A full term infant with a birth weight of 3.5 kg, length of 50 cm and head circumference of 35 cm (all at 50th percentile) comes for an office appointment at two weeks of age. The baby is being fed infant formula. He is gaining weight appropriately. Considering the appropriate nutritional management of infants, select the appropriate advice to be given to new mothers who are thinking about whether they will choose to feed their babies with breast milk or infant formula exclusively.
Correct Answer C:
To recognize abnormal growth, one needs to understand normal growth. The average birth weight for a term infant is 3.3 kg. Weight drops as much as 10% in the first few days of life, probably as a result of loss of excess fluid; however, birth weight is regained within 1 week to 2 weeks after birth in majority of children.
In breastfed infants and formula-fed infants, the frequency of feeds, number of wet diapers and stools each day, and a history of sequential weights allow the physician the ability to gauge if the child is receiving adequate amounts of fluid and calories and is gaining weight appropriately.
Breast milk lacks vitamin D (choice C) and cows milk lacks iron. Babies who don’t get enough vitamin D are at risk of getting rickets, a disease that affects the way bones grow and develop.
→ Avoid feeding newborn infants in the first 12 hours of life in order to prevent aspiration (choice A) is incorrect. The baby can start to feed shortly after birth and does not need to wait for 12 hours.
→ Breast milk is deficient in iron and iron supplementation is recommended for breast fed infants (choice B) is incorrect. Cow's milk is deficient in iron.
→ Institute solid food at three months of age (choice D) is incorrect. Solid food is typically introduced between 4-6 months of age.
→ Breast milk may causes diarrhea if used exclusively, so formula should be added (choice E) is incorrect. Breast milk has many benefits for infants and the American Academy of pediatrics recommends breast feeding for at least the first year of life. There has been no study that established breast milk causes diarrhea if used exclusively; in fact, it is believed that breast milk decreases the risks of diarrhea.
In assessing the nutritional status of an infant it is useful to know that birth weight is expected to be regained within:
Correct Answer B:
A helpful guideline for assessing normal growth in the very young infant is that birth weight should be regained by the 14th day.
Between 7 and 8 years of age, your patient has grown 4.5 cm. His height, however, remains below and parallel to the 50th percentile. Clinical examination is entirely normal. His mother is anxious for further investigations to be undertaken.
Which one of the following would you undertake?
Correct Answer E: The growth percentiles by themselves don't say much. What really matters is the velocity of growth. A normal velocity of growth means the child's growth points will closely parallel the percentile line above it on the chart. Physicians don't worry about insufficient (or excessive) growth until a child's growth velocity has crossed at least two percentile lines (e.g., from above the 90th to below the 50th percentile).
Additionally, if a child's weight, height, or head size is below the 50th percentile, they might also call them small for age. In that case, what's most important is to see if the growth points parallel the 50th percentile line (meaning growth velocity is normal) or if the child is falling further behind (which is more concerning).
An 8-year-old boy is brought to the office because his mother is concerned he is entering puberty already. You examine him and note the beginnings of facial hair, axillary hair and Tanner stage 2 external genitalia. If you suspect premature adrenarche, which of the following would you want to order:
Correct Answer E: Premature adrenarche refers to the precocious secretion of adrenal androgens, which results in the isolated development of pubic hair (pubarche) before the age of eight years in girls and nine years in boys. The female to male ratio is approximately 10:1. The condition is characterized by activation of adrenal androgen production and by impressive increases in dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), androstenedione, and testosterone.
Serum concentrations of DHEA, DHEAS, androstenedione, and testosterone and urinary 17-ketosteroids should be measured. In premature adrenarche, these levels are usually increased for chronologic age and are in the range of those found in early puberty. A bone age x-ray should be preformed. In premature adrenarche, the bone age is usually within 2 standard deviations of chronologic age.
Moderately elevated levels of serum androgen other than DHEAS, bone age advancement, or signs of atypical premature pubarche such as cystic acne or signs of systemic virilization indicate the need for an ACTH test to rule out congenital adrenal hyperplasia. An excessive increase in serum 17-hydroxyprogesterone level to >45 nmol/L after an ACTH stimulation test suggests late-onset congenital adrenal hyperplasia.
Marked elevation of serum androgen levels and advanced bone age suggest the possibility of an adrenocortical or gonadal tumor. A patient with an androgen-producing adrenocortical tumor does not respond to ACTH stimulation or dexamethasone suppression, whereas a patient with congenital adrenal hyperplasia does respond.
An 8-year-old black male comes in with an asymptomatic erythematous eruption characterized by oval patches with collarette scaling. It is distributed as a "Christmas tree" pattern on the back. The father states that there was originally one lesion on the abdomen a few weeks prior.
What is the most likely diagnosis?
Correct Answer A: Pityriasis rosea (PR) is a condition that classically begins with a single, primary, 2- to 10-cm “herald” patch that appears on the trunk or proximal limbs. A general centripetal eruption of 0.5- to 2-cm rose- or fawn-colored oval papules and plaques follows within 7 to 14 days. The lesions have a scaly, slightly raised border (collarette) and resemble ringworm (tinea corporis). Most patients itch, occasionally severely. Papules may dominate with little or no scaling in blacks, children, and pregnant women; the rose or fawn color is not as evident in blacks; blacks also more commonly have inverse PR (lesions in the axillae or groin that spread centrifugally).
Classically, lesions orient along skin lines, giving PR a Christmas tree-like distribution when multiple lesions appear on the back. A prodrome of malaise and headache precedes the lesions in a minority of patients. Diagnosis is based on clinical appearance and distribution.
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