Pediatrics

Question 1

What is the average age at which the following milestone is achieved: social smile?

Answer 1

1-2 months

Question 2

What is the average age at which the following milestone is achieved: cooing?

Answer 2

2-4 months

Question 3

What is the average age at which the following milestone is achieved: while prone, lifts head up 90 degrees?

Answer 3

3-4 months

Question 4

What is the average age at which the following milestone is achieved: rolls front to back?

Answer 4

4-5 months

Question 5

What is the average age at which the following milestone is achieved: voluntary grasp (no release)?

Answer 5

5 months

Question 6

What is the average age at which the following milestone is achieved: stranger anxiety?

Answer 6

6-9 months

Question 7

What is the average age at which the following milestone is achieved: sits with no support?

Answer 7

7 months

Question 8

What is the average age at which the following milestone is achieved: pulls to stand?

Answer 8

9 months

Question 9

What is the average age at which the following milestone is achieved: waves “bye-bye”?

Answer 9

10 months

Question 10

What is the average age at which the following milestone is achieved: voluntary grasp with voluntary release?

Answer 10

10 months

Question 11

What is the average age at which the following milestone is achieved: plays pat-a-cake?

Answer 11

9-10 months

Question 12

What is the average age at which the following milestone is achieved: first words?

Answer 12

9-12 months

Question 13

What is the average age at which the following milestone is achieved: imitates others’ sounds?

Answer 13

9-12 months

Question 14

What is the average age at which the following milestone is achieved: separation anxiety?

Answer 14

12-15 months

Question 15

What is the average age at which the following milestone is achieved: walks without help?

Answer 15

13 months

Question 16

What is the average age at which the following milestone is achieved: can build tower of 2 cubes?

Answer 16

13-15 months

Question 17

What is the average age at which the following milestone is achieved: understands 1-step commands (no gesture)?

Answer 17

15 months

Question 18

What is the average age at which the following milestone is achieved: good use of cup and spoon

Answer 18

15-18 months

Question 19

What is the average age at which the following milestone is achieved: can build tower of 6 cubes?

Answer 19

2 years

Question 20

What is the average age at which the following milestone is achieved: runs well?

Answer 20

2 years

Question 21

What is the average age at which the following milestone is achieved: ties shoelaces?

Answer 21

5 years

Question 22

How do you assess developmental milestones for premature infants?

Answer 22

Reduce their age in the first 2 years when assessing. For example, for children born at 6 months gestation, subtract 3 months from their chronological age (expected to perform only at the 6-month-old level when they are 9 months old).

Question 23

True or false: The overall pattern of development is more important than the age at which individual milestones are reached.

Answer 23

True. The exact age is not as important as the overall pattern in looking for dysfunctional development. When in doubt, use a formal developmental test.

Question 24

What screening and preventative are measures should be done at every pediatric visit?

Answer 24

Height, weight, BP, developmental/behavioral assessment, and anticipatory guidance (counseling/discussion about age-appropriate concerns)

Question 25

True or false: Screening and preventative care are important mainly during a well check-up.

Answer 25

False. They are an important part of every encounter with a patient (adult or child). Example: Mother complains that her 4 y/o child sleeps 11 hours per night. This is normal behavior. The answer to the question, “What should you do next?” may be to give an objective hearing exam, which is routine in a 4 y/o child.

Question 26

What are the commonly performed screening tests for metabolic and congenital disorders?

Answer 26

States very widely in their policies. All states screen for hypothyroidism and phenylketonuria at birth; must be done within first month or life. Most states screen for galactosemia and hemoglobinopathies (e.g. sickle cell). Some include screening for homocystinuria, maple syrup urine disease, congenital adrenal hyperplasia, cystic fibrosis, biotinidase deficiency, tyrosinemia, and toxoplasmosis. If any of these are positive, first step is to order a confirmatory test.

Question 27

What are the frequently tested items under the umbrella of primary prevention using “anticipatory guidance”?

Answer 27

Tell parents the following: keep water heater under 110-120 F, use car restraints, put the infant to sleep on his or her side or back to help prevent SIDS (most common cause of death in children aged 1-12 months), do not use infant walkers because they cause injuries, watch out for small objects (aspiration risk), do not give cow’s milk before 1 year of age, introduce solid foods gradually starting at 6 months, supervise children in bathtubs and swimming pools

Question 28

How often should height, weight, and head circumference be measured? What do they signify?

Answer 28

Head circumference should be measured at every visit in the first 2 years; height and weight should be measured routinely until adulthood. All three are markers of general well-being.

Question 29

What if a child has low height, weight, or head circumference compared with peers?

Answer 29

The pattern of growth along plotted growth curves over times tells you more than a single measurement. If a child has always been low or high compared with peers, generally the pattern is benign. A patients who goes from a normal to an abnormal curve is more worrisome.

Question 30

Define failure to thrive. What causes it?

Answer 30

Commonly used definitions include a head circumference, height, or weight less than the 5th percentile for age; weight less than 80% of ideal weight for age; or a weight loss that causes a decrease in 2 or more major percentage lines on the growth curve. Most commonly due to psychosocial or functional problems. Watch for signs of neglect and child abuse.

Question 31

What conditions are suggested by obesity in children?

Answer 31

Usually due to overeating and too little activity (more than 95% of cases). Less than 5% of cases are due to organic causes (e.g. Cushing syndrome, Prader-Willi syndrome).

Question 32

What conditions should you consider in a child with an abnormal head circumference?

Answer 32

Increase in head circumference may mean hydrocephalus or tumor, whereas decreased head circumference may mean microcephaly (e.g. congenital TORCH infection).

Question 33

How are hearing and vision screened?

Answer 33

Measured objectively at least once by 4 years of age. After the initial screen, measure every few years until adulthood or more often if necessary.

Question 34

In what situations should you worry about hearing loss?

Answer 34

• After a bout of meningitis (hearing loss it he most common neurologic complication)
• With congenital TORCH (toxoplasmosis, other [e.g. syphilis, HIV], rubella, CMV, HSV) infections
• With measles or mumps
• With chronic middle ear effusions or chronic or recurrent otitis media
• With the use of ototoxic drugs (e.g. aminoglycosides)

Question 35

What is the red reflex? What should an abnormal reflex suggest?

Answer 35

When penlight is shined at pupil, usually see red because of underlying funds. If a cataract (or tumor) is present in the eye, the reflex disappears and you see black (with a cataract) or white (known as leukocoria and classically 2/2 retinoblastoma).

Question 36

True or false: Before a certain age, intermittent strabismus is normal.

Answer 36

True. It is normal for infants to have occasional ocular misalignment (strabismus) until 3 months of age. After 3 months (or with constant eye deviation), strabismus should be evaluated and managed by an ophthalmologist to prevent possible blindness in the affected eye.

Question 37

How is screening for anemia done?

Answer 37

Hemoglobin or hematocrit measurement is recommended at 12 months of age. Recommendations during adolescence vary, but should typically be done at least once. Any risk factors for iron deficiency (e.g. prematurity, low birth weight, ingestion of cow’s milk before 1 year of age, low dietary intake, low socioeconomic status) warrant a screen.

Question 38

True or false: All children should be given prophylactic iron supplements.

Answer 38

False. Exclusively breast-fed infants do not require supplementation. All other children should receive supplementation. Start iron-supplements in full-term infants at 4-6 months of age and in preterm infants at 2 months of age. Most infant formulas and cereals contain iron, thus separate supplements are usually not required.

Question 39

How and when do you screen for lead exposure?

Answer 39

Routine screening is no longer recommended. However, all Medicaid-eligible children must be screened. Consider screening high-risk children (live in old buildings, have sibling or playmate with lead toxicity, eat paint chips, live near battery recycling plant). Screen by doing serum lead level. If abnormally high, first best step is to stop the exposure.

Question 40

True or false: Most children need fluoride supplementation.

Answer 40

False. Because most water is fluorinated, supplementation is not needed. If, however, a child lives in an area where the water is inadequately fluoridated (rare) or the child is fed exclusively from premixed, ready-to-eat formulas (which use nonfluoridated water), fluoride supplements should be given.

Question 41

True or false: Breast-fed infants are more likely to require vitamin D supplements than formula-fed infants.

Answer 41

True. The American Academy of Pediatricians recommends that exclusively and partially breastfed infants receive vitamin D supplements shortly after birth and continue until they are weaned and consume formula or whole milk. Formula-fed infants do not require supplements in the US because all formulas contain them.

Question 42

Wen should children be screened for TB?

Answer 42

Universal screening is not recommended. There is no need to screen children who have no risk factors. Risk assessment should occur regularly until 2 years of age, then annually. Test those are high risk (family member with TB or positive TB test, born in high-risk country, traveled to high-risk country, consumed unpasteurized milk or cheese).

Question 43

True or false: Screening children for renal disease with a urinalysis is not recommended.

Answer 43

True. However, you should screen for congenital/anatomic abnormalities (e.g. vesicoureteral reflux) after a UTI in children 2 months to 2 years of age by getting an ultrasound and either voiding cystourethrogram or radionuclide cystogram.

Question 44

True or false: Sexually active teenaged girls need screening for chlamydial infection and gonorrhea.

Answer 44

True.

Question 45

When should you recommend that a child see a dentist for the first time?

Answer 45

Around 2 to 3 years of age.

Question 46

What are the Tanner stages? When do they occur?

Answer 46

Measure the stages of puberty. Stage 1 is preadolescent, stage 5 is adult. Average age of puberty is 10.5 years in girls and 11.5 years in boys. The classic first events of puberty are testicular enlargement in boys and breast development in girls.

Question 47

Define delayed puberty. What is the most common cause?

Answer 47

Defined by lack of testicular enlargement in boys by age 14 years or a lack of breast development or pubic hair in girls by age 12 years. The most common cause is constitutional delay, a normal variant. Watch for parents with a similar history of being “late bloomers.” The children’s growth curve consistently lags behind that of peers, but is parallel to the normal growth curve. Treatment is reassurance only.

Question 48

What are other causes of delayed puberty?

Answer 48

Rarely, may be due to primary testicular failure (Klinefelter syndrome, cryptorchidism, history of chemotherapy, gonadal dysgenesis) or ovarian failure (Turner syndrome, gonadal dysgenesis). Even more rarely, is it due to a hypothalamic/pituitary defect (Kallman syndrome or tumor).

Question 49

What causes precocious puberty?

Answer 49

Usually idiopathic but may be due to McCune-Albright syndrome (in girls), ovarian tumors (granulosa, theca-cell, or gonadoblastoma), testicular tumors (Leydig-cell tumors), CNS disease or trauma, adrenal neoplasm, or congenital adgrenal hyperplasia (causes precocious puberty only in boys usually 2/2 21-hydroxylase deficiency).

Question 50

True or false: If the underlying cause for precocious puberty is uncorrectable or idiopathic after diagnostic work-up, patients should receive treatment.

Answer 50

True. Most patients are given long-acting gonadotropin-releasing hormone agonists to suppress the progression of puberty. This helps prevent premature epiphyseal closure with short statue.

Question 51

How are cavernous hemangiomas treated?

Answer 51

Benign vascular tumors often first noticed a few days after birth. They tend to increase in size after birth and gradually resolve within the first 2 years of life. The best treatment is to do nothing but observe and follow.

Question 52

Distinguish between caput succedaneum and cephalohematoma. How are these conditions treated?

Answer 52

Both are noted in newborns after vaginal delivery. Caput succedaneum defines diffuse swelling or edema of the scalp that crosses the midline, is benign, and requires no further investigation or treatment. Cephalohematomas are subperiosteal hemorrhages that are sharply limited by suture and do not cross the midline. They are usually benign and self-resolving, but in rare cases may indicate an underlying skull fracture. Order a radiograph or CT to rule out fracture.

Question 53

When does the anterior fontanelle usually close? What disorder should you suspect if it fails to close?

Answer 53

Usually is closed by 18 months of age. Delayed closure or an unusually large anterior fontanelle may indicate hypothyroidism, hydrocephalus, rickets, or intrauterine growth retardation.

Question 54

How many vessels does a normal umbilical cord have? What disorder should you suspect if one of the vessels is absent?

Answer 54

Three normal vessels: two arteries and one vein. If only one artery is present, consider the possibility of congenital renal malformations.

Question 55

True or false: Milky-white and possibly blood-tinged vaginal discharge is usually abnormal in the first week of life for a female newborn.

Answer 55

False. This discharge is usually physiologic and due to maternal hormone withdrawal.

Question 56

What findings should make you suspect child abuse?

Answer 56

Failure to thrive, multiple fractures/bruises/injuries in different stages of healing, metaphyseal “bucket handle” or “corner” fractures, shaken baby syndrome (retinal hemorrhages or subdural hematomas with no external signs of trauma), behavioral/emotional/interactional problems, sexually transmitted diseases, multiple personality disorder (classically due to sexual abuse), whenever a parent’s story does not fit the child’s injury

Question 57

True or false: You do not need proof to report child abuse.

Answer 57

True. In fact, reporting any suspicious of child abuse is mandatory. You do not need proof and cannot be sued for reporting your suspicion.

Question 58

True or false: Children have the same range of normal vital signs as adults.

Answer 58

False. Children have lower BP and higher HR and RR than adults.

Question 59

What is an APGAR score? When is it measured?

Answer 59

General measure of well-being in newborns. Commonly assessed at 1 and 5 minutes after birth if values are normal. If the score is 100), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing).

Question 60

True or false: The APGAR score is important because it is the first assessment of how a child is doing.

Answer 60

False. Do not wait until the 1-minute mark to evaluate the infant. You may have to suction or intubate the infant seconds after delivery.

Question 61

What should you always remember when a question mentions that a child was given aspirin?

Answer 61

Reye syndrome, which causes encephalopathy and/or liver failure. It usually occurs after aspirin is given for influenza or varicella infection. Use acetaminophen in children to avoid this rare condition.

Question 62

When should the Moro and palmar grasp reflex disappear?

Answer 62

By 6 months of age.