Practice Test Flashcards
Which condition uses the rule of 3’s: More than 3 hours, more than 3 days a week, for more than 3 months?
Colic
What is the criteria for a child to have enuresis?
Child over 5- 2x a week for 3 months
Most common cause of encopresis?
Constipation (90%)
What is the definition of failure to thrive (FTT)?
Weight less than 5th percentile on multiple occasions or weight deceleration that crosses two major percentile lines.
Most common primary nephrotic syndrome and between what ages does it occur?
Minimal Change Nephrotic Syndrome (Ages 1-8)
Test of choice for voiding dysfunctions ?
Voiding Cystourethrogram
What specific gravity is required for a 1+ protein on dipstick to be considered proteinuria and what if it is higher than that?
A. Less than or equal to 1.015
B. Needs to be 2+ if higher
What conditions should imaging be done for a child with a UTI?
A. Kids with 1st UTI before age 5
B. Febrile UTI
C. Recurring UTI
D. Male with UTI
What is heme-positive urine caused by and what do each of these indicate?
A. Hemoglobin – Hemolytic anemia
B. Myoglobinuria – Skeletal muscle injury
A child comes in with his foreskin trapped behind the glans penis, what is this condition and how is it treated?
Paraphimosis – Emergent circumcision
Which pediatric orthopedic condition is more common in females?
Developmental Dysplasia of the Hip
What tests would you perform on a child with idiopathic osteonecrosis of the femoral head and what sign is seen on x-ray?
A. Barlow’s test – Dislocation test
B. Ortolani test – Relocation test
C. Crescent sign
What is the most common cause of sudden hip pain and limp in children ?
Transient Synovitis of the Hip
What condition would you expect to see in an overweight child who is having a painful limp and how common is this
A. Slipped Capital Femoral Epiphysis (SCFE)
B. Most common adolescent hip disorder
What is the most common cause of “toeing in” ?
Internal tibial torsion
What is the most common type of salter-Harris fracture?
Type II – 75%
What condition is known as the 100 day cough and requires treatment of everyone in the family?
Pertussis
A child comes in to urgent care with a barking cough, what would you expect to see on x-ray?
Steeple sign
What is a medical condition has fallen in incidence due to HiB vaccination and what would you see on x-ray
A. Epiglottitis
B. Thumb sign
A patient has fatty white stools and recurrent respiratory infections. What test would you order to confirm your diagnosis and what disease are you testing for?
A. Sweat chloride test
B. Cystic Fibrosis
What medication could be good to try in a child who has asthma and why?
Trial of PPI’s since Asthma and GERD are commonly connected
What types of foreign bodies in the nose are you very concerned with and why?
A. Batteries
B. Magnets
C. Septal perforation
When would you see a ground glass appearance on CXR in an infant and what are they lacking?
A. Hyaline Membrane Disease
B. Surfactant
What is the most common craniofacial anomaly?
Cleft lift and palate
What is an esophageal atresia and tracheoesophageal fistula?
A. Connection of the esophagus to the trachea and a false pouch instead of an esophagus
An infant comes in who projectile vomits after being fed but is continuously hungry, what would you expect to find on an upper GI series and on physical exam?
A. String sign
B. Olive shaped mass in RUQ
Abdominal x-ray shows a “double bubble sign”. What is causing this sign?
Ladd bands have caused a volvulus which is showing air in the duodenum and stomach only
What condition would present with currant jelly stool and a bulls eye or target sign?
Intussusception
What disease involves an absence of ganglion cells in the distal rectum and colon and what sign would be present on DRE?
A. Hirschsprungs Disease
B. Squirt Sign
What type of hernia is most common in children and which type is most dangerous?
A. Umbilical
B. Diaphragmatic
A child presents after a possible untreated ear infection. When you look at him you immediately notice that one of his ears is “sticking out”. What condition do you immediately need to consider?
Mastoiditis
What physical finding would you expect to see in a child with Erythemia infectiosum?
Slapped cheek appearance
A child presents to your office with a 4 day history of high fever that finally stopped last night. The child now has a rash. What do you think is going on with them?
Roseola
What condition can cause a potential life threatening formation of a pseudo membrane in the posteriod pharynx?
Diphtheria
What is the most common congenital heart disease?
Ventricular Septal Defect (VSD)
What physical finding would you expect upon auscultation of a patient with an atrial septal defect?
Widely split S1/S2 through inspiration and expiration
What condition would you expect to find a continuous “machinery murmur” and how is it treated?
A. Patent ductus arteriosus
B. Indomethacin
What condition would you expect to find a difference of more than 10mmHg between the upper and lower extremities?
Coarctation of aorta
What disease is treated with high dose aspirin and puts a child at risk for coronary artery aneurysm?
Kawasaki Disease
What is the most common nutritional deficiency in children?
Iron deficiency
What is the most common malignancy in children?
Leukemia – 33%
What is the most common abdominal tumor in children?
Wilms tumor
What type of juvenile rheumatoid arthritis involves a quotidian fever pattern with a rash?
Systemic
What condition involving a deletion in chromosome 22 causes low PTH and Ca levels?
DiGeorge Syndrome
What disorder involves a female phenotype with an XY genotype?
Androgen Insensitivity
What is a cephalohematoma?
Blood between the periosteum and the bone due to difficult labor or delivery with suction or forceps.
What condition is caused by a brachial plexus injury at birth?
Erb Palsy
Why is it dangerous for cat ladies to become pregnant?
Toxoplasmosis Gondii
What are the three components of atopy?
A. Asthma
B. Allergic Rhinitis
C. Atopic Dematitis
What is the most common allergic disorder and what are some physical exam findings you would see?
A. Allergic rhinoconjunctivitis
B. Allergic shiners
C. Transverse nasal crease
D. Cobblestoning of the posterior pharynx
What are the most common causes of anaphylaxis in children, adults, and elderly?
A. Children – Food
B. Adults – Venom
C. Elderly – Medication
What immunologic disease requires daily prophylactic antibiotic and antifungal agents?
Chronic granulomatous disease
What is the most common neurologic disorder of infants and young children?
Febrile seizures
What is considered abnormal head size?
2 standard deviations above or below normal
What is the most common cause of hypertension in children (according to the lecture) ?
Vesicoureteral Reflux
What is the age is considered pediatrics?
newborn to 21
What is recommended frequency of well visits?
1-2 weeks, then
2, 4, 6, 9, 12, 15, 18 and 24, then annually
How do you check growth development?
Physical Exam
Growth Charts
Milestones
What is the overall goal of pediatrics?
Disease Prevention and health promotion
What factors affect development?
Physical, Cognitive, Social, Environmental, and Diseases
What components of a history is important?
Maternal health
Gestational age at bar
Apgar, Hospital course
Meds and allergies
Immunizations
Family history
Social history
When do you start checking BP in kids?
3 and check annually
When does a child triple its birth weight?
within a year
When does a child achieve two-thirds of brain size?
by 2 1/2- 3 years
How does the WHO chart kids up to 36 months of age?
Length for age
Weight for age
Head circumference for age
Weight for length
How does the CDC chart kids from 2 to 20 years?
Stature for age
Weight for age
BMI for age
Weight for Stature (2 to 5 yrs)
What is Hypertension in children?
Systolic or Diastolic BP equal to or above the 95th percentile measured on 3 occasions.
Newborn HR and RR?
HR: 120-160
RR: 40-60
T: 36.5- 37.5 rectally
6 Months HR and RR?
HR: 110-160
RR: 24-38
1 year HR and RR?
HR: 90-150
RR: 22-30
3 year HR and RR?
HR: 80-125
RR: 22-20
What O2 sat is dangerous?
less than 93%
What is considered a temperature?
> 100.5
What are considered vital signs?
ht, wt, head circumference, BMI, BP
What are the common diagnoses detected on WCC?
Failure to thrive
Sensory Deficits (no tracking, no no loud stimuli)
Congenital Heart Defects
Fetal Alcohol Syndrome
Cerebral Palsy
Musculoskeletal disorders
What are the components of a newborn PE?
Complete PE
Circumcision
Screen for Congenital heart disease w/ pulse ox after 24 hr and before discharge
What do you want to review with parents in terms of a newborn schedule?
feeding
sleeping
diapering
bathing
What should you be checking on the 1st week visit?
Monitor weight- Should regain or exceed birth weight by 2 weeks
Postpartum Depression
How long should you exclusively breastfeed according to the AAP?
6 months
then add complementary food
What important milestones would you expect from a 2 month old?
Turning head to sounds
Eyes able to follow people
What important milestones would you expect from a 4 month old?
Holds head up unsupported
Recognizes people
What important milestones would you expect from a 6 month old?
Responds to name
Crawls
Pass between hands
What important milestones would you expect from a 9 month old?
Stands while holding on
Understands “no”
Plays peek-a-boo
What important milestones would you expect from a 12 month old?
Says mama and dada
Grazing
Takes a few steps without holding on
Can switch from breastfeeding to whole milk
What important milestones would you expect from an 18 month old?
Uses single words
Walks alone
Helps dress themselves
What important milestones would expect from a 3 year old?
Shows affection
Rides a tricycle
Plays make believe
What important milestones would you expect from a 4 year old?
Correct grammar
Hops on 1 foot
Understands counting
What important milestones would you expect from a 5 year old?
Uses future tense
uses fork, spoon and table knife
Toilets
Understands money and time
What important milestones can you expect in a 2 year old?
Can switch from whole to skim milk
Avoid choking by sitting down
Toilet readiness
When adding food at 6 months what is it best to start with?
thin consistency
What is considered baby food?
Cereal Fruits Veggies Meat Snacks
What age does a baby go through a night without being fed?
6 months
How do children 6 to 10 years of age attempt goals?
Achievement by trial and error, goal- directed
What can be difficult about adolescence (11-21 years of age)?
Puberty (girls 10 ends at 14 , guys 11 ends at 16)
Struggle for identity, independence and eventually intimacy
What scale do you use for sexual maturity?
Tanner stage
I- Preadolescence, no hair
II-Sparse pigmented, long straight along labia and base of penis with breast budding
III-Darker courser curlier, continued enlargement of boobs
IV-Adult but decreased distribution, Areola and papilla form in secondary mound
V- Adult in quantity and type and medial spread to thighs with mature female breasts
What are the priorities for the Middle childhood and adolescence visits?
School bullying, academics and sports
Mental health, self esteem, temper and independence
Nutrition and Development
Oral Health
Safety
What Screening Tests should be done 24 hours after birth?
Newborn Metabolic Screening
What screening tests should be done at 12 months?
Hematocrit or hemoglobin (risk assessment at 15 and 30 months)
Lead Screening
What screening test should be started at age 3 and checked periodically?
(BP)
Visual Acuity
When should you screen for hearing?
after birth and then at age 4
When should you do dyslipidemia screening?
once between 9-11 and again between 17-21
When do you start screening for STI’s?
HIV between 16 and 18 and if sexually active then annually
How long do you stay in rear facing car seats?
age 2 (cant sit up front til 13)
When will kids have most of their baby teeth?
age 3 should have 20 teeth
When will a kid start showing teeth?
between 4 months and 15 months
When can you expect permanent teeth?
5-7 years start and ends by age 13-14 yrs.
According to CA what is the most chronic disease in children?
Dental Caries. brush with fluoridated toothpaste
When should kids get a fluoride varnish?
6 months to 5 years and then every 3-6 months
How much screen time is recommended?
avoid before age 2 and limit 2 hours for children and teens
What is the leading cause of death in children and adolescents after 1st year of life?
Injuries
When should you be screening for depression?
ages 11 to 21 (also screen for alcohol and drug use)
What is your work up for enuresis?
H&P and UA/UC
How do you treat enuresis?
education limit liquids wake child at night bed wetting alarms desmopressin
What is encopresis?
repeated passage of stool into inappropriate places by child who is older than 4 years old
How do you work up and treat enopresis?
H&P with DRE
educate, behavioral strategies, tx constipation
When does colic usually peak?
age 2-3 months
What is a common feeding problem?
food refusal due to pain or frightening
When is a feeding problem getting severe?
failure to thrive
When do kids usually have nightmares?
ages 3-5
When does Sleep walking occur?
Ages 4-8
What happens to the body during a night terror?
Increased HR and RR, sweating, screaming and thrashing
When are temper tantrums common?
ages 1-4
How frequent do temper tantrums happen?
once a week in 50-80% of kids ages 1-4
When does the anterior fontanelle usually close?
18 months- 2 years
When does the posterior fontanelle close?
Within 1-2 days
Baby has unequal red reflexes?
Congenital cataracts maybe, punt to optho
What are the components of a cardiovascular PE?
auscultation of murmurs Skin color Assess Perfusion Assess Respiratory Effort O2 stats pre and post ductal
What are the components of the lung PE?
Auscultation
Observe for: Retractions, grunting, nasal flaring and rate
What are common Lung findings?
Transient tachypnea of the newborn Neonatal pneumonia Meconium aspiration syndrome pneumothorax Hyaline membrane disease
What are the components of the Abd exam?
palpate, ubilical cord, abd wall defects
What are normal findings on a GU exam?
Female:
Vernix and discharge may be present
Male:
Palpate testes
Check urethral meatus position
What is the rooting reflex?
brush face and face will turn to you
What is the galant reflex?
tickle side and baby will curl to that side
What are the risk factors or having a jaundice baby?
Premature Breast feeding Illness/sepsis ABO incompatibility G6PD deficiency
What is preterm considered?
less than 34 weeks
What is late preterm considered?
35-36/37 weeks
What is term considered?
37-42 weeks
What is post term considered?
> 42 weeks
What are you looking at for gestational age assessment?
Skin texture Lanugo Plantaer markings Joint mobility Eyes/ears Genitalia and breast development Tone and posture
What should your newborn screening involve?
Hearing Hyperbilirubinemia Metabolic state screen Critical Congential Heart Disease Infection Hypoglycemia (SGA/LGA, prematurity, diabetic moms, sepsis, maternal beta blocker use)
Symptoms of Sepsis?
tachycardia and tachypnea Respiratory distress Low tone Poor feeding HYpoglycemia apnea lethargy temp instability hyperbilirubinemia pallor
What procedures are parental consent NOT needed for?
Substance abuse treatment STI screening Pregnancy prevention and care Sometimes abortion Mental health care Emergency care
What is the purpose of Well checks in adolescence?
Reduce morbidity and premature mortality, both during adolescence and in later years
Major components:
Screening, Counseling to reduce risk, Providing immunizations and giving general health guidance
What are the major causes of Morbidity in adol?
Mostly psychosocial and often correlate with poverty unintended pregnancy STI's Substance abuse Smoking Dropping out of school Depression Homelessness and Physical violence
What are some common mental health red flags?
Excessive sleeping: insomnia
Loss of self esteem
Abandonment or loss of interested in favorite activities
Unexpected and dramatic declines in academic performance
Weight loss & loss of appetite
Personality shifts and changes
What are common issues that arise during puberty?
Anemia (girls, Fe)
Gynecomastia (50% boys 13)
Acne (opened and closed comodones)
Psychological changes (depression- girls, pre-frontal cortex impulse)
Gynecologic issues (anovulatory, AUB)
MSK (strains,sprains, asynchronous growth of body parts)
Myopia (growth of axial diameter of the eye)
Scoliosis
STI’s ( high risk, incrased columnar epithelial cells on exocervix)
What is the definition of delayed puberty?
Absence or incomplete development of secondary sexual characteristics by an age at which 95% of children of that sex & culture have initiated sexual maturation
How would you evaluate delayed puberty?
Look at growth velocity
Tanner stages
X-ray of L hand and wrist to check skeletal maturation
Pelvic or testicular US, brain MRI, hormone testing and karotyping
What is included in a targeted history for sports physical?
PMH- chronic disease, prior surgery, hx heat-related illness, menstraul hx
Past injuries, LOC
Cardio HX- dyspnea, chest pain, syncope, palpitations, lightheadedness
Family hx- sudden death, hypertrophic cardiomyopathy, marfan syndrome, QT syndrome, pacemaker or defibrillator
What is included in the sports physical examination?
vitals- BMI, BP, HR HEENT- visual acuity, hearing Cardiac- murmurs Lung- wheezing Abd- organomegaly MSk- 2 minute screening exam for weakness, ROM, previous injury Neuro- hx concussion Skin- contagious infx
What are the components of a 2 minute sports physical/
- stand straight, facing forward
- Move neck in all directions
- Shrug shoulders against resistance
- Hold arms out to side against resistance
- Hold arms out to side w/ elbows bent raise & lower
- Hold arms out, completely bend & straighten elbows
- Bend elbows 90 then pronate & supinate forearms
- Make a fist, clench, then spread fingers
- Squat and duck-walk for 4 steps forward
- Stand straight, facing back
- Bend forward w/ knees straight, touch toes
- Stand on heels, then on top-toes
What do you get if you have a normal sports physical?
Full clearance for participation
Clearance to participate with limitations
Exclusion from participating pending further evaluation
What is the female athlete triad?
Eating disorder
menstrual dysfunction
low bone density
What sports and complications are related to the female athlete triad?
Running, Dance, gymnastics Fractures Arrhythmias Hyopglycemia seizures resp. failure
What are the typical CBC findings in an early infection?
leukocytosis with neutrophil response
What are the typical CBC findings in a viral infection?
neutrophil response is transient followed by increased lymphocytes
What are the typical CBC findings in a bacterial infection?
Greater neutrophil counts (left shift with increased # immature cells)
When would you order a peripheral blood smear?
to detect abnormalities in form and function
confirmatory test like leukemia and sickle cell disease
Adjunct in evaluation of anemia
What information can you get from a urinalysis?
pH Specific gravity Protein Glucose Nitrite Ketone Bilirubin Blood Leukocytes
Lumbar punctures are gold standard tests for what?
meningitis or encephalitits (always get CX)
What are normal LP values?
Pressure: 70-200 mm H20
Leukocytes:
What are the LP results of bacterical meningitis?
increased pressure
leukocytes: 200-20,000 (mostly PMN’s)
Preotein: > 50
What are the LP results of viral meningitis?
Pressure: normal or slightly raised
Leukocytes: 100-1,000 (mostly lymphocytes or monocytes)
protein: normal or slightly increased
Gold standard for UTI?
urine culture with antibiotic sensitivites
What are rapid tests usually testing?
antigens
When do you use rapid tests?
for preliminary diagnosis,
Strep, Influenza, Monospot
What are serologic tests looking at?
immune response , development of antibodies like HIV,Lyme, HSV, Hep
What are molecular tests looking at?
Genetic diseases, dna sequencing via polymerase chain reaction
used to determine carrier status..Examples:
CF, Fragile X, Huntington
What hormones are you testing for?
HCG FSH TSH Prolactin LH DHEA-S Estradiol Testosterone
What can you use ultrasound on?
Abd (mass, appendicitis)
Pelvic (PCOS)
Scrotal
Ultrasound-guided imaging
When are CT’s usually used?
primary modality in acute or emergent situations
When are MRI’s used?
test of choice for CNS abnormalities, Non invasive but time consuming and sedation sometimes required
How do you work up a fever?
Febrile infants
How often do you do an APGAR test?
1 minute and 5 minute
What is the most likely cause of conjunctivitis on day 1?
Chemical Irritation
What is the most likely cause of conjunctivitis on days 2-7?
Gonorrhea
What is the most likely cause conjunctivitis past day 7?
Chlamydia
What is the most likely cause of conjunctivitis after 3 weeks?
Herpes
What drops do you give directly after birth to prevent opthalmia neonatium?
Erythromycin ointment and Silver nitrate
What screening tests do you need to do before discharge?
PKU Biotinidase Beta- thalassemia Congenital Adrenal Hyperplasia Galactosemia Hypothyriodism homocysteinuria cystic fibrosis
Who gets the Hep b vaccine?
Every baby but those whose mothers are HbsAg- positive will get HBIG
How many babies are born jaundice?
60%
Do cephalohematoma’s cross suture lines?
NO, they don’t cross suture lines
What is a common shoulder dystocia and what are the complications?
Erbs Palsy, Cant abduct shoulder, cant externally rotate shoulder or supinate arm
What is the most common hernia in babies?
umbilical hernias
What are umbilical hernias sometimes associated with?
Congenital hypothyroidism
What is commonly seen in patients with the absence of an iris?
Wilms tumor
Opening of the urethra on ventral surface?
Hypospadias
Opening of the urethra on dorsal surface?
epispadias
What is most likely happening when a kid has exercise intolerance and squats to decrease right to left shunting?
Tet Spell
What are the components of Tetralogy of fallot?
Bi-ventricular origin of the aorta
Large VSD
Obstruction to pulmonary blood flow
RVH
Holosystolic murmur heard at lower sternal border?
Ventricular Septal Defect
Most common congenital heart lesion?
VSD
Loud pulmonic S2 and xray shows increased vascular markings?
VSD
Fixed wide splitting of S2 and chest XRAY shows increased vascular markings and cardiomegaly
Atrial Septal Defect
Most common atrial septal defect?
Ositum secundum (central atrial septum)
What commonly causes dysrhytmias and paradoxical emboli DVT?
ASD
Machinery like murmur, wide pulse pressure. bounding pulses?
Patent Ductuc Arteriosus
EKG shows Left ventricular dysfunction and failure?
Patent Ductus Arteriosus
How do you close a patent ductus arteriosus?
indomethacin
Severe CHF and Resp. Distress within first few months, Differential pressure and reduced pulses with rib notchings, EKG LVH?
Coarctation of the aorta
What conditions are commonly seen with Coarctation of the aorta
turner syndrome
failure to pass meconium in first 72 hours of life?
Hirchsprung Disease
How do you confirm Hirchsprung?
Full thickness biopsy showing lack of ganglionic cells
What is commonly seen with imperforate anus?
V-vertebral anomalies A- anal atresia L- limb anomalies C- cardiovascular anomalies T- tracheoesphageal fistula E- Esophageal atresia R- Renal anomalies
Persistent, multiple air bubbles, bowel looped obstruction?
volvulus
Sudden onset, telescope on ultrasound?
intussuception
Grade 2-3 midsystolic Crescendo Decresendo murmur on upper LSD, S2 widely split through inspiration/ expiration?
ASD
Systolic thrill-suprasternal
Early systolic click upper LSB
Crescendo decresencdo upper LSB radiating towards clavicle and louder with inspriation?
Pulmonic Stenosis
chorioretinitis, hydroscephalus, and multiple ring- enhancing lesions on CT caused by Toxoplasma gondii?
toxoplasmosis
Best initial and accurate test for toxoplasmosis?
Initial IgM
Accurate PCR
Treat for toxo?
pyrimethamine and sulfadiazine
Rash on the palms and soles, snuffles, frontal bossing, hutchinson eighth nerve palsy and saddle nose
Syphilis
Best initial and accurate test for syphilis?
Initial VDRL
Accurate FTA ABS or dark field microscopy
Treat syphilis?
penicillin
Periventricular calcifications with microencephaly, chorioretinitie, hearing loss, and petechiae?
CMV
Best initial ad accurate test for CMV?
initial- urine or saliva viral titers
Most accurate is urine or saliva PCR for viral DNA
Treat CMV?
ganiciclovir with signs of end organ damage
PDA, cataracts, deafness, hepatosplenomegaly, thrombocytopenia, blueberry muffin rash, and hyperbilirubinemia
Rubella
Best initial and accurate test for rubella?
maternal IgM status. TX supportive
Week 1: shock and DIC
Week 2: Vesicular skin lesions
Week 3: encephalitits
Herpes
Best initial and most accurate test for Herpes?
Initial is tzanck smear and most accurate is PCR
Multiple highly pruritic vesicular rash that begins on face, possible fever and malaise
Varicella zoster virus
Diagnostic test for for varicella?
tzanck smear showing multinucleated giant cells and most accurate test is viral culture
The 3 C’s: cough, coryza and conjunctivitis with a koplik spot (grayish macule on buccal surface)
Rubeola or measles (parmyxovirus)
How do you diagnose rubeola or measles?
IgM antibodies
parvovirus b19?
fifth disease (erythema infectiosum)
Roseola
Herpesvirus types 6 and 7
Mumps
paramyxovirus, fever precedes classic parotid gland swelling with poissibe orchitis
When do you get MMR vaccine?
1st dose 12-15 months then 2nd atleast 28 days after (4-6 years of age)
When do you get pertussis vaccine?
DTap: 2, 4, 6, 15-18 months, 4-6 years
Accelerated 1st three doses at 6, 10, and 14 weeks; 4th dose given 6-12 months after 3rd dose; 5th dose age 4-6 years
Meningococcal vaccine
kids aged 11-12 years with a booster at age 16 ages (HIV 2 doses, 2 months apart)
Zoster Vaccine
single dose for adults 60 years of age and older
Influenza virus
approved 6 months and older, live virus for 2-49 who aren’t pregnant
HPV
4 or 2 for females
2 for males
HPV is 4 doses begins at 11 and 12
Prevnar vaccine
Routine vaccination: 4-dose series at ages 2, 4, and 6 months and at age 12-15 months
