Pediatric

Question 1

During a well child examination, you notice that a 2-month-old male has a flattened left occiput. His records show that his skull was normally shaped at birth. Further evaluation shows that the left frontal region is more prominent than the right, and the left ear is slightly forward of its expected position. The infant seems comfortable rotating his head to either side while being held in his mother’s arms.

Which one of the following would be appropriate at this time? (check one)
Recommend that the infant sleep in a prone position, and follow up in 1 month
Educate the parents about positioning and follow up in 2 months
Order physical therapy
Order CT of the head E
Refer for surgical evaluation

Answer 1

Educate the parents about positioning and follow up in 2 months

The parallelogram shape of this infant’s head is typical of positional skull deformity, also known as benign positional molding or occipital plagiocephaly. This condition has been estimated to be present in at least 1 in 300 infants, with some studies showing milder variants in up to 48% of healthy infants. The incidence of positional skull deformity is increased in children who sleep in the supine position, but switching to prone sleeping is not recommended because this would increase the risk of sudden infant death syndrome. The deformity can be prevented by routine switching of the dependent side of the infant’s head. Supervised “tummy time” for 30–60 minutes each day can also decrease the amount of flattening and can increase the child’s motor development. Children who have positional skull deformity should also be screened for torticollis. This condition can prevent correct positioning and is remedied with physical therapy techniques.

Positional skull deformity should be differentiated from cranial synostosis, which is the result of abnormal fusion of one or more of the sutures between the skull bones. Ipsilateral frontal bossing and ear advancement are not seen, resulting in a trapezoid-shaped head.

Most infants with positional skull deformity improve within 2–3 months with the institution of positional changes and tummy time. If the condition does not significantly improve after this amount of time, referral to a pediatric neurosurgeon with expertise in craniofacial malformations would be appropriate.

Question 2

The mother of a 6-month-old male tells you that he sometimes wheezes while feeding, and this is occasionally associated with a cough. Changing his position does not help.

Which one of the following is the most likely diagnosis?
(check one)
Tracheoesophageal fistula
Laryngeal cleft
Gastroesophageal reflux disease
Foreign body aspiration
Tracheomalacia

Answer 2

Gastroesophageal reflux disease

There are many causes of wheezing in infants and children. Wheezing associated with feeding is most commonly due to gastroesophageal reflux disease (level of evidence 3). Tracheoesophageal fistula and laryngeal cleft also cause wheezing associated with feeding, but are rare. Foreign body aspiration is most common between 8 months and 4 years of age and the child is most likely to have a history of the sudden onset of wheezing associated with choking. The wheezing present with tracheomalacia is position related.

Question 3

You have recently acquired several patients from a retiring colleague. These patients have been using topical corticosteroids over a prolonged period of time.

Which one of the following patient groups is at highest risk for adverse systemic reactions to prolonged topical corticosteroid use? (check one)
Children
Young adults
Middle-aged adults
Pregnant women
Breastfeeding women

Answer 3

Children

All patients using topical corticosteroids chronically should be monitored for adverse systemic effects, such as adrenal suppression, cataracts, decreased growth rate, and hypertension. Patients at highest risk for adverse systemic reactions to prolonged topical corticosteroid use are children and the elderly. There has been no evidence that maternal use of topical corticosteroids causes adverse pregnancy outcomes or that their use while breastfeeding is problematic.

Question 4

Which one of the following interventions for bed-wetting in children should be recommended as initial therapy?

(check one)
Waking a child during the night and carrying him or her to the toilet
Restriction of fluids during the day
An enuresis alarm
Imipramine (Tofranil)
Oxybutynin (Ditropan)

Answer 4

An enuresis alarm

Enuresis alarms should be offered as initial treatment for bed-wetting, based on randomized, controlled trials and cost-effectiveness evidence. Desmopressin can also be considered if the child or parents do not want to try an alarm. Restriction of fluids during the day should not be recommended, as it is important that children have enough to drink. Waking a child and carrying him or her to the toilet has not been shown to have a long-term effect on bed-wetting. Oxybutynin and imipramine should only be considered in cases where bed-wetting does not respond to initial treatment.

Question 5

An abandoned infant is brought to the hospital for evaluation. Based on the presence of a dried umbilical cord remnant and her overall appearance, you believe her to be no more than 5 days of age. A thorough examination is normal except for a finding of bilateral conjunctival erythema and exudate. A Gram stain of the exudate is remarkable for numerous WBCs, very few of which are noted to contain gram-negative diplococci.

Which one of the following treatment options is most appropriate?
(check one)
Application of moist, warm saline eye compresses
Irrigation of both eyes with povidone-iodine (Betadine)
One-time application of ophthalmic erythromycin ointment into both eyes
Instillation of silver nitrate solution into both eyes
Intramuscular injection of ceftriaxone (Rocephin)

Answer 5

Intramuscular injection of ceftriaxone (Rocephin)

Infantile gonococcal infection is usually the result of exposure to infected cervical exudate during delivery and manifests 2–5 days after birth. Ophthalmia neonatorum and sepsis are the most severe gonococcal infections in newborns and immediate treatment is warranted based on the presumptive diagnosis. Topical antibiotics are appropriate for prophylaxis, but not for treatment. Silver was used for prophylaxis at one time, but is no longer available. Povidone-iodine has not been studied for prevention. A single dose of 25–50 mg/kg of ceftriaxone administered intravenously or intramuscularly is the recommended treatment.

Question 6

Which one of the following treatments for childhood nocturnal enuresis has both the highest cure rates and the lowest relapse rates? (check one)
Bed-wetting alarms
Positive reinforcement
Responsibility training
Desmopressin (DDAVP)
Imipramine (Tofranil)

Answer 6

Bed-wetting alarms

Treatments available for childhood nocturnal enuresis include nonpharmacologic and pharmacologic treatments. Compared to other techniques and pharmacologic treatments, the bed-wetting alarm has a higher success rate (75%) and a lower relapse rate (41%).

Question 7

You are evaluating a 5-month-old with fever, tachypnea, and mild respiratory distress in the emergency department. You hear mild basilar rales. The child does not appear toxic. Which one of the following tests would be the most appropriate as an initial study? (check one)
A chest radiograph
A CBC
A C-reactive protein level
Oxygen saturation by pulse oximetry

Answer 7

Oxygen saturation by pulse oximetry

Pulse oximetry should be obtained on all pediatric patients with significant tachypnea, pallor, or respiratory distress. It has been found that CBCs, C-reactive protein levels, and erythrocyte sedimentation rates are not effective in differentiating between viral and bacterial pneumonia. Chest radiographs are also ineffective in distinguishing viral and bacterial pneumonia, and should be obtained in cases of ambiguous clinical findings, prolonged pneumonia, and pneumonia that is unresponsive to antibiotic therapy, as well as when there is the possibility of complications such as pleural effusions.

Question 8

A 4-week-old full-term male is brought to your office by his parents. They report that their child started vomiting just after his 1-week visit. The parents are concerned because they think the vomiting is worsening, occurring after every feeding, and “shooting across the room.” You note that the baby is afebrile, but has not gained any weight since birth. Based on this information, the most likely diagnosis is: (check one)
Formula intolerance
Meningitis
Viral gastroenteritis
Pyloric stenosis
Inappropriate feeding

Answer 8

Pyloric stenosis

Pyloric stenosis fits the described scenario; it is characterized by the early onset of worsening projectile vomiting and poor weight gain, and occurs most often in full-term male infants who are otherwise healthy. Formula intolerance causes regurgitation, as would inappropriate feeding. Meningitis, whether viral or bacterial, would be associated with fever. Viral gastroenteritis is a common cause of vomiting in older children, and is usually associated with fever and diarrhea.

Question 9

A mother brings her 12-month-old son to your clinic, concerned that he is repeatedly banging his head against the floor, wall, or crib. She reports that this behavior began about 2 months ago. It now occurs several times per week, and at times is incited when the child is frustrated with a toy or when he does not get what he wants from his parents. The mother notes that she is sometimes awakened at night by the sound of her son rhythmically banging his head against the rail of his crib. Physical examination reveals a normal child with some soft-tissue swelling of the forehead, but no broken skin, ecchymosis, or signs of bony damage. Developmental milestones and growth have been normal, and the child is not on any medications. Children with this presentation are most likely to have which one of the following? (check one)
A history of child abuse
A skin laceration or skull fracture
An eventual diagnosis of Lesch-Nyhan syndrome
Extinction of this habit by age 3
Future cognitive delay when compared with children without this habit

Answer 9

Extinction of this habit by age 3

Head banging has been estimated to be present in 3%–15% of normal children and usually begins between the ages of 5 and 11 months. The vast majority of these children will engage in this activity for only a few months, and most will stop by age 3. Rarely does the behavior cause lacerations or skull fractures, and the presence of either should prompt the physician to consider the possibility of another cause such as abuse. The incidence of head banging is higher in children with developmental disorders such as Lesch-Nyhan syndrome, Down syndrome, or autism. However, this child has no sign of any such disorder and has normal developmental milestones.

Question 10

A 3-week-old white male presents with a history of several days of projectile vomiting after feeding, and documented weight loss despite a good appetite. There is a questionable history of a paternal uncle having surgery for a similar problem when he was an infant. Which one of the following findings is a characteristic sign of this disease? (check one)
Hypochloremic alkalosis
Pneumonia
Generalized abdominal distention
Currant jelly stool
Direct hyperbilirubinemia

Answer 10

Hypochloremic alkalosis

Hypertrophic pyloric stenosis is the most likely diagnosis in this case. If it is allowed to progress untreated, there may be signs of malnutrition, constipation, oliguria, and profound hypochloremic metabolic alkalosis. The latter is a characteristic sign of pyloric obstruction. As the child vomits chloride and hydrogen-rich gastric contents, hypochloremic alkalosis sets in. Pneumonia is not a common problem with pyloric stenosis, as it can be with congenital tracheoesophageal fistulae for example. After feeding, there may be a visible peristaltic wave that progresses across the abdomen. However, since the point of obstruction is proximal to the small and large intestines and affected infants lose weight, the abdomen is usually flat rather than distended, especially in the malnourished infant. Currant jelly stool is a common clinical manifestation of intussusception. Mild jaundice with elevated indirect bilirubin is seen in about 5% of infants with pyloric stenosis, but is not a characteristic sign.

Question 11

A 15-month-old male is brought to the emergency department following a generalized tonic-clonic seizure at home. The parents report that the seizure lasted 5 minutes, with confusion for the next 15 minutes. This is the child’s first seizure. There is no family history of seizures. His medical history is normal except for a 1-day history of a URI. While initially lethargic in the emergency department, the child is now awake and playful, with a temperature of 39.5 degrees C (103.2 degrees F) and a normal examination. Appropriate diagnostic tests are performed, including a blood glucose level, which is 96 mg/dL. Which one of the following would be most appropriate to administer at this point? (check one)
Phenytoin (Dilantin) intravenously
Ceftriaxone (Rocephin) intravenously
Acetaminophen orally
Carbamazepine (Tegretol) orally
Phenobarbital orally

Answer 11

Acetaminophen orally

This child has had a simple febrile seizure, the most common seizure disorder of childhood. Treatment includes finding a source for the fever; this should include a lumbar puncture if meningitis is suspected. The most common infections associated with febrile seizures include viral upper respiratory infections, otitis media, and roseola. Antipyretics are the first-line treatment. Antibiotics are indicated only for appropriate treatment of underlying infections. Phenytoin and carbamazepine are ineffective for febrile seizures. Phenobarbital is sometimes used for prevention of recurrent febrile seizures, but is not indicated as an initial therapy. Only 30%–50% of children with an initial febrile seizure will have recurrent seizures.

Question 12

Which one of the following is recommended regarding oral fluoride supplementation? (check one)
Supplementation for all children whose primary water source is well water
Starting supplementation at 6 months of age if the primary water supply is fluoride deficient
Starting supplementation at 2 years of age even in children who have received topical fluoride varnish
No supplementation if fluoride varnish is applied once all primary teeth have come in or by 3 years of age, then yearly thereafter
No supplementation for most children

Answer 12

Starting supplementation at 6 months of age if the primary water supply is fluoride deficient

The U.S. Preventive Services Task Force recommends oral fluoride supplementation for the prevention
of dental caries beginning at age 6 months for children whose primary water supply is fluoride deficient
(B recommendation). Well water may be fluoridated naturally depending on the aquifer, but the water is
highly variable and should be tested before deciding on the need for supplementation. Testing well water
is also advisable because excessive fluoride may lead to fluorosis of the bones. Bottled water is variable,
making it undependable as an adequate source of fluoride. Topical fluoride, in toothpaste or applications
of fluoride varnish, is effective in preventing tooth decay in children and can be used in addition to
properly fluoridated water. Twice-yearly application of fluoride varnish to primary teeth should begin
when the first tooth comes in and repeated every 6 months thereafter in children (SOR B).

Question 13

You see a 20-month-old male approximately 1 hour after he had a generalized seizure that lasted 2-3 minutes according to his mother. His past medical history is unremarkable except for two episodes of otitis media. On examination his temperature is 38.9°C (102.0°F), and he is awake, interactive, and consolable, with obvious otitis media of the left ear. A neurologic examination is unremarkable, and there are no meningeal signs. Which one of the following would be most appropriate at this point? (check one)
Lumbar puncture
Electroencephalography
Neuroimaging studies
Serum levels of electrolytes, calcium, phosphate, and magnesium, plus a blood glucose level and a CBC
No diagnostic studies at this time

Answer 13

No diagnostic studies at this time

This patient had a classic simple febrile seizure and no additional diagnostic studies are recommended. A lumbar puncture following a seizure is not routinely recommended in a child over 18 months of age, since by that age a patient with meningitis would be expected to demonstrate meningeal signs and symptoms or clinical findings suggesting an intracranial infection. There is no evidence to suggest that routine blood tests or neuroimaging studies are useful in a patient following a first simple febrile seizure, and it has not been shown that electroencephalography performed either at the time of presentation or within the following month will predict the likelihood of recurrence. Ref: Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures: Practice parameter: The neurodiagnostic evaluation of the child with a first simple febrile seizure.

Question 14

A 9-month-old male is brought to your office by his mother because of concerns about his eating. She states that he throws tantrums while sitting in his high chair, dumps food on the floor, and refuses to eat. She has resorted to feeding him cookies, crackers, and juice, which are all he will eat. A complete physical examination, including a growth chart of weight, length, and head circumference, is normal. Which one of the following would be the most appropriate recommendation? (check one)
Use disciplinary measures to force the child to eat a healthy breakfast, lunch, and dinner
Leave the child in the high chair until he has eaten all of the healthy meal presented
Play feeding games to encourage consumption of healthy meals or snacks
Skip the next meal if the child refuses to eat
Provide healthy foods for all meals and snacks, and end the meal if the child refuses to eat

Answer 14

Provide healthy foods for all meals and snacks, and end the meal if the child refuses to eat

It is estimated that 3%-10% of infants and toddlers refuse to eat according to their caregivers. Unlike other feeding problems such as colic, this problem tends to persist without intervention. It is recommended that caregivers establish food rules, such as healthy scheduled meals and snacks, and apply them consistently. Parents should control what, when, and where children are being fed, whereas children should control how much they eat at any given time in accordance with physiologic signals of hunger and fullness. No food or drinks other than water should be offered between meals or snacks. Food should not be offered as a reward or present. Parents can be reassured that a normal child will learn to eat enough to prevent starvation. If malnutrition does occur, a search for a physical or mental abnormality should be sought.

Question 15

A parent brings their 2-month-old infant to your office for a routine well check. The infant, who was born at full term, is formula fed and the parent is concerned about vomiting that occurs after every feeding. After taking a history and examining the infant you diagnose uncomplicated reflux.

The next appropriate intervention would be (check one)
prone positioning for sleep
celiac testing
a trial of thickened feeds
a trial of an acid suppressor
abdominal ultrasonography

Answer 15

a trial of thickened feeds

For uncomplicated reflux, a trial of thickened feeds and/or switching to a soy formula would be appropriate, as a milk protein allergy can present similarly. Prone positioning for sleep is not recommended for infants due to increased risk of sudden infant death syndrome (SIDS). Celiac testing may not be helpful in a formula-fed infant who has not been exposed to gluten-containing grains. A trial of an acid suppressor should take place if symptoms are not improved after omitting cow’s milk formula and thickening feeds. Abdominal ultrasonography would be indicated for bilious forceful vomiting, failure to thrive, or other clinical signs that would suggest pyloric stenosis.

Question 16

Which one of the following is the most appropriate timing to initiate the use of fluoride varnish in infants and children to prevent dental caries? (check one)
At age 6 months if their primary water source is deficient in fluoride
At age 6 months and then four times yearly
At age 6 years and then four times yearly
When the first primary tooth erupts and then twice yearly
When the first permanent tooth erupts and then four times yearly

Answer 16

When the first primary tooth erupts and then twice yearly

Fluoride helps to prevent tooth decay and is an important aspect of good oral care. Family physicians can impact oral health, which directly affects overall health, by incorporating this into their routine practice.
Fluoride varnish should be applied when the first primary tooth erupts. It should then be applied twice yearly in all infants and young children (SOR B). Also, if the patient’s primary water source is deficient in fluoride, then fluoride supplements should be prescribed for children beginning at 6 months of age.

Question 17

A 16-year-old male accompanied by his mother presents to your outpatient clinic with concerns about his short stature and “boyish” looks. He is a sophomore in high school but is frequently mistaken for someone much younger. Radiographs reveal a bone age of 14.7 years.
Which one of the following would suggest the need for further evaluation?
(check one)
A family history of delayed growth
Height below the fifth percentile for age
Weight below the fifth percentile for age
Prepubescent testicular size

Answer 17

Prepubescent testicular size

Most cases of short stature are due to constitutional growth delay, a term which implies that the child is normal but delayed in his development. A hallmark of this condition is being below the fifth percentile for height for most of childhood. Usually these children are thin and have a family history of delayed development. Bone age would be expected to be at least 2.5 standard deviations below the mean for agematched peers of the same chronologic age. However, most experts agree that if no signs of puberty are seen by 14 years of age (no breast development in girls, no testicular enlargement in boys), then further workup for a more serious condition should be sought. Other indications for evaluation would be no menarche in a girl by 16 years of age and underdeveloped genitalia in a boy 5 years after his first pubertal changes.

Question 18

A U.S. hospital or birthing center seeking to be certified as “Baby-Friendly” by the Baby-Friendly Hospital Initiative must satisfy which one of the following criteria in addition to meeting other requirements? (check one)
Demonstrating proper use of an infant car seat to parents prior to discharge
Providing no other food or fluids to breastfeeding infants without a medical indication
Providing a pacifier to each baby prior to discharge
Providing easy access to a variety of infant formulas
Providing on-site daycare facilities for staff

Answer 18

Providing no other food or fluids to breastfeeding infants without a medical indication

The Baby-Friendly Hospital Initiative is a global program established by UNICEF and WHO to promote healthy infant feeding and mother-baby bonding. The primary objective is to educate the public on the benefits of breastfeeding and encourage, promote, and facilitate breastfeeding as outlined in the UNICEF/WHO Ten Steps to Successful Breastfeeding chart. These steps promote breastfeeding to the public and provide guidelines for hospitals and birthing centers for the successful initiation and continuation of breastfeeding.

Baby-friendly facilities must have a written breastfeeding policy that is routinely communicated to all health care staff, and all health care staff must be trained in the skills necessary to implement this policy. All pregnant women should be informed about the benefits and management of breastfeeding. Mothers should be helped to initiate breastfeeding within an hour after birth and shown how to breastfeed and to maintain lactation, even if they are separated from their infants. Breastfeeding infants should not be given food other than breast milk, unless medically indicated. If mothers choose to give formula after appropriate education, they should be instructed in proper preparation and use.

Rooming in should be practiced, allowing mothers and infants to remain together 24 hours a day. Mothers should be encouraged to breastfeed on demand. Breastfeeding infants should not be given pacifiers or artificial nipples. Mothers should be referred to breastfeeding support groups on discharge from the hospital. In addition, the hospital must comply with the International Code of Marketing of Breast Milk Substitutes, which requires that formula companies cannot give free gifts to staff or mothers, that breast milk substitutes are not marketed in the maternity unit, and that breast milk supplements and infant feeding supplies are purchased at fair market price.

Question 19

A 14-year-old male is brought to your office with a 2-month history of a lump in his left chest. An examination reveals a slightly tender 2-cm area of concentric firm mobile tissue under the left areola. He has no skin changes, nipple discharge, or associated adenopathy. The right side is unremarkable. A genital examination reveals Tanner 3 development but is otherwise unremarkable. Growth curves are appropriate for the patient’s age, with a BMI of 19 kg/m2.

Which one of the following would be most appropriate at this point? (check one)
Follow-up in 6–12 months
A prolactin level
Ultrasonography of the left breast
Tamoxifen (Soltamox), 10 mg/day for 3 months
A biopsy

Answer 19

Follow-up in 6–12 months

This patient’s history and the examination support the diagnosis of adolescent physiologic gynecomastia. The most appropriate next step is follow-up with this patient in 6–12 months. One-half of all adolescent males will experience some form of gynecomastia. This condition is often bilateral, but it is more common on the left side if it is unilateral. It will typically resolve 6–24 months after onset. Patients should be asked about medications and supplements, because these may be a cause of nonphysiologic breast enlargement. Concerning factors include persistence for longer than 2 years; hard, immobile, nontender masses; masses >5 cm; nipple discharge; testicular masses; and systemic symptoms such as weight loss. Evaluation for persistent gynecomastia can include laboratory studies to exclude hepatic, renal, and thyroid disorders, and can progress to include tests to detect gonadotropin and hormone-related tumors and disorders. Imaging and/or a biopsy would be indicated if signs of a carcinoma were noted. The additional options listed are not indicated at this point, although they are a part of the recommended algorithm for further evaluation and treatment considerations.

Question 20

Which one of the following is appropriate in the care of adolescent patients? (check one)
Recommending that parents accompany their children at all times during visits in order to increase rapport and trust
Avoiding discussion of weight with teenagers who are obese, because of the negative impact on self-image
Recommending education about sex and contraception, aimed at reducing the rate of unintended pregnancy
Beginning cervical cancer screening at age 18, or earlier with sexually active patients

Answer 20

Recommending education about sex and contraception, aimed at reducing the rate of unintended pregnancy

Sex education programs have been associated with a reduction in the rates of sexually transmitted infections in adolescents. Clinicians should meet with adolescents privately to provide confidentiality. Adolescents should be screened for obesity and provided appropriate behavioral counseling. Cervical cancer screening should begin at age 21.

Question 21

Additional workup or referral to an endocrinologist for evaluation of precocious puberty would be indicated in which one of the following patients? (check one)
A 7-year-old female with some pubic hair
An 8-year-old female with breast buds
An 8-year-old male with some pubic hair and axillary odor
An 8-year-old male with penile enlargement
A 10-year-old female who has recently begun having menses

Answer 21

An 8-year-old male with penile enlargement

Penile enlargement in an 8-year-old male is a sign of precocious puberty. Isolated sparse pubic and axillary hair growth and axillary odor is referred to as premature adrenarche, and represents high levels of dehydroepiandrosterone rather than activation of the hypothalamic-pituitary-gonadal axis that leads to puberty. The isolated findings of premature adrenarche are generally considered benign. An 8-year-old with breast buds and a 10-year-old with menarche are within the normal range of expected pubertal development. Penile enlargement typically represents full activation of the hypothalamic-pituitary-gonadal axis and warrants endocrinologic evaluation in boys younger than 9 years of age.

Question 22

A 4-year-old male is brought to your office for evaluation of fever, coryza, and cough. On examination the child appears mildly ill but in no respiratory distress. His temperature is 37.4°C (99.3°F) and other vital signs are within the normal range. An HEENT examination is significant only for light yellow rhinorrhea and reddened nasal mucous membranes. Lung auscultation reveals good airflow with a few coarse upper airway sounds. While performing the examination you note multiple red welts and superficial abrasions scattered on the chest and upper back. When you question the parents they tell you the marks are where “the sickness is leaving his body,” and were produced by rubbing the skin with a coin.

This traditional healing custom is practiced principally by people from which geographic region? (check one)
Sub-Saharan Africa
Southeast Asia
The Middle East
The Caribbean
The Andes Mountains

Answer 22

Southeast Asia

Coin rubbing is a traditional healing custom practiced primarily in east Asian countries such as Cambodia, Korea, China, and Vietnam. The belief is that one’s illness must be drawn out of the body, and the red marks produced by rubbing the skin with a coin are evidence of the body’s “release” of the illness. These marks may be confused with abuse, trauma from some other source, or an unusual manifestation of the illness itself.

Question 23

You are discharging a mother and her infant after delivery. The infant was born at 35 weeks gestation, is exclusively breastfed, and has a weight that is appropriate for her gestational age. No blood transfusions were necessary and all evaluations have been unremarkable.

According to the guidelines of the American Academy of Pediatrics, at what age should you recommend initiation of iron supplementation for this infant? (check one)
Now
1 month
3 months
6 months
9 months

Answer 23

1 month

According to the guidelines of the American Academy of Pediatrics, elemental iron supplementation (2 mg/kg per day) should begin at 1 month of age for exclusively breastfed infants born before 37 weeks gestation and should continue until 12 months of age, unless the infant had multiple blood transfusions.

Question 24

An adolescent male is concerned because he is the shortest boy in his class. His age is 14.3 years and his parents are of normal height. He has a negative past medical history and no symptoms. On examination he is 151 cm (59 in) tall. The average height for his age is 165 cm. His weight is 43 kg (95 lb). His sexual maturity rating is 3 for genitalia and 2 for pubic hair. A wrist radiograph shows a bone age of 12.2 years. The average height for this bone age is 152 cm.

On the basis of this evaluation you can tell the patient and his parents that (check one)
he should have a growth hormone stimulation test
his adult height will be below average
his sexual development is about average for his age
he will begin to grow taller within approximately a year
an underlying nutritional deficiency may be the cause of his short stature

Answer 24

he will begin to grow taller within approximately a year

Constitutional growth delay, defined as delayed but eventually normal growth in an adolescent, is usually genetic. If evaluation of the short adolescent male reveals no evidence of chronic disease, if his sexual maturity rating is 2 or 3, and if his height is appropriate for his skeletal age he can be told without endocrinologic testing that he will begin to grow taller within a year or so. His adult height may be below average but cannot be predicted reliably. Average sexual maturity ratings for a male of 14.3 years are 4 for genitalia and 3–4 for pubic hair. The history and physical examination would have given clues to any illnesses or nutritional problems.

Question 25

A 2-month-old male is brought to your office for a well child check. The parents tell you that he regurgitates with every feeding, and they are getting very frustrated. He takes about 4–5 ounces of formula every 4 hours. With every feeding he regurgitates a large amount of formula. They have tried frequent burping and elevating his head during and after feeding, but he continues to regurgitate. He does not appear to be uncomfortable and overall is a happy baby. He is growing well and a complete examination is normal.

Which one of the following is the most appropriate management for this patient? (check one)
Reassurance
Metoclopramide (Reglan)
Omeprazole (Prilosec)
Ranitidine (Zantac)
Abdominal ultrasonography

Answer 25

Reassurance

This child has gastroesophageal reflux. This is a normal physiologic process that occurs in infants. Most reflux events are caused by transient lower esophageal sphincter relaxation that is triggered by postprandial gastric distention. This relaxation can continue into childhood, but with growth and an upright eating position it generally improves. Reflux in infants can be treated by implementing body position changes while awake, lower volume feedings if they are overfed, thickening agents, and antiregurgitant formula. It is recommended to avoid the use of medication in infants that have regurgitation that is effortless, painless, and not affecting growth. When the infant is not growing well or appears to be in pain, it would be appropriate to initiate pharmacotherapy with an acid-suppressing medication. Abdominal ultrasonography would be indicated if there were forceful vomiting and concerns about possible pyloric stenosis.

Question 26

A 7-month-old infant is hospitalized for the third time with lower-lobe bronchopneumonia. Findings include a weight and height below the 10th percentile. A sibling died of sudden infant death syndrome.

Laboratory testing reveals a hemoglobin level of 9.0 g/dL (N 10.5–14.0), a mean corpuscular volume of 85 μm3 (N 72–88), and a serum calcium level of 9.0 mg/dL (N 9.0–10.5). A sweat chloride level is 20 mEq/L (N <60).

Which one of the following is the most likely cause of this infant’s failure to thrive? (check one)
Cystic fibrosis
DiGeorge’s syndrome
Battered child syndrome
Gastroesophageal reflux
β-Thalassemia

Answer 26

Gastroesophageal reflux

Gastroesophageal reflux accounts for a significant number of cases of failure to thrive, crib death, and recurrent pneumonia. Features of gastroesophageal reflux include a history of recurrent pneumonia, a low growth curve, a family history of sudden infant death syndrome, and normocytic anemia. A sweat chloride level of 20 mEq/L rules out cystic fibrosis. Normal serum calcium excludes DiGeorge’s syndrome. The battered child generally presents with more than just a single recurring medical problem. β-Thalassemia would be indicated by a microcytic anemia.

Question 27

A 7-year-old female is brought to your office by her mother, who says that the child has developed underarm odor and is beginning to develop acne. The patient has an unremarkable history, was born at full term, and has no chronic medical problems. There is no family history of endocrine disorders or precocious puberty.

An examination reveals normal vital signs and a normal BMI, and her height is stable on the growth curve with no increased velocity. Her sexual maturity rating is stage 1. She has some open and closed comedones on her forehead and back.

Which one of the following would be most appropriate at this point? (check one)
Reassurance and surveillance over the next 3–6 months
TSH, LH, and FSH levels
Bone age radiography
Bone age radiography and TSH, LH, and FSH levels

Answer 27

Reassurance and surveillance over the next 3–6 months

Premature adrenarche without development of secondary sex characteristics is usually idiopathic and does
not lead to an abnormal pattern of development. Reassurance and surveillance over the next 3–6 months
would be most appropriate at this time. Laboratory studies and radiography warrant consideration if the
patient develops secondary sex characteristics before the age of 8, or if her height velocity increases
rapidly during the surveillance period.

Question 28

A mother brings in her 2-week-old infant for a well child check. She reports that she is primarily breastfeeding him, with occasional formula supplementation.

Which one of the following should you advise her regarding vitamin D intake for her baby? (check one)
Breastfed infants do not need supplemental vitamin D
He does not need supplemental vitamin D if he is taking at least 16 oz of formula per day
Vitamin D supplementation should not be started until he is at least 6 months old
He should be given 400 IU of supplemental vitamin D daily
Intake of vitamin D in excess of 200 IU/day is potentially toxic

Answer 28

He should be given 400 IU of supplemental vitamin D daily

The American Academy of Pediatrics recommends a daily intake of 400 IU of vitamin D in infants, children, and adolescents (SOR C). Breastfeeding does not provide adequate levels of vitamin D. Exclusive formula feeding probably provides adequate levels of vitamin D, but infants who consume less than 1 liter of formula per day need supplementation with 400 IU of vitamin D daily. Vitamin D supplementation should be started within the first 2 months of life.