d

0

:

Sonali Mehta Patel
Kent elson
S�e�banie Jennings
Se

·es
•

Ed.

em:

Veerai 5. Sheth
Stanley �·aslam

Robert Casa·neva

Wolters Kluwer
Health





Editors

Series Editors

Sonali Mehta Patel, MD, FAAP

Veeral Sudhakar Sheth, MD, FACS

Assistant Professor of Clinical Pediatrics
Rosalind Franklin University of Medicine
Associate Program Director
Pediatric Residency Program
Advocate Children's Hospital
Oak Lawn, Illinois

Director, Scientific Affairs
University Retina and Macula Associates
Clinical Assistant Professor
University of Illinois at Chicago
Chicago, Illinois

Stanley Zaslau, MD, MBA, FACS
Kent Nelson, MD, FAAP
Lecturer of Clinical Pediatrics
Rosalind Franklin University of Medicine
Informatics Director
Pediatric Residency Program
Advocate Children's Hospital
Oak Lawn, Illinois

Professor and Chief

Urology Residency Program Director
Department of Surgery/Division of
Urology
West Virginia University
Morgantown, West Virginia

Robert Casanova, MD
Stephanie R. Jennings, MD, FAAP

Assistant Dean of Clinical Sciences
Curriculum
Associate Professor Obstetrics and
Gynecology
Texas Tech University Health Sciences
Center
Lubbock, Texas

Associate Program Director
Pediatric Residency Program
Inpatient Director, Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois

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Library of Congress Cataloging-in-Publication Data

Shelf-life pediatrics /editors, Sonali Mehta Patel, Kent Nelson, Stephanie R. Jennings.
p.; em.

Includes index.
ISBN 97 8- 1- 4511- 8957- 5
I. Patel, Sonali Mehta, editor of compilation.

II. Nelson, Kent, editor of compilation.

III. Jennings, Stephanie R., editor of compilation.
[DNLM: 1. Pediatrics-Problems and Exercises. WS 18.2]

RJ 48.2
6 18.920007 6-dc23
2013046934
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe
generally accepted practices. However, the authors, editors, and publisher are not responsible for
errors or omissions or for any consequences from application of the information in this book and
make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy
of the contents of the publication. Application of this information in a particular situation remains
the professional responsibility of the practitioner; the clinical treatments described and recom­
mended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection
and dosage set forth in this text are in accordance with the current recommendations and practice
at the time of publication. However, in view of ongoing research, changes in government regula­
tions, and the constant flow of information relating to drug therapy and drug reactions, the reader
is urged to check the package insert for each drug for any change in indications and dosage and
for added warnings and precautions. This is particularly important when the recommended agent
is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It is the responsi­
bility of the health-care provider to ascertain the FDA status of each drug or device planned for
use in their clinical practice.

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Contributors

Caitlin J. Agrawal, MD

Heather Dyer, MD

Pediatric Hematology/Oncology Fellow
Department of Hematology/Oncology
Nationwide Children's Hospital
Columbus, Ohio

Instructor of Clinical Pediatrics
Rosalind Franklin University of
Medicine & Science
North Chicago, Illinois
Director, Pediatric Hospitalist
Program
Department of Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois

Tara Altepeter, MD
Pediatric Gastroenterology Fellow
Division of Pediatric Gastroenterology
Department of Pediatrics
Thomas Jefferson University
Philadelphia, Pennsylvania
Alfred I duPont Hospital for Children
Wilmington, Delaware


Corrie E. Fletcher, DO

Attending Pediatrician
Atlanta, Georgia

Chief Resident, Pediatric Residency
Program
Department of Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois

Harit K. Bhatt, MD

Rama D. Jager, MD, FACS

Joana Benayoun, MD

University Retina and Macula Associates
Bedford Park, Illinois
Clinical Assistant Professor
Department of Ophthalmology & Visual
Sciences
University of Illinois at Chicago
Chicago, Illinois

Diana C. Bottari, DO

University Retina and Macula Associates
Oak Forest, Illinois

Clinical Professor
Department of Ophthalmology & Visual
Sciences
University of Illinois at Chicago
Chicago, Illinois

Stephanie R. Jennings, MD, FAAP

Medical Director, Pediatric Pain and
Sedation Services
Pediatric Pain Specialist
Pediatric Sedationist
Advocate Children's Hospital
Oak Lawn, Illinois

Associate Program Director
Pediatric Residency Program
Inpatient Director, Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois

Mark M. Butterly, MD

Nicole Keller, DO

Director Pediatric Residency Program
Department of Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois


Attending Physician
Department of Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois

v


vi

Contributors

Jason Mitchell, MD

Rinku Patel, DO

Attending Physician
Division of Pediatric Cardiology
Department of Pediatric Subspecialties
Mid-Atlantic Permanente Medical
Group
Washington, D.C.

Lecturer of Clinical Pediatrics
Rosalind Franklin University of Medicine
and Science
North Chicago, Illinois
Academic Pediatric Hospitalist
Department of Pediatrics
Advocate Children's Hospital

Oak Lawn, Illinois

Kent Nelson, MD
Assistant Professor of Clinical
Pediatrics
Rosalind Franklin University of
Medicine & Science
North Chicago, Illinois
Informatics Director, Pediatric Residency
Program
Department of Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois

Sonali Mehta Patel, MD
Assistant Professor of Clinical Pediatrics
Rosalind Franklin University of Medicine
and Science
North Chicago, Illinois
Associate Director, Pediatric Residency
Program
Department of Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois

Patricia M. Notario, MD
Chief Resident, Pediatric Residency
Program
Department of Pediatrics
Advocate Children's Hospital

Oak Lawn, Illinois

Nikita Williamson, MD
Academic Pediatric Hospitalist
Department of Pediatrics
Advocate Children's Hospital
Oak Lawn, Illinois


Introduction to
the Shelf- Life Series

The Shelf-Life series is an entirely new concept. The books have been
designed from the ground up with student input. With academic faculty
helping guide the production of these books, the Shelf-Life series is meant
to help supplement the student's educational experience while on clinical
rotation as well as prepare the student for the end-of-rotation shelf-exam.
We feel you will find these question books challenging but an irreplace­
able part of the clinical rotation. With high-quality, up-to-date content and
hundreds of images and tables, this resource will be something you will
continue to refer to even after you have completed your rotation.
The series editors would like to thank Susan Rhyner for supporting
this concept from its inception. We would like to express our appreciation
to Catherine Noonan, Laura Blyton, Amanda Ingold, Ashley Fischer, Tari
Broderick and Stacey Sebring, all of whom have been integral parts of the
publishing team; their project management has been invaluable.

Veeral S. Sheth, MD, FACS
Stanley Zaslau, MD, MBA, FACS
Robert Casanova, MD


••

VII


We would like to dedicate this book to all our medical students and the
patients we serve. Without them the knowledge, guidance, and feedback to
make this book would not have been possible. We would like to specifically
thank, Dr. Savannah Ross, for her feedback as a medical student and future
pediatrician on the construct, design, and information presented within this
book. We are forever thankful to our many colleagues who helped author each
chapter and each other for endless support along the way. Lastly, we would like
to thank our families for their support and patience.

Stephanie R. Jennings, MD, FAAP
Kent Nelson, MD, FAAP
Sonali Mehta Patel, MD, FAAP

•••

VIII


Contents

1

General Pediatrics


2

Newborn

21

3

Development

39

4

Adolescent Medicine

65

5

Genetics and Metabolic Disorders

89

6

Cardiology

103


7

Pulmonology

161

a

Nephrology

207

9

Fluids and Electrolytes

233

1o

Endocrinology

249

11

Dermatology

277


12

Allergy and Immunology

299

13

Gastroenterology

329

1

•

IX


x

Contents

14

Hematology and Oncology

367

15


Rheumatology

397

16

Nutrition

411

17

Surgical Subspecialties

423

Sample Shelf-Exam

457

Figure Credits

547

Index

555



CHAPTER

A 6-month-old infant comes to clinic for her 6-month health main­
tenance visit. Her weight is at the 75th percentile and her height is at
the 90th percentile. The child sits with assistance, rolls from prone to
supine, and says ''dada:' The parents ask whether it is safe to place the
baby in a front-facing car seat due to her size.
Of the following, what is the best advice to give these parents regard­
ing car seat safety?

(A) Children should not be placed in a front-facing car seat until they
(B)
(C)
(D)
(E)

are >24 months old
Due to her size, she should be placed in a booster seat
Car safety seat should face forward until the infant is 1 year old
Car safety seat could be placed in the front seat as long as the
vehicle is equipped with passenger-side airbags
It is acceptable to use only the lap belt for restraint

The answer is A: Children should not be placed in a front-facing car
seat until they are >24 months old. Car seat safety is a very important
part of pediatric anticipatory guidance. Every infant should be secured in a
rear-facing car seat whenever riding in a moving vehicle. (C) Children aged
0 to 24 months old should use rear-facing infant-only car seats or rear-facing
convertible car seats. Children aged >24 months old can be placed in a con­
vertible or forward-facing harness car seat. (B) Children aged 4 to 1 2 years,

weighing >40 to 80 lb (18 to 36 kg), and shorter than 4' 9" ( 1 .4 m) should be
placed in a belt-positioning booster seat. (D) An infant car seat should never
be placed in a seat equipped with airbags including front passenger-side and
side-impact airbags. (E) The use of lap belts alone has been associated with a
marked rise in seatbelt- related injuries.
At what ages is it recommended to routinely administer the DTaP
(diphtheria, tetanus, and acellular pertussis) vaccine?
1


2

Shelf-Life Pediatrics

(A)
(B)
(C)
(D)
(E)

2, 4, 6, and 12 to 15 months
2, 4, 6, 15 to 18 months, and 4 to 6 years
12 months and 4 to 6 years
Birth, 2, and 6 to 18 months
2, 4, and 6 months

The answer is 8: 2, 4, 6,

15


to

18

months, and 4 to 6 years. The admin­

istration of the DTaP vaccine is routinely recommended at the following ages:
2 months, 4 months, 6 months, between 15 and 18 months, and between 4 and
6 years of age. The minimum age for administration of the first dose in this series
is 6 weeks. The minimum interval between the second and third doses is 4 weeks
and 6 months should pass between the third and fourth doses. The minimum age
for the fifth dose is 4 years.
(A) Pneumococcal vaccine (13 -valent) is recommended to be given at 2,
4, 6, and between 1 2 and 15 months. (C) The measles, mumps, and rubella and
varicella vaccines are recommended at 12 months and between 4 and 6 years
of age. (D) It is recommended to providers to give the hepatitis B vaccine prior
to the infant's leaving the hospital (birth), at 2 months, and then between 6
and 1 8 months of age. The first and the last doses of the hepatitis B vaccine
should be at least 6 months apart. (E) The rotavirus vaccine is a live oral vac­
cine commercially available in two different formulations. Both formulations
are recommended to be given at 2 and 4 months of age. One of the formula­
tions requires an additional dose at 6 months of age.
A 2-year-old girl is noticed to have dry scalp with small pinpoint lesions
on the hair shaft as shown in Figure 1 - 1 . Her mother reports that her
older son had similar lesions on his scalp and hair and that the children
share a bathroom. The appropriate prescription is given for treatment
of this disorder.
Of the following, what is the most appropriate additional advice
regarding this treatment?


Figure 1-1


Chapter 1: General Pediatrics

3

(A) Treatment should be applied only once
(B) Children cannot return to school for 2 weeks to ensure complete
resolution of symptoms
(C) Apply the permethrin 5% cream from the neck to the toe
(D) Wash all clothing and linen in very hot water
(E) Apply lindane 1% cream to scalp

The answer is D: Wash all clothing and linen in very hot water. The
child in the vignette has head lice infestation. There are three types of lice
that affect humans: head louse (Pediculosis capitis), body louse (Pediculo­
sis corporis), and pubic louse (Pediculosis pubis). Head lice can be transmit­
ted from person to person by direct casual contact. Lice can easily be spread
when children play together; share combs, headphones, towels, and bedding;
and from articles of clothing. Symptoms usually include itchy, irritated, and
dry scalp. The irritation is caused by a reaction from the lice saliva, which is
injected into the skin while they feed. Diagnosis of lice is by examination of the
scalp and hair. Whitish-gray insects are noticeable as well as eggs, or nits, that
attach to the base of the hair shaft near the scalp. In children older than 2 years,
topical, over-the-counter pediculicides can be used. The treatment of choice is
permethrin 5% given its safety and improved efficacy as compared to lindane.
(E) Lindane is not recommended because of resistance and its association with
neurotoxicity. (C) Permethrin cream should be applied to dry hair only and
left on for 12 hours. (A) A second application may be applied 7 to 9 days after

the initial application. Neck to toe application is recommended if the child in
the vignette had scabies. All household members should be treated at the same
time regardless of symptoms. Nits should be removed with a fine-toothed
comb after application of therapy. Brushes and combs should be discarded or
cleaned in boiling water and advised to not share between family members. All
clothing and bed linen should be dry cleaned or laundered in very hot water.
(B) Children with head lice may return to school after the initial treatment has
been completed.
An 18-month -old girl presents to the emergency department with
complaints of irritability, inconsolable crying, fever, chills, and flushed
skin. Her mother reports that the baby is teething and that she is giv­
ing acetaminophen and diphenhydramine every night for her fever
and to help her sleep. She denies any previous illnesses or sick contacts
but reports an older brother with attention-deficit hyperactivity disor­
der (ADHD). Her mother reports a dry diaper for the past 12 hours.
Vital signs on presentation are temperature 39.7°C, pulse 150 beats
per minute, respiratory rate 40 breaths per minute, and blood pressure
130/90 mmHg. On examination, she is inconsolable. Her skin is red
and dry and her pupils are dilated but sluggish.
Of the following, which is the most likely cause of this infant's
symptoms?


4

Shelf-Life Pediatrics

(A)
(B)
(C)

(D)

Acetaminophen overdose
Diphenhydramine overdose
Meningitis
Methylphenidate toxicity
(E) Dehydration

The answer is B: Diphenhydramine overdose. The patient in the vignette
is experiencing symptoms consistent with anticholinergic toxicity secondary to
antihistamine overdose. Classes of medications with anticholinergic properties
include antihistamines (diphenhydramine), tricyclic antidepressants (amitrip­
tyline), sleep aids (doxylamine), muscle relaxants (cyclobenzaprine), cold prepa­
rations (scopolamine), jimson weed, and belladonna alkaloids (glycopyrrolate).
Anticholinergic medications block the action of acetylcholine by competitively
binding to and blocking muscarinic receptors on the postganglionic cholinergic
nerves. As a result, each organ system experiences a parasympathetic response.
Clinical manifestations from anticholinergic toxicity include thirst, dry mucous
membranes, warm and dry skin from inhibition of secretions from the sali­
vary and sweat glands, flushed skin from dilatation of cutaneous blood vessels,
fever from the inability to sweat, mydriasis (dilated pupils) with poor pupillary
response, tachycardia, urinary retention, hypertension, decreased bowel sounds
from inhibition of gastrointestinal motility, confusion and hallucinations, sei­
zures, and coma. Tachycardia is the earliest and most reliable sign of anticho­
linergic toxicity. Treatment for anticholinergic toxicity includes supportive care,
early decontamination, and antidotal therapy with physostigmine.
(A) Acetaminophen overdose is one of the most common poisonings
worldwide. Children present with abdominal pain, diarrhea, irritability, nausea,
vomiting, sweating, jaundice, and convulsions. Acetaminophen toxicity can cause
serious liver damage requiring the need for a liver transplant. (C) In children

with high fevers and history of recent illnesses or sick contacts, organic processes
such as meningitis and sepsis should also be considered. (D) Sympathomimetic
overdose (methylphenidate) can also mimic anticholinergic overdose with the
presence of agitation, tachycardia, dilated pupils, and hyperthermia. Sweating
and increased bowel sounds are hallmarks of sympathomimetic toxicity, whereas
with anticholinergic toxicity there are decreased bowel sounds and lack of sweat.
(E) Dehydration should be considered in a patient with dry mucous membranes,
dry skin, and decreased urination; however, this is a less likely diagnosis given
the history and physical findings of the patient in the vignette.
Of the following, which is a contraindication to giving the human pap­
illomavirus (HPV) vaccine to adolescents?

(A)
(B)
(C)
(D)

Breastfeeding mothers
Positive HPV on Papanicolaou smear
Immunocompetent patient
Previous sexual exposure to genital warts
(E) Pregnant adolescents


Chapter 1: General Pediatrics

5

The answer is E: Pregnant adolescents. HPV vaccine is a quadrivalent
vaccine that protects individuals from HPV types 6, 1 1, 1 6, and 18. These types

lead to various cancers including cervical, vulvar, vaginal, anal, and penile
cancers. Immunizations are recommended for girls and boys aged 9 through
26 years old. The vaccine is administered as a three-injection series. The first and
last doses must be given at least 6 months apart and the second dose is given at
least 2 months after the initial dose. Individuals with life-threatening allergic
reactions to any component of the HPV vaccine or to a previous dose of HPV
vaccine should not receive the vaccine. (A) This vaccine is not recommended
for pregnant women; however, breastfeeding mothers are able to safely receive
it. (B, C, D) Previously positive HPV results on Papanicolaou smear, healthy
individuals (immunocompetent), and recent exposure to genital warts are not
contraindications to receiving the vaccine.
Of the following, which group of children should be identified and
referred for early dental evaluation and preventative care?

(A)
(B)
(C)
(D)

Premature infants
Children with milk protein allergy
Children who are thumb suckers
Children with passive tobacco smoke exposure
(E) Children with a family history of dental caries

The answer is D: Children with passive tobacco smoke exposure.
Because of the increased risk of development of dental caries and other oral
health problems, children with the following risk factors should be referred for
early dental evaluation, preventative care, and counseling:
e

e
e
e
•

e

•
e

Prolonged breast or bottle feeding > 12 months
Exposure to maternal and passive tobacco smoke
Frequent intake of sugary drinks and snacks
Prolonged use of a training cup ( sippy cup)
Bottle use at bedtime
Longer than 3-week use of liquid medication (teeth staining)
Insufficient fluoride exposure
Notable plaque on upper front teeth
Enamel defects
Children with special health -care needs

(A, B, C, E) The rest of the conditions should still have a formal dental evalua­
tion at 1 year, but do not require earlier evaluation.
A sophomore in high school plans to participate in a Peace Corp proj­
ect to Central Africa.
Of the following, which is the preferred chemoprophylactic therapy
for malaria prior to her travel?


6


Shelf-Life Pediatrics

(A)
(B)
(C)
(D)

Chloroquine
Atovaquone-proguanil
Primaquine phosphate
Levofloxacin
(E) No prophylaxis indicated

The answer is B: Atovaquone-proguanil. Malaria is the most important pre­
ventable life-threatening, insect-borne illness that affects international travelers.
Malaria is transmitted by the Anopheles mosquito and produces symptoms such as
high fever, shaking chills, and flu-like illness. There are four species of Plasmodium
that cause malaria: P. falciparum, P. malariae, P. ovale, and P. vivax. P. falciparum is
the predominant species in Africa and Haiti, and it is the cause of the majority of
fatalities in these regions. Although malaria can be fatal, morbidity and mortal­
ity can usually be prevented. Preventive measures include avoiding mosquito bites
and maintaining antimalarial chemoprophylaxis when traveling. The Centers for
Disease Control provides up-to-date listings of regions where malaria transmission
occurs, the regions where antimalarial drug resistance is prevalent, and chemo­
prophylaxis recommendations for each specific region. Chemoprophylaxis should
begin days to weeks prior to arrival to the endemic area depending on the recom­
mended medication. Mefloquine should be initiated at least 2 weeks before arrival;
chloroquine should be given 1 week prior; and both doxycycline and atovaquone­
proguanil should be started 1 to 2 days prior to arrival. Therapy should be taken

throughout the exposure time and continued 1 to 4 weeks after departure.
(E) The student in the vignette is traveling to Central Africa where malaria is
highly prevalent and prophylaxis is highly recommended. P. falciparum accounts
for a high majority of cases and this region has a high rate of chloroquine resis­
tance, so the listed drug of choice for prophylaxis in this student is atovaquone­
proguanil. (A) Chloroquine is not adequate therapy because of the high incidence
of resistance. (C) Primaquine is recommended for prophylaxis in areas mostly
exposed to P. vivax. Primaquine can cause hemolytic anemia in persons with glu­
cose-6-phospate dehydrogenase deficiency; thus, patients must be screened prior
to starting this medication. (D) Levofloxacin is a quinolone used to treat bacterial
infections and has no role in malarial prophylaxis or treatment.
A 4-month-old infant is seen in the clinic because her mother reports
that she is fussy and has a decreased appetite. She denies fevers. The
child has tacky mucous membranes, mild erythema in the oropharynx,
and white plaques inside her cheeks and on her hard palate.
Of the following, which is the best therapy for this condition?

(A)
(B)
(C)
(D)

Acyclovir
Viscous lidocaine
Amoxicillin
Nystatin suspension
(E) Acetaminophen


Chapter 1: General Pediatrics


7

The answer is D : Nystatin suspension. The infant in the vignette has
findings consistent with oral thrush. Oral thrush is a common infection of
the mucus membranes affecting normal newborns. Candida albicans is the
most common species found in thrush plaques. This infection is character­
ized by white, curd-like patches on the tongue, palate, and buccal mucosa.
Oral thrush may be asymptomatic or can cause pain, fussiness, and decreased
feeding leading to dehydration. Thrush is uncommon in immunocompetent
children after 1 year of age although it can occur in children treated with
antibiotics or inhaled corticosteroids without the use of a spacer. Persistent
or recurrent thrush without explanation warrants further investigation for
an underlying immunodeficiency. Oral nystatin is the first-line treatment of
choice in children with uncomplicated thrush.
(A) Acyclovir is a treatment for herpes simplex virus. (B) Viscous lido­
caine is not recommended for infants or young children due to the potential
for swallowing and systemic absorption. (C) Amoxicillin is an antibiotic used
to treat bacterial rather than fungal infections. (E) Acetaminophen is an anal­
gesic and antipyretic and is used in many conditions as supportive care but is
not the best therapy for thrush.
A previously healthy 8-year-old girl presents to the emergency depart­
ment with complaints of nausea, vomiting, severe headache, dizziness,
and lethargy. She noticed her symptoms today after traveling with her
father and brother in a car from Chicago to Florida to visit her grand­
parents. Both her father and brother complain of moderate headaches
at present. She denies fevers, chills, or nasal drainage. Of the following,
what is the best initial management for this patient?

(A)

(B)
(C)
(D)

100% oxygen via a face mask
Perform a lumbar puncture
Obtain a magnetic resonance image of the head
Administer intravenous morphine
(E) Consult neurosurgery for a possible intracranial process

The answer is A: 1 00o/o oxygen via a face mask. Carbon monoxide
(CO) is an odorless, tasteless, colorless, nonirritating gas formed by incomplete
hydrocarbon combustion. CO poisoning is responsible for many emergency
department visits and carries a significant mortality risk. CO readily diffuses
across the pulmonary capillary membrane and binds to the iron component
of the heme molecule. Once CO binds to the heme molecule, it greatly dimin­
ishes the ability of the oxygen-binding sites to release oxygen to the peripheral
tissues. CO poisoning may cause mild-to-severe symptoms, including nausea,
slight dyspnea, headaches, dizziness, rapid fatigue, hypoxemia, hallucinations,
confusion, and coma. Carboxyhemoglobin (HbCO) is not detected by pulse
oximetry; thus, the PaO2 value can be normal despite high HbCO concentra­
tions. CO poisoning is treated with 1 00% oxygen, and in severe cases, patients


8

Shelf-Life Pediatrics

may require hyperbaric oxygen therapy. Automobile exhaust contains high lev­
els of CO and exposure during long car rides with inadequate or malfunction­

ing exhaust systems is a risk factor for CO poisoning. Old or malfunctioning
home furnaces can also produce high levels of CO.
(B) The patient in the vignette is afebrile; and thus, less likely presenting
with a central nervous system infection that would indicate a lumbar puncture.
Even though this patient may eventually need further testing and therapies
including (C) magnetic resonance imaging, (D) intravenous pain control, and
(E) subspecialty consults, these steps would not be the best initial step in this
patients management.
.

)

A 5-year-old girl being treated for Kawasaki disease develops a cough,
runny nose, sore throat, muscle aches, and a temperature of 40°C. Of
the following illnesses, which is she at an increased risk of developing?

(A)
(B)
(C)
(D)

Reye syndrome
Osteomyelitis
Pneumonia
Septic arthritis
(E) Gastroenteritis

The answer is A : Reye syndrome. Patients with Kawasaki disease are treated
with aspirin. The symptoms of the patient in the vignette are consistent with a viral
illness, such as influenza. Reye syndrome is a rare but severe illness affecting chil­

dren who use aspirin during a viral infection. The greatest risk is associated with
influenza or varicella. The hallmark of this illness involves acute encephalopathy
and fatty degeneration of the liver due to mitochondrial dysfunction. Patients
with Reye syndrome present with vomiting and mental status changes. There is
no definitive diagnostic testing; however, abnormal labs may include elevated liver
enzymes, elevated ammonia, and low serum glucose levels. Treatment for Reye
syndrome is supportive care. (B, C, D, E) Patients with Kawasaki disease are not
at increased risk for osteomyelitis, pneumonia, septic arthritis, or gastroenteritis.
The back to sleep campaign has reduced the incidence of SIDS (sudden
infant death syndrome) greatly. Of the following, which other preventa­
tive measure is important in reducing the incidence of SIDS?

(A)
(B)
(C)
(D)

Use of bumper pads in cribs
Cessation of maternal and secondhand cigarette smoking
Cosleeping with parents
Swaddling the infant
(E) Placing the infant on a propped pillow to avoid aspiration

The answer is B : Cessation of maternal and secondhand cigarette
smoking. SIDS is the leading cause of infant mortality between 1 month and
1 year of age. A vast majority of SIDS cases are associated with one or more


Chapter 1: General Pediatrics


9

risk factors. Numerous risk factors for SIDS have been identified including
young maternal age, maternal smoking during pregnancy, late or no prenatal
care, preterm birth, low birth weight, prone sleeping position, (A, E) sleeping
on a soft surface and/or with bedding accessories such as loose blankets and
pillows, (C) bed sharing (co sleeping), and (D) overheating. Maternal smok­
ing is a very important risk factor for SIDS. The rate of SIDS increases with
the amount of smoke to which an infant is exposed. The strongest risk is from
mothers who smoke during pregnancy; however, exposure to secondhand
smoke is an additional independent risk factor for SIDS.
A 4-day-old, full-term newborn comes to clinic for her first newborn
visit. During the examination, a small mobile mass is noted under the
left breast with white drainage (see Figure 1 -2). There is no redness or
tenderness. The rest of her physical examination is unremarkable.
Of the following, what is the most appropriate next step in the diag­
nosis or treatment of this infant's breast mass?

Figure 1-2

(A)
(B)
(C)
(D)

Ultrasound of the breast
Fine-needle aspiration of the breast mass
Reassurance given to the parents
Antibiotic therapy
(E) Excisional biopsy


The answer is C: Reassurance given to the parents. Breast enlarge­
ment in the newborn period is quite common and is called neonatal breast
hypertrophy. This results from circulating maternal endogenous steroid


10

Shelf-Life Pediatrics

hormones in the late gestational period. This condition is usually benign
and no further management is necessary. (A) Ultrasound, (B) biopsies, and
(D) antibiotics are not necessary for the resolution of this condition. On
occasion, breast hypertrophy may be associated with mastitis, or inflam­
mation of the breast tissue, which could be caused by staphylococcal or
streptococcal infections. Mastitis is often accompanied by overlying skin
inflammation with or without purulent discharge and is an indication for
antibiotic administration. (E) Excision of the mass is contraindicated and
results in abnormal development of the breast during adolescence.
Lactoferrin is a protein found in milk that assists with iron absorption.
Of the following, which type of milk has the highest concentration of
lactoferrin?

(A)
(B)
(C)
(D)

Cow milk
Goat milk

Soy milk
Human breast milk
(E) Human colostrum

The answer is E: Human colostrum. Human milk is recommended as the
primary food source for feeding infants in the first 6 months of life with the
addition of solids from 6 months to 1 2 months. Lactoferrin is a glycoprotein
found in high concentrations in breast milk as well as mucosal secretions and
has iron-binding properties. These properties have a bacteriostatic effect
on microorganisms and contribute to the nonspecific immune system. The
highest concentration of lactoferrin is found in human colostrum, followed
by (D) breast milk, (A) cow milk, and then (C) soymilk. (B) Goat milk is not
recommended for human infants because it contains inadequate quantities of
iron, folate, lactoferrin, and several other vitamins and nutrients.
A 1 5-year-old boy presents to his primary care physician's office 1 week
after returning from a class trip to South Africa. He complains of inter­
mittent fevers, rigors, nausea, vomiting, and fatigue. He received his
last set of immunizations upon entering high school last year. A com­
plete blood count reveals a white blood count of 4.3 X 103 cells/�L,
hemoglobin of 9.5 g/dL, hematocrit of 28%, and platelet count of
1 50 X 103 cells/�L. On examination, his sclerae are mildly icteric.
Of the following, which is his most likely diagnosis?

(A)
(B)
(C)
(D)

Hepatitis A
Yellow fever

Dengue fever
Malaria
(E) Acute lymphoblastic leukemia


Chapter 1: General Pediatrics

11

The answer is D: Malaria. Malaria should be suspected in all patients with
febrile illness after exposure to a region where malaria is endemic. Clinical
manifestations are nonspecific and may include fever, chills, malaise, fatigue,
tachycardia, tachypnea, headache, nausea, vomiting, abdominal pain, diar­
rhea, arthralgias, and myalgias. Physical findings may include mild anemia,
jaundice, and splenomegaly. The patient in the vignette traveled to an endemic
malaria location and has signs and symptoms consistent with this infection.
Like malaria, yellow fever and dengue fever are mostly found in endemic
areas and transmitted via mosquito vector. (B) The clinical manifestations of
yellow fever occur mostly in the liver and kidneys. Findings of yellow fever may
also include hemorrhagic emesis, fever, epistaxis, jaundice, anuria, stupor, shock,
and coma. (C) Dengue fever is endemic to the tropical and subtropic areas of the
world. Mild dengue fever causes high fever, rash, muscle pain, and joint pain.
The severe form of dengue fever can cause hemorrhage, shock, and death.
(A) Hepatitis A is a common infection in the United States, and because
the virus is excreted in the stool, it is easily transmitted between children in
daycare centers. Hepatitis A infection in children typically presents as an acute,
self-limiting illness associated with fever, malaise, anorexia, vomiting, jaundice,
diarrhea, and abdominal pain. Hepatitis A vaccine is recommended for chil­
dren 1 year and older in a two-dose schedule based on the particular manu­
facturer of the vaccine. This vaccine must be given at least 2 weeks prior to

foreign travel to an endemic area. (E) Leukemia is a cancer of the blood or bone
marrow and patients suffer from an abnormal production of blood cells and
can present with fever and pancytopenia; however, the history of travel to South
Africa makes malaria the most likely diagnosis for the patient in the vignette.
A 12-month-old, previously healthy girl arrives in the emergency
department with vomiting, poor appetite, lethargy, and a bulge on the
right side of her head. Her father reports that the infant was napping
on the couch and she rolled off onto a carpeted floor. Radiograph of the
skull shows a small fracture of the parietal bone. Computed tomogra­
phy ( CT) of the head as shown in Figure 1 -3 reveals a small amount of
acute bleeding in the subdural space.
Of the following, what is the most appropriate next step in the
evaluation of this patient?

(A)
(B)
(C)
(D)

Complete blood count (CBC)
CT scan of the abdomen
Radiographic skeletal survey
Lumbar puncture
(E) Reassurance that this injury will heal without the need for
intervention

The answer is C: Radiographic skeletal survey. Based on the history
and physical examination findings of the child in the vignette, there is a high



12

Shelf-Life Pediatrics

Figure 1-3
suspicion for nonaccidental head injury. Infants with nonaccidental injuries
often present with nonspecific clinical features and may not have any admit­
ted history of trauma. Shaken baby syndrome describes the development of
cranial injury by the use of blunt force trauma, shaking, or more commonly,
by a combination of forces. Violent shaking of an infant causes the brain to
move within the skull yielding bruising of the brain parenchyma and shearing
of the blood vessels often resulting in hemorrhage in the subdural and sub­
arachnoid spaces, as well as retinal hemorrhages. These findings alone or in
combination with other traumatic findings are consistent with nonaccidental
injuries. When evaluating a child for suspicion of nonaccidental head injury,
initial studies should include nonenhanced CT of the brain and a radiographic
skeletal survey. In addition to making a diagnosis, these studies may provide a
record of the level of extent and timing of the injuries.
(A) A CBC may be useful in children who present with bruising, pallor,
fatigue, and fever to discover underlying infection, bleeding disorders, anemia,
or oncologic illnesses. A CBC may be warranted in the patient in the vignette
if there is concern for continued blood loss; however, a skeletal survey is more
valuable in her evaluation. (B) Abdominal CT should be performed if the his­
tory and physical examinations suggest abdominal injury. Duodenal hema­
toma is concerning for abuse; however, the patient in the vignette does not


Chapter 1: General Pediatrics

13


have abdominal complaints. (D) Lumbar puncture should be obtained when
considering meningitis, subarachnoid hemorrhage, or any central nervous sys­
tem infections, which would be rare in a healthy, afebrile child. (E) Although
the infant's injuries in the vignette may heal without intervention, she needs to
be properly evaluated for abuse and a safe discharge plan established prior to
sending her home.
A 13-year-old boy is brought to clinic for his high school sports physi­
cal examination. He denies any significant past medical history and his
vaccines are up to date. On examination, he has a small amount of dark
curly pubic hair, testicular enlargement, and gynecomastia. He denies
any smoking, alcohol, or illicit drug use. His weight and height are at
the 50th percentile. His mother is concerned about his breast enlarge­
ment and asks what she should do.
Of the following, what is the most appropriate next step in the
management of this patient's gynecomastia?

(A)
(B)
(C)
(D)

Refer him to a pediatric surgeon for a biopsy of the mass
Refer to a pediatric endocrinologist for further evaluation
Send for a urine toxicology screen
Send for chromosome testing
(E) Reassure the mother and patient that this is a normal pubertal
finding

The answer is E: Reassure the mother and patient that this is a nor­

mal pu bertal finding. Puberty is a biological process in which a child expe­
riences the anatomic and physiologic changes that lead to adulthood. These
changes include the appearance of secondary sexual characteristics and
development of reproductive capacity. Once the onset of puberty begins, the
resulting sequence of somatic and physiologic changes gives rise to the sexual
maturity rating (SMR) or Tanner stages. The first visible sign of puberty in a
male is testicular enlargement ( SMR 2). This characteristic can begin as early
as age 9 Y2 years. This is followed by development of small, curly pubic hair and
penile lengthening ( SMR 3). Growth acceleration begins in early adolescence
and peak growth velocities are usually reached during SMR 3 to 4. Adolescent
boys typically experience peak growth velocity approximately 2 to 3 years later
than girls. Due to excess estrogenic stimulation, boys can display some degree
of breast hypertrophy, typically bilateral, during SMR 2 to 3. See Figure 1 -4.
(A) Since breast pathology is uncommon in this age group, sending for a
surgical biopsy is not the next step in evaluation. (C) Marijuana use has been
attributed to causing breast hypertrophy in adolescent boys, but if this were
suspected, obtaining a thorough social history including a HEADSS exami­
nation (Home, Education, Activity, Drugs, Social, Suicidal ideation) would be
recommended. (D) While gynecomastia in a phenotypic male could be the
presentation of androgen insensitivity and diagnosed with karyotype testing,