiliar person. He has just started to say “mama” and “dada” nonspecifically, and has started to use polysyllabic babbling. He pulls to stand.

Based on his level of development, how old is this child?

Answer 24

9 months of age
Explanation
Stranger anxiety typically begins around 6 months of age. Polysyllabic babbling begins at 9 months of age; most 9-month-old children say “mama” and “dada” nonspecifically. Specific use of “mama” and “dada” usually begins at 9–12 months of age. Most 9-month-old children are able to pull to stand but are not yet able to walk while holding onto furniture.

Question 25

When does birth length double? Triple?

Answer 25

4 years of age; 13 years of age
Explanation
Birth length doubles by 4 years, triples by 13 years, and increases an average of 2 inches/year from 4 years of age until adolescence.

Question 26

At what age does a child roll from front to back? Back to front?

Answer 26

4–5 months of age; 5–6 months of age
Explanation
A child should be able to roll from front to back by 4–5 months of age, and back to front by 5–6 months of age.

Question 27

A young child has a vocabulary of 50–100 words, uses 2-word sentences, and is able to identify 6 body parts. He has just started to use personal pronouns but does not yet use prepositions. When he is with other children, he parallel plays. He is not able to button large buttons.

Based on his level of development, how old is this child?

Answer 27

24 months of age
Explanation
At 24 months of age, most children have a vocabulary of 50-100 words, can identify at least 6 body parts, and use 2-word sentences. Personal pronouns are first used around 24 months of age. Use of prepositions or articles begins around 30 months of age. Absence of meaningful phrases by 24 months of age requires evaluation. Parallel play, rather than cooperative play, is to be expected. Most children cannot dress themselves completely, including large buttons, until 3 years of age.

Question 28

A child was born with a “large head” (but within normal range). Now, at 3 months of age, he presents with a head circumference that exceeds the 98th percentile. Radiologic study confirms isolated enlargement of the subarachnoid space.

What is the recommended treatment?

Answer 28

Reassurance
Explanation
Isolated enlargement of the subarachnoid space is a common cause of benign macrocephaly. The head is large, but within normal limits at birth, and subsequently parallels or exceeds the 98th percentile. In addition to an enlarged subarachnoid space, minimally increased ventricular size and widening of the sulci and sylvian fissure are often noted on CT. About 2/3 of affected infants are boys. No intervention is necessary

Question 29

What is the most common reason for failure to thrive (FTT)?

Answer 29

Inadequate consumption of appropriate amounts and/or kinds of food
Explanation
FTT is the result of insufficient nutrition to maintain appropriate growth. Most cases can be managed on an outpatient basis. Definitions for FTT include:
cessation of weight gain after a period of stable growth that manifests as weight < the 3rd percentile for age,
weight for height < the 5th percentile, or
growth that has fallen, crossing 2 percentile curves in a short time.

Question 30

An infant female is able to lift her head to 45° and can lift her head, but not her chest, off a table when lying down. Head lag is present when she is pulled to sitting. She has a social smile and “coos,” but does not smile at a mirror. The palmar grasp and Moro reflex are both present.

Based on her level of development, how old is this infant?

Answer 30

2 months of age
Explanation
A developmentally normal 2-month-old should be able to lift her head to 45° and lift her head (but not chest) off a table when lying down. Head lag persists until 4 months of age when pulled to sitting. Absence of a social smile in a 2-month-old is abnormal; many, but not all, 2-month-old infants also “coo” (“cooing” can occur anywhere from 2-4 months of age). Smiling at a mirror typically begins at 4 months of age. The palmar grasp reflex persists until 3–4 months of age, and the Moro reflex persists until 3-6 months of age.

Question 31

At what age do most children lose their Moro reflex?

Answer 31

3–6 months of age
Explanation
The Moro reflex is absent in most children by 3-6 months of age. The abnormal persistence of primitive reflexes like the Moro indicates central nervous system dysfunction. This can interfere with the development of voluntary motor movements, causing changes in muscle tone and limb position.

Question 32

At what age can most children follow a 1-step command and use at least several words other than “mama” and “dada”?

Answer 32

Explanation
Most children are able to follow a 1-step command by 15 months of age. The number of vocabulary words may vary greatly at this age, but the majority of 15-month-old children have 3-6 words in their vocabulary in addition to “mama” and “dada.”

Question 33

A 6-month-old boy plots below the 3rd percentile for weight. Height and head circumference plot at the 10th and 12th percentiles, respectively.

Birth history is unremarkable.
Newborn metabolic screen is normal.
Physical examination demonstrates an apathetic child with wasting of subcutaneous tissue in the lateral buttocks and thighs.
What is the most likely cause of failure to thrive (FTT) in this infant?

Answer 33

Inadequate consumption of appropriate amounts and/or kinds of food.
Explanation
The majority of FTT cases are the result of inadequate consumption of appropriate amounts and/or kinds of food, and can be managed on an outpatient basis. Psychosocial and behavioral feeding problems are common, while organic causes are rare (and typically associated with specific signs and symptoms of underlying disease). Perform step-wise laboratory evaluation only if caloric intake is proven to be adequate.

Question 34

An infant male has a social smile and has just started to “coo.” He does not smile at a mirror.

Based on his level of development, how old is this infant?

Answer 34

2 months of age
Explanation
Developmentally normal infants at 2 months of age will have a social smile; absence of this would be abnormal. Many (but not all) 2-month-old infants “coo,” a milestone that occurs from 2-4 months of age. Smiling at a mirror typically does not occur until 4 months of age.

Question 35

A young child understands at least 50 words and follows simple commands. He often points at and identifies an object (e.g., “tree”), is able to name several body parts, and has just started to use several 2-word sentences. When he is with other children, he parallel plays.

Based on his level of development, how old is this child?

Answer 35

18 months of age
Explanation
Most 18-month-old children understand 50–100 words and follow simple commands. Pointing with words is very common (e.g., pointing and saying “house”, pointing at and identifying body parts). Around 18 months of age, many children begin to use simple 2-word sentences, though most achieve this milestone by 2 years of age. Absence of any words by 18 months of age requires evaluation for language delay. Parallel play, rather than cooperative play, is expected at this age.

Question 36

A 12-year-old African American boy is noted to have:

A BMI at the 98th percentile
A waist circumference at the 95th percentile
Systolic and diastolic blood pressure at the 95th percentile
List the indices for serum HDL cholesterol, triglycerides, and fasting glucose that would support the diagnosis of metabolic syndrome in this patient.

Answer 36

HDL Cholesterol < 40 mg/dL; Triglycerides > 110 mg/dL; Fasting Glucose > 110 mg/dL
Explanation
Obesity can cause insulin resistance, which leads to hyperinsulinemia, hyperglycemia, and dyslipidemia associated with hypertension and vascular inflammation. The co-occurrence of metabolic risk factors for both Type 2 diabetes and atherosclerotic cardiovascular disease is referred to as “metabolic syndrome.” The presence of ≥ 3 of the following measures fulfills the suggested criteria for the diagnosis of metabolic syndrome:
BMI > 97th percentile,
systolic/diastolic BP > 90th percentile,
waist circumference > 90th percentile,
triglycerides > 110 mg/dL,
HDL cholesterol < 40 mg/dL, and/or
fasting glucose > 110 mg/dL or oral glucose tolerance test > 140 mg/dL.

Question 37

A 10-year-old presents with the following:

BMI ≥ 97th percentile 
Triglycerides 160 mg/dL 
HDL cholesterol 20 mg/dL 
Systolic BP > 90th percentile 
Fasting glucose 100 mg/dL 
Waist circumference > 90th percentile
What is the most likely diagnosis?

Answer 37

Metabolic syndrome
Explanation
Metabolic syndrome is not a disease, but a cluster of related diseases that are well described in adults but not in children. Even though there is no clear definition for children, if a child has ≥ 3 of the 6 suggested metabolic syndrome indeces, a diagnosis of metabolic syndrome can be made:
BMI ≥ 97th percentile 
Triglycerides > 110 mg/dL 
HDL cholesterol < 40 mg/dL 
Systolic/diastolic BP > 90th percentile 
Fasting glucose > 110 mg/dL or oral glucose tolerance test > 140 mg/dL 
Waist circumference > 90th percentile

Question 38

When is the fastest rate of head growth?

Answer 38

Between 0 and 2 months of age
Explanation
The fastest rate of head growth is between 0 and 2 months of age, when the child’s head grows at 0.5 cm/week (2 cm/month). The average head circumference at full term is 35 cm (with a range of 33–37 cm). By 12 months, the brain has completed half its postnatal growth and is 75% of adult size.

Question 39

When does a full-term infant’s birth weight double? Triple? Quadruple?

Answer 39

4 months of age; 12 months of age; 24 months of age
Explanation
Full-term infants double their birth weight by 4 months, triple their birth weight by 12 months, and quadruple their birth weight around 2 years. Average weight gain is about 5 pounds per year.

Question 40

How much does birth length increase by 1 year of age?

Answer 40

50%
Explanation
The average birth length is 20 inches. Average height at 1 year of age is 30 inches, an increase of 50%.

Question 41

An 18-month-old can:

Squeal and babble
Say “Mama”
Point at a bottle or chair
The child cannot:

Say more words than “Mama”
Identify body parts
Does this child have delayed development?

Answer 41

Yes
Explanation
This child has an expressive language delay. By 18 months of age, the child should be able to say 10–25 words, identify 2 body parts, and follow simple instructions. Conduct a hearing screen whenever a language delay is suspected.

Question 42

At what age range are the majority of children able to walk without help and grasp a cube with the fingertip and distal thumb?

Answer 42

11–13 months of age
Explanation
Wide ranges in the attainment of early gross motor milestones in healthy children are the rule rather than the exception. On average, children pull to stand at 9 months, walk holding onto furniture at 11 months, and walk without help by 13 months. Almost all children have developed a “mature” cube grasp (fingertip and distal thumb) by 12 months of age.