Chapter 29

Pediatrics

1 Give the average ages at which the following commonly tested milestones are achieved

MILESTONE	AGE∗
Social smile	1-2 mo
Cooing	2-4 mo
While prone, lifts head up 90°	3-4 mo
Rolls front to back	4-5 mo
Voluntary grasp (no release)	5 mo
Stranger anxiety	6-9 mo
Sits with no support	7 mo
Pulls to stand	9 mo
Waves “bye-bye’”	10 mo
Voluntary grasp with voluntary release	10 mo
Plays pat-a-cake	9-10 mo
First words	9-12 mo
Imitates others’ sounds	9-12 mo
Separation anxiety	12-15 mo
Walks without help	13 mo
Can build tower of 2 cubes	13-15 mo
Understands 1-step commands (no gesture)	15 mo
Good use of cup and spoon	15-18 mo
Can build tower of 6 cubes	2 yr
Runs well	2 yr
Ties shoelaces	5 yr

^∗Reduce the age of premature infants in the first 2 years for assessing development. For example, for children born after 6 months of gestation, subtract 3 months from their chronologic age. Therefore, they should be expected to perform only at the 6-month-old level when they are 9 months old.

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

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.

3 What screening and preventive care measures should be done at every pediatric visit?

Height, weight, blood pressure, developmental/behavioral assessment, and anticipatory guidance (counseling/discussion about age-appropriate concerns) should be done at every pediatric visit.

4 True or false: Screening and preventive care are important mainly during a well checkup

False. Screening and preventive care are an important part of every encounter with a patient (adult or child). USMLE questions may try to fool you on this point. For example, a mother complains that her 4-year-old child sleeps 11 hours every night. This is normal behavior. The answer to the question, “What should you do next?” may be to give an objective hearing examination, which is a routine screening procedure in a 4-year-old child.

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

States vary widely in their policies regarding newborn screening. All states screen for hypothyroidism and phenylketonuria at birth; screens must be done within the first month of life. Most states screen for galactosemia and hemoglobinopathies such as sickle cell disease. Some states include screening for homocystinuria, maple syrup urine disease, congenital adrenal hyperplasia, cystic fibrosis, biotinidase deficiency, tyrosinemia, and toxoplasmosis. If any of these screens are positive, the first step is to order a confirmatory test to make sure that the screening test gave a true-positive result.

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

Tell parents the following:

 Keep the water heater under 110°F to 120°F.

 Use proper car restraints (e.g., child safety seat, booster seat).

 Put the infant to sleep on his or her side or back to help prevent sudden infant death syndrome (SIDS), the most common cause of death in children aged 1 to 12 months.

 Do not use infant walkers because they cause injuries.

 Watch out for small objects, which may be aspirated.

 Do not give honey before 1 year of age.

 Do not give cow’s milk before 1 year of age.

 Introduce solid foods gradually, starting at 6 months of age.

 Supervise children in bathtubs and swimming pools.

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

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

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

The pattern of growth along plotted growth curves over time (which you may be asked to interpret) tells you more than any single measurement. If a child has always been low or high compared with peers, generally the pattern is benign. A patient who goes from a normal to an abnormal curve is much more worrisome. Parents commonly bring in a child with delayed physical growth or delayed puberty. You need to know when to reassure and when to do further testing and questioning.

9 Define failure to thrive. What causes it?

There is no consensus definition for failure to thrive, but commonly used definitions include a head circumference, height, or weight less than the fifth percentile for age; a weight less than 80% of ideal weight for age; or a weight gain that causes a decrease in two or more major percentage lines on the growth curve. Failure to thrive is most commonly a result of psychosocial or functional problems. Watch for signs of neglect and child abuse. Organic causes usually have specific clues to trigger your suspicion.

10 What conditions are suggested by obesity in children?

Obesity usually is caused by overeating and too little activity (>95% of cases). Less than 5% of cases are a result of organic causes (e.g., Cushing syndrome, Prader-Willi syndrome).

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

Increased head circumference may mean hydrocephalus or tumor, whereas decreased head circumference may mean microcephaly (e.g., from congenital TORCH infection). Again, the pattern of head circumference over time (plotted on a growth curve) is most helpful in defining pathology.

12 How are hearing and vision screened?

Hearing and vision should be measured objectively at least once by 4 years of age. After the initial screen, measure every few years until adulthood or more often if the history so dictates.

13 In what situations should you worry about hearing loss?

 After a bout of meningitis (hearing loss is the most common neurologic complication)

 With congenital toxoplasmosis, other (e.g., syphilis, HIV), rubella, cytomegalovirus, herpes simplex (TORCH) 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)

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