Pediatrics

A pediatric resident is preparing for a developmental assessment clinic. The attending physician asks the resident to review the expected chronological progression of fine motor and adaptive skills in healthy children. Arrange the following developmental milestones in the correct chronological order from earliest to latest typical age of acquisition.

A 12-month-old girl is brought to the clinic for a routine well-child visit. She was diagnosed with acute lymphoblastic leukemia three months ago and is currently receiving induction chemotherapy. The parents are concerned about her development because she cannot run yet. Her mother reports that the child stands independently, takes a few steps on her own, uses a neat pincer grasp, specifically calls her parents "mama" and "dada", and waves goodbye. The parents ask which vaccines she is allowed to receive today. Which of the following is the most appropriate recommendation for this patient?

A male infant, born at 26 weeks gestation, is currently 8 weeks old (chronological age) and remains hospitalized in the neonatal intensive care unit (NICU). He has a history of respiratory distress syndrome and is currently receiving supplemental oxygen via high-flow nasal cannula for bronchopulmonary dysplasia. His weight today is 2.2 kg (4.8 lb), appropriately increased from a birth weight of 850 g. The mother's prenatal screening was negative for hepatitis B surface antigen. The infant received his first dose of the hepatitis B vaccine at 30 days of life. He is clinically stable, afebrile, and feeding well via a nasogastric tube. The medical team is planning his routine immunizations for his 8-week chronological milestone. Which of the following is the most appropriate immunization strategy for this patient today?

A mother brings her 12-month-old daughter to the pediatrician for a scheduled health maintenance visit. The child has had a mild runny nose and an occasional cough for the past two days. Her temperature in the office is 37.9°C (100.2°F), pulse is 120/min, and respirations are 28/min. Physical examination reveals clear rhinorrhea and a slightly erythematous posterior pharynx. The lungs are clear to auscultation, and the heart rate is regular. When asked about development, the mother reports that the child pulls to a stand and cruises along furniture but is not yet walking independently. The child says 'mama' and 'dada' specifically to her parents and points to objects she wants. The child's 6-year-old brother was recently diagnosed with acute lymphoblastic leukemia and is currently receiving induction chemotherapy. Which of the following is the most appropriate next step in the management of this patient?

Match each pediatric patient's medical history or underlying condition with the specific vaccine that is absolutely contraindicated for them.

A 24-month-old boy is brought to the clinic for a routine well-child visit. His mother is concerned that his development is lagging behind his older sister's development at the same age. She notes that the patient walks up and down the stairs by placing both feet on each step before moving to the next. He enjoys kicking a ball but cannot yet pedal a tricycle. When playing with blocks, he successfully builds a tower of 6 cubes. His vocabulary consists of approximately 60 words, and he frequently uses 2-word phrases such as "want milk." His mother reports that strangers can understand about half of what he says. During a playdate, he plays next to other children but does not engage in cooperative play with them. He is not yet toilet trained. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A young boy recently adopted from an international orphanage is brought to the clinic for a comprehensive initial evaluation. The adoptive parents do not possess his birth certificate, but the adoption agency estimated his age to be "around 2 years old." The parents are anxious to know if his development is appropriate for his estimated age.

During the assessment, the physician observes the child exploring the exam room. He runs stiffly and falls occasionally. He is able to walk up the clinic's step-stool when holding the physician's hand. When given wooden blocks, he successfully builds a tower of exactly 4 cubes before it topples. He is also given a crayon and spontaneously scribbles on the exam paper. His parents report that he uses a spoon to feed himself, though he often spills.

Based on the child's demonstrated motor and adaptive skills, which of the following communication or social milestones is most consistent with his current developmental age?

A 4-year-old girl is brought to the clinic by her father for a scheduled well-child visit. She was born at 32 weeks gestation following an uncomplicated pregnancy. The father expresses several concerns regarding his daughter's development and physical findings. He notes that she frequently repeats syllables when she is excited to tell a story. He is also worried because she firmly believes a "monster" lives in her closet and refuses to sleep without a nightlight. Additionally, he reports she is unable to tie her own shoelaces.

During the examination room observation, the girl is seen hopping on one foot and playing a turn-taking board game with her father. When handed paper and crayons, she successfully copies a cross and draws a person with three body parts, but she is unable to copy a triangle.

Physical examination reveals a temperature of 37.1°C (98.8°F), heart rate of 102/min, and blood pressure of 90/55 mm Hg. When she stands with her legs straight and knees gently touching, the distance between her medial malleoli is measured at 5 cm (2 in). Cardiac auscultation reveals a grade 2/6, low-pitched, vibratory systolic ejection murmur at the left lower sternal border that becomes significantly softer when the patient transitions from a supine to a standing position.

Which of the following is the most appropriate next step in the management of this patient?

A 24-month-old boy is brought to the clinic by his parents for a routine well-child visit. His parents express concern regarding his development. They report that he frequently refuses to share toys with his older sister and prefers to play alongside her rather than together. Furthermore, they are worried because he cannot pedal the tricycle he received for his second birthday. On physical examination, the child runs well and walks up and down the examination room steps by placing both feet on each step. He is able to kick a ball forward. During the visit, he stacks 6 wooden blocks to build a tower. His vocabulary consists of approximately 50 words, and he uses 2-word phrases. His speech is roughly 50% intelligible to the physician. Which of the following is the most appropriate next step in management?

A mother brings her 12-month-old boy to the clinic for a routine well-child visit. He was born at 28 weeks of gestation via emergency cesarean delivery due to severe maternal preeclampsia. He spent 6 weeks in the neonatal intensive care unit primarily for respiratory distress syndrome but was discharged on room air and has since done well. Today, the mother expresses deep concern regarding his neurodevelopment. She notes that her older daughter was walking independently and saying specific words like 'dog' and 'milk' by her first birthday. In contrast, her son currently only pulls himself up to a standing position while holding onto furniture and babbles 'mamama' and 'bababa' without directing it at anyone specifically. On physical examination, the infant sits steadily without support and transitions smoothly from lying down to a seated position. He transfers a wooden block from one hand to the other and picks up a small piece of cereal using his thumb along with his index and middle fingers. When the physician covers a small toy with a towel, the infant immediately pulls the towel away to retrieve it. Muscle tone and deep tendon reflexes are normal throughout. Which of the following is the most appropriate next step in the management of this patient?

Match the following developmental milestone clusters with the age at which a typically developing child is expected to achieve them.

A 15-month-old girl is brought to the clinic for a routine well-child visit. She was born at 28 weeks gestation due to severe maternal preeclampsia. She spent two months in the neonatal intensive care unit primarily for respiratory support and feeding optimization, but was discharged without major complications. Her parents are anxious about her development, noting that her 15-month-old cousin is already walking independently and speaking several words.

On examination, the patient is alert and interactive. She can pull herself to a stand and cruises along the examination table, but she does not take independent steps. She uses a neat pincer grasp to pick up a small cereal piece. She says "mama" and "dada" specifically to her parents and points to a toy stethoscope she wants. She readily plays peek-a-boo with the physician. Neurologic examination reveals normal muscle tone, 2+ symmetric deep tendon reflexes, and no cranial nerve deficits. Growth parameters (adjusted for prematurity) are tracking along the 50th percentiles.

Which of the following is the most appropriate next step in management?

A 15-month-old boy is brought to the clinic for a routine well-child evaluation. His parents are anxious because his growth percentiles have 'dropped' over the past several months, and they are concerned he may have a developmental delay because he is not yet running or climbing stairs. The boy was born at 39 weeks gestation following an uncomplicated pregnancy. His birth weight was 3.9 kg (85th percentile) and length was 52 cm (90th percentile). His mother's height is 152 cm (5 ft 0 in) and his father's height is 163 cm (5 ft 4 in). Review of the boy's growth chart shows that he tracked along the 85th percentile for both weight and length until 4 months of age. Since 6 months of age, his weight and length have gradually crossed percentiles downward concurrently. Today, his weight is 9.5 kg (25th percentile) and length is 76 cm (25th percentile). His head circumference has consistently tracked along the 50th percentile since birth. His diet consists of a variety of table foods, 16 oz of whole milk daily, and water. He has 1 to 2 soft bowel movements daily. On developmental assessment, he walks independently, uses a neat pincer grasp, drinks from a cup, and stacks 2 blocks. He says 'mama' and 'dada' specifically, uses 3 additional words consistently, and points to objects he wants. Physical examination shows a healthy-appearing boy with normal muscle tone. Which of the following is the most appropriate next step in management?

A 4-year-old boy is brought to the clinic for a well-child visit. Three months ago, he was diagnosed with minimal change disease. He experienced a relapse one month ago and has been taking oral prednisone at a dose of $2 \text{ mg/kg/day}$ for the past four weeks. His blood pressure is normal, and a physical examination shows resolving periorbital edema. The parents note he is due for his routine pre-kindergarten vaccinations and ask if they can be administered today. Which of the following vaccines must be withheld from this patient at this visit?

A 12-month-old male infant presents to the primary care office for a wellness evaluation. His parents report that he is generally healthy and they have no acute concerns. The patient was born at 40 weeks gestation via an uncomplicated vaginal delivery. Developmentally, he can sit without support, pull himself to a standing position, and cruise along furniture. He says "mama" and "dada" specifically to his parents and can successfully wave "bye-bye." While observing the patient playing on the examination table, the physician notes that he consistently uses a mature pincer grasp with his right hand to pick up small objects. His left hand remains largely clenched in a fist resting on his leg. Furthermore, when a toy is placed on his left side, he crosses his midline with his right hand to retrieve it. His height, weight, and head circumference are tracking consistently at the 60th percentile. Which of the following is the most appropriate next step in management?

Match each pediatric patient's clinical presentation with the most accurate developmental assessment or underlying etiology.

A pediatrician is analyzing the growth charts and skeletal maturation data of several patients. Match each described clinical growth trajectory with its most likely underlying etiology.

During a health maintenance evaluation, a physician sees a 12-month-old infant who was recently diagnosed with profound T-cell lymphopenia secondary to complete DiGeorge syndrome. The patient's parents report that he has not received any immunizations since his 6-month checkup. They are requesting that he receive all age-appropriate vaccines today to protect him from circulating illnesses. Given the patient's underlying genetic condition and immunologic status, which of the following preparations is strictly contraindicated?

A mother brings her 15-month-old son to the pediatric office for a scheduled health maintenance visit. She expresses concern regarding his speech, noting he only uses four distinct words regularly. Observations in the clinic show the child walking independently, stacking three blocks, and pointing to objects he desires. He follows a simple command to 'give me the ball'. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$) and physical examination is entirely normal. He had a mild viral rhinitis one week ago, but his symptoms have fully resolved. The mother asks about the appropriateness of giving him his scheduled immunizations today given his recent cold and speech development. Which of the following is the most appropriate action?

A $6$-month-old boy is brought to the pediatric clinic by his parents for evaluation of chronic noisy breathing. The parents report the noise started around $2$ months of age and has progressively worsened. It is described as a harsh, high-pitched sound heard during both inspiration and expiration. The parents also report that he frequently regurgitates his formula and has been resisting the recent introduction of pureed solid foods, often coughing when swallowing. They note that the infant's breathing seems to improve when he sleeps with his neck hyper-extended. He is at the $15$ th percentile for weight and $50$ th percentile for length. Vital signs are within normal limits for age. Physical examination reveals a prominent biphasic stridor that does not improve with the administration of nebulized racemic epinephrine. Which of the following is the most likely underlying mechanism of this patient's condition?