Module 2 - infant milestones Flashcards
A 15-month-old boy is brought for evaluation of a cough and runny nose. He has a fever of 100.2°F (37.9°C), but his examination is only remarkable for the clear nasal discharge, and he is alert and playful. Which of the following is true?
- Minor illness with fever does not contraindicate immunization
- Fever alone is a contraindication to immunization
- The infant has an undefined immunodeficiency
- Fever of 102.2°F (39°C) after the first set of immunizations is a contraindication to diphtheria, tetanus, and pertussis vaccine.
- Minor illness with fever does not contraindicate immunization
POINTS
- Minor illnesses such as an upper respiratory infection or gastroenteritis, with or without fever, are not a contraindication to any of the routine childhood vaccines.
- A temperature of 104.9°F (40.5°C) within 48 hours after immunization with a previous dose of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) is considered a precaution not a definite contraindication, to subsequent administration of DTaP vaccine.
- Parents must know ways to decrease discomfort from immunization injection sites. These may include gentle movement of the affected extremity, analgesics. And cool compresses. Slight redness at the injection site and low-grade fever are common after vaccinations.
- It is important to get, assess, and update accurate immunization status upon each interaction with new patients. If the child’s parents refuse vaccinations due to religious reasons, this must appear in the medical record.
A 17-year-old male patient presents to the outpatient department for an annual routine evaluation in November. He has no active complaints. The patient has a past medical history of gastroesophageal reflux disease, for which he takes famotidine. His last vaccinations included a tetanus-diphtheria toxoid booster four years ago. The patient does not smoke or drink alcohol. Vitals show a blood pressure of 125/75 mmHg, a pulse of 77/min, a respiratory rate of 13/min, and a temperature of 98.6 F (37 C). No abnormalities are seen on physical examination. No abnormalities are seen in laboratory and radiological investigations. It is decided to administer the influenza vaccine. Which of the following is a possible contraindication to the administration of the vaccine?
- Severe prior allergy to influenza vaccination
- Chronic liver disease
- History of severe seizures
- Immunocompromised status
- Severe prior allergy to influenza vaccination
POINTS
- A history of a severe allergic reaction (e.g., anaphylaxis) to any influenza vaccine (i.e., any egg-based IIV, ccIIV, RIV, or LAIV of any valency) is a contraindication to future receipt of all egg-based IIV4s and LAIV4.
- A history of allergy or hypersensitivity to any vaccine component (i.e., egg protein allergy) is a contraindication. Per the Centers for Disease Control, “If ccIIV4 is administered in such instances, vaccination should occur in an inpatient or outpatient medical setting and should be supervised by a health care provider who is able to recognize and manage severe allergic reactions. Providers also can consider consultation with an allergist to help determine the vaccine component responsible for the allergic reaction..”
- “If RIV4 is administered in such instances, vaccination should occur in an inpatient or outpatient medical setting and should be supervised by a health care provider who is able to recognize and manage severe allergic reactions. Providers can also consider consultation with an allergist to help determine the vaccine component responsible for the allergic reaction.”
- A universal influenza vaccine is undergoing trials and serves the purpose of building a single vaccine that targets all strains of the virus; this will, in turn, minimize the need for frequent vaccination and be the bright future of this vaccination.
An 8-week-old baby is brought in by her parents for the childhood vaccination program. She was born at term via cesarean delivery after an uneventful pregnancy. She has no past medical history and is in good health. The first dose of the pneumococcal conjugate vaccine is given, and a second dose is scheduled. Which of the following is correct regarding this vaccine?
- It is a single 0.5 ml injection subcutaneously only.
- A 12-month-old infant needs to receive a single dose of the vaccine.
- It acts against at least thirteen different serotypes of Streptococcus pneumoniae.
- If the patient has had no prior vaccination, the patient should receive a double dose of pneumococcal vaccine (PCV13)
- It acts against at least thirteen different serotypes of Streptococcus pneumoniae.
POINTS
- The current pneumococcal conjugate vaccines contain 13 or 15 serotypes.
- The 13 serotypes account for approximately 85% of the serotypes causing invasive pneumococcal infections, including bacteremia and meningitis, in children younger than six years of age in the United States.
- According to the Centers for Disease Control and Prevention, the pneumococcal conjugate vaccine should be given to infants as a series of four doses, 1. two months,
2. four months
3. six months
4. 12 through 15 months.
- A 12-month-old infant should receive two doses of vaccine 6 to 8 weeks apart.
A 4-year old girl, whom you have followed in your practice since birth, was recently exposed to chickenpox. What is appropriate management?
- Obtain a history of whether or not the child has had varicella vaccine
- Administer the varicella vaccine to the child
- Contact the medical provider of the preschool classmate to verify the diagnosis of varicella
- Draw blood for serologic testing
- Obtain a history of whether or not the child has had varicella vaccine
POINTS
- This child is healthy, so the first step is to assertain if the vaccine had been given.
- Immunocompromised children are candidates for Varicella-zoster immune globulin (VZIG) if there is no prior history of varicella.
- Acyclovir has been shown to lower the intensity and duration of symptoms if administered within 24 hours of the onset of symptoms. However, the drug is usually not recommended in otherwise healthy children.
- Varicella-zoster immune globulin is usually indicated for those individuals highly susceptible or those who are immunosuppressed.
- Varicella-zoster immune globulin if administered within ten days of exposure can alter the course of infection but can’t prevent it. Maximal effectiveness of the immunoglobulin is evident when administered right after exposure.
A 12-year-old boy from China with normal growth and development is known to have hepatitis B infection: hepatitis B surface antigen positive, antibody to hepatitis B core antigen positive and antibody to hepatitis B surface antigen negative. A mother of one of your patients who is in the same classroom is concerned, because her son has only received one dose of hepatitis B vaccine 1 year ago. You recommend that her child does which of the following?
- Begin the three-dose series of hepatitis B vaccine again immediately
- Complete the three-dose series of hepatitis B vaccine with 2 more doses
- Receive hepatitis B immune globulin and hepatitis B vaccine
- Have blood drawn for hepatitis B serology and be given hepatitis B vaccine, if seronegative
- Begin the three-dose series of hepatitis B vaccine again immediately
POINTS
- There is no increased risk of transmission of hepatitis B infection in the school setting.
- An exception is that residents and staff of institutions for people with developmental disabilities represent a high-risk group for hepatitis B virus infection and should be immunized.
- In this clinical situation involving the school setting, the classmate of the 12-year-old who is the hepatitis B surface antigen positive should complete the three-dose series.
- It is not necessary to begin the series again even though the last dose of vaccine was 1 year previously.
A child is brought in by her mother for a well-child care visit. She has no past medical history and was born at term after an uncomplicated pregnancy via cesarean delivery. Her vaccinations are up to date. All her vital signs are within normal limits. When assessing her developmental milestones, at what age should the infant be able to imitate speech sounds while babbling?
- 3 months
- 6 months
- 10 months
- 12 months
- 6 months
POINTS
- Infants only respond to sounds, but they do not make sounds at 3 months of age.
- At 6 to 8 months, infants can imitate speech sounds and may respond to their names.
- At 9 to 10 months, infants can say mama and dada.
- At 12 months, infants can speak simple words
A 6-month-old female infant is brought to the pediatrician because she has not started speaking. Her mother states that she is worried that something might be wrong with her daughter. She says it has been weeks since she has been trying to teach her the word “mama,” but her baby fails to mention it properly and babbles gibberish instead. Her elder daughter started talking at the age of 5 months. On review of other milestones, the mother says that she can sit up unsupported and can transfer objects between her hands. She has recently also started getting uncomfortable with people other than her parents. Physical examination is unremarkable. What statement should the physician give regarding the mother’s concern?
- You must be mistaken, children are unable to speak their first words at the age of 5 months
- We need to perform an urgent hearing screen to prevent permanent damage
- Rest assured, your daughter has met all her developmental milestones
- Your child may be suffering from autism, I recommend closely monitoring her social actions
- Rest assured, your daughter has met all her developmental milestones
POINTS
A 6-month-old infant can only babble.
This child has met all her developmental milestones, therefore reassurance is the next best step.
Most infants start saying their first words after the age of 9 months.
Whenever counseling a parent, the physician should adopt a non-judgemental and non-attacking tone.
A 15-month-old has had a fever with each immunization. At the 12 month visit, the shots resulted in local cellulitis requiring oral antibiotics. Which is the best management for this patient?
- Assure the mother that the reactions were trivial and just give the vaccines
- Reassure the mother that fever is a common reaction and the child can be treated with antipyretics after vaccination
- Explain to the mother that the vaccine doses should be reduced by one half
- Explain to the mother that the child is allergic to the vaccines and pretreat with diphenhydramine
- Reassure the mother that fever is a common reaction and the child can be treated with antipyretics after vaccination
POINTS
Fever and local reactions are not contraindications to immunizations, but informed consent is required before administering an immunization.
Antipyretics should be given if the temperature is greater than 38 C within 48 hours.
Absolute contraindications to immunization are rare. They include anaphylactic reactions and the development of encephalopathy within 7 days.
Live virus vaccines such as varicella and measles-mumps-rubella should not be given to immunocompromised patients or those in the household.
A male infant is brought to the clinic by his mother for a developmental assessment. The mother just came to the United States from a refugee camp. She states that she delivered her baby while she was in the camp but cannot remember how old her son is. The baby was not born prematurely. On examination, the mouth is stroked with a cotton swab, but the newborn does not turn his head towards the swab and open his mouth. The plantar grasp reflex is present. All other developmental tests are normal. What does this result infer about the age of her baby boy?
- Younger than 2 months
- Between 2 to 4 months
- Between 4 and 9 months
- Older than 12 months
- Between 4 and 9 months
POINTS
The rooting reflex is present at birth (approximately 28 weeks) and occurs when the corner of a baby’s mouth is stimulated.
When the mouth is stroked or touched, the newborn will turn his or her head towards the stimulation and open the mouth with tongue thrusting.
The rooting reflex lasts about 4 to 6 months until the frontal lobe develops and suppresses the reflex.
The plantar grasp reflex disappears after about 9 to 12 months. The infant with a normal plantar grasp reflex suggests the age of the boy to be younger than nine months.
A 20-month-old baby boy is brought to the hospital by his parents with concerns of poor verbal skills. He is the youngest of 3 siblings. His mother said that he started understanding and imitating different words by the age of 17 months but is unable to make 2-word phrases. The rest of the developmental milestones were normal. Parents are concerned as his other siblings started speaking 2 words and 3-word phrases at 20 months. What is the next best step for management?
- Refer for audiometry
- Refer for a developmental evaluation
- Reassure the parent that this level of speech is normal and there is variation between siblings
- Refer to a neurologist as the child may have a mild intellectual disability
- Reassure the parent that this level of speech is normal and there is variation between siblings
POINTS
A child normally starts understanding and imitating words at the age of 18-20 months.
2-word sentences are normal at 24 months.
Further screening or referral is not needed.
Parents are over-concerned about their child, and reassurance is important for their satisfaction.
A 2-year-old boy is brought in by his mother for a well-child visit. The child is up to date with his vaccines and is generally healthy. He runs around the house and plays kickball with his older brother. However, he can not walk up and down stairs or jump. He can turn pages and copy lines on a paper. He has a vocabulary of 40 words, but he can not link words to make three worded sentences. His mother has started toilet training him and says that he is picking it up well. What is the most appropriate next step in the management of this child?
- Assessment of fine motor function
- Assessment of language skills
- Assessment of gross motor function
- Assessment of social skills
- Assessment of gross motor function
POINTS
Even though the achievement of these milestones may vary from child to child, this should prompt further evaluations to make an evidence-based decision regarding the management of the patient.
He is lagging in his gross motor functions.
Proper and timely assessment of his gross motor function is the next best step.
This patient has met development milestones for language, fine motor, and social function.
A 5-year-old child is brought to the clinic because of difficulties in learning the language. Upon inquiry, parents report a delay in acquiring social and motor skills. The patient has been prompt with well-child visits. The patient is up-to-date with vaccination. The patient scored 31 on an IQ test. Which of the following is the most likely etiology of the child’s diagnosis?
- Child abuse
- Known genetic or environmental etiology
- Unknown etiology
- Hearing deficit
- Known genetic or environmental etiology
POINTS
The patient has a severe intellectual disability.
The cause is known in about 75 percent of patients with severe disabilities.
The cause is known in less than 50 percent of patients with mild disabilities.
Sensory deficit such as hearing problems is part of routine well-child visits and would have been detected earlier.
A 3-month-old baby is brought in by her parents for feeding advice. The mother has a past medical history of gluten intolerance and asthma. She says the baby is breastfeeding well, but she is concerned about starting giving the baby formula and solid food. What is the most appropriate advice that the nurse can give to this patient’s mother?
- Introduce allergenic foods one at a time after four to six months of age when breastfeeding
- Introduce allergenic foods one at a time after six months of age after stopping breastfeeding
- Introduce allergenic foods one at a time after six months of age when feeding with formula
- Introduce allergenic foods one at a time at 2 years of age and stopping breastfeeding and formula
- Introduce allergenic foods one at a time after four to six months of age when breastfeeding
POINTS
In the prevention of food allergies, the recommendations are to introduce complementary solid foods, such as egg, peanut products, fish, wheat, and other allergenic foods one at a time after four to six months of age when breastfeeding.
There is no need to avoid or delay the introduction of allergenic foods.
Food allergy is defined as an immune reaction to proteins in the food and can be immunoglobulin (Ig)E-mediated or non–IgE-mediated.
Any food can cause allergy but overall only a few foods account for the vast majority of allergies. This includes milk, eggs, peanuts, shellfish, wheat, and nuts.
A previously healthy 15-year-old female patient was evaluated by the health care provider, complaining of crampy abdominal pain, flatulence, and bloating for about two months. Her menses are regular, she has not lost weight, and she is not sexually active. She has started drinking milk twice a day as she read that she should increase her calcium intake. The physical examination is remarkable for mild generalized tenderness without rebound tenderness and guarding. An abdominal x-ray is significant for generalized distended bowels. Laboratory tests are WBC: 8900 cells per mm^3, hemoglobin: 12.9 g/dL, platelet: 189000 cells per microliter. What is the most preferred next step in management?
- Oral administration of lactose followed by hydrogen breath excretion measurement
- Check stool pH and for reducing substances
- Discontinue all lactose from the diet and then rechallenge
- Serum lactose levels
- Discontinue all lactose from the diet and then rechallenge
POINTS
The patient most likely has lactase deficiency.
The most cost-effective method to determine this is to remove lactose from her diet and see if her symptoms resolve.
The diagnosis will be confirmed if the rechallenge of lactose causes symptoms.
A breath test for hydrogen excretion after lactose challenge or a check of the stool pH and reducing substances can be done.
A child presents for a well-baby check. She was born to a 35-year-old G3P2 female via spontaneous vaginal delivery at 38 weeks gestation. At this visit, she is 12 months old and is assessed to have reached the milestones appropriate for this age. Which of the following milestones should the baby have reached by her next visit at 18 months of age?
- Climbs stairs with one foot per step
- Draws some letters and numbers
- Hops on one foot
- Scribbles with a writing tool
- Scribbles with a writing tool
POINTS
An 18-month-old child should be able to scribble with a writing tool.
The Developmental milestones are a set of goals or markers that a child is set to achieve from infancy to childhood. They are categorized into five domains: gross motor, fine motor, language, cognitive, and social-emotional, and behavioral.
Developmental delays can be specific (present in one area), or global (present in more than two areas). Children can present initially with developmental delay in a specific area, and this could affect the skills in other areas, thus progressing to global delay.
A child should be able to climb stairs with one foot per stair by age 3. A child should be able to draw some letters and numbers by the age of 5. A child should be able to hop on one foot by the age of 4.
A 2-week-old infant presents to the office with parents to evaluate his reflexes. When the side of the lips is touched, the baby turns the head towards that side. If this reflex was to persist after 12 months, what another clinical sign can be expected on the repeat physical exam?
- Tongue will deviate towards one side
- Mouth will always be open
- Tongue sitting too forward
- Absence of saliva secretion
- Tongue sitting too forward
POINTS
The rooting reflex appears soon after birth and can be reproduced by a light touch on the cheek or lips. The baby will turn the head towards that side.
The rooting reflex involves opening the mouth and extending the tongue in preparation for feeding.
In most healthy babies, the rooting reflex disappears by 4 to 6 months.
If the rooting reflex persists, the infant can have several problems, including drooling, speech difficulties, and a tongue that sits too forward in the mouth. The child will have difficulty swallowing and chewing because of the dysfunctional tongue.
