Growth and Devlopment Prep

I.
Growth and development

Question 5.
Answer.
A reporter for the local newspaper is interviewing you for an article on preschoolers. He asks
you to list some normal milestones for 4-year-olds.
Of the following, the MOST typical milestone for a 4-year-old is to
A.
copy a square and triangle
B.
prefer solitary or parallel play
C.
print his or her first name
D.
speak clearly in sentences
E.
tie his or her shoelaces
Question 27.
Answer.
A male infant is born at an estimated gestational age of 34 weeks. His measurements at birth
are: weight, 1,200 g (<10th percentile); crown-heel length, 40 cm (10th percentile); and head
circumference, 31.5 cm (50th percentile).
Of the following, the MOST likely explanation for the growth pattern of this infant is
A.
chromosomal abnormality
B.
congenital viral infection
C.
gestational diabetes
D.
hereditary constitution
E.
pregnancy-induced hypertension
Question 47.
Answer.
The mother of a 3-year-old boy reports that a neighbor thinks that her son has poor muscle
tone and needs therapy. On evaluation, the boy stacks eight cubes, copies a circle, does a
broad jump, and stands on one foot briefly. Physical examination reveals normal reflexes,
muscle palpation, muscle strength, movement, posture, and range of motion. During the
examination, he points to the otoscope and asks, "What's that for?"
Of the following, the MOST appropriate next step is to
A.
measure creatine phosphokinase concentration to rule out muscular dystrophy
B.
obtain magnetic resonance imaging of the brain to rule out adrenoleukodystrophy
C.
reassure the mother that her son has normal motor development
D.
refer the boy to a physical therapist for exercises to increase his muscle tone
E.
refer the boy to determine eligibility for special education services
Question 67.
Answer.
You are examining a term newborn in the nursery. His weight is 3.27 kg (50th percentile), and
his length is 50.5 cm (50th percentile). The pregnancy, labor, and delivery were unremarkable.
There are no significant findings on physical examination.
The MOST likely head circumference in this child, if it is consistent with his other growth
parameters, is
A.
31 cm
B.
33 cm
C.
35 cm
D.
37 cm
E.
39 cm
Question 88.
Answer.
During a health supervision visit for their 4-year-old daughter, a couple asks you to examine
their 2-month-old son. They place him supine on the examining table where he smiles
responsively and gurgles.
Of the following, you would expect this 2-month-old to be MOST able to
A.
exhibit the Moro reflex
B.
raise his head off the table when prone
C.
reach for a rattle
D.
roll over
E.
transfer objects from hand to hand
Question 107. Answer.
You are examining a girl at her 1-year health supervision visit. Her weight, length, and head
circumference all were at the 10th percentile at birth. There were no pregnancy, labor,
delivery, or nursery complications. Physical examination reveals her weight, length, and head
circumference are at the 5th percentile.
Of the following, this child's growth parameters MOST likely represent
A.
a chromosomal abnormality
B.
a malabsorptive disorder
C.
an endocrine disorder
D.
inadequate caloric intake
E.
normal growth
You are examining a 4-year-old girl for the first time at a health supervision visit. Her mother
reports that the child was at the 50th percentile for weight and height at birth. Physical
examination reveals her weight to be 15 kg (25th percentile) and her height to be 90 cm (<5th
percentile). Family growth history is unremarkable. Findings on the remainder of the physical
examination are unremarkable.
The MOST likely cause of this girl's poor growth is
A.
constitutional growth delay
B.
growth hormone deficiency
C.
parental neglect
D.
poor nutrition
E.
rickets
A 2-week-old infant whose birthweight was 3.23 kg now weighs 3.0 kg. The mother is
breastfeeding and reports good milk production. The infant nurses every 2 to 3 hours and has
eight wet diapers per day. Findings on physical examination are unremarkable.
Of the following, the BEST advice for this mother is to
A.
continue to breastfeed and return to the office in 1 week to recheck the infant's weight
B.
hospitalize the infant for an evaluation of failure to thrive
C.
return to the office for the 2-month health supervision visit
D.
stop breastfeeding and change to formula
E.
supplement breastfeeding with formula
You are examining a 4-month-old boy, who is brought in by his foster mother for his first health
supervision visit. His weight, length, and head circumference were at the 50th percentile at
birth. You now note a decrease in the head circumference from the 50th to the 10th percentile,
although his weight and height remain at the 50th percentile. The infant was delivered at term.
The mother reports that the boy had an infection at 3 weeks of age.
Of the following, the MOST likely cause of his microcephaly is
A.
familial microcephaly
B.
maternal diabetes
C.
maternal hypertension
D.
meningitis
E.
poor nutrition
A healthy 2-month-old infant was born at 32 weeks' gestation. She has grown well since birth.
On physical examination of this infant, the MOST likely finding is
A.
ability to fixate on a face and follow it briefly
B.
ability to reach and grasp a rattle
C.
ability to watch an object and follow it to midline
D.
absence of the Moro reflex
E.
babbling and cooing vocalizations
The parents of a healthy term baby ask you at the 12-month health supervision visit what they
should expect of the baby developmentally by the 15-month visit.
Of the following, the milestone MOST likely to be met by 15 months of age is
A.
drawing a circle
B.
drinking from a cup
C.
having a vocabulary of at least 50 words
D.
throwing a ball overhand
E.
walking well without tripping
A cheerful, energetic 36-month-old girl bursts into the room at her health supervision visit and
begins talking. Her mother explains what the girl says because you can understand only about
50% of her speech. The girl does answer some questions about a playmate. When you
question the mother about her daughter's speech, she seems surprised and asks if something
is wrong.
Of the following, your MOST appropriate response is to

A.
ask her to keep a list of all the words her daughter uses
B.
assure her that the girl's speech development is normal
C.
refer the girl for brainstem auditory evoked response testing
D.
refer the girl for evaluation of language delay
E.
request a follow-up visit in 3 months to follow the girl's speech development
You are planning to spend the weekend with a group of 5-year-old children.
Of the following, the milestone that can help you BEST plan activities for the group is
A.
an attention span of 2 to 3 minutes
B.
naming three or four colors
C.
playing board or card games
D.
pointing to pictures in books
E.
speaking in three-word sentences with 50% intelligibility
Answers
Critique 5.
Preferred Response: D
[View Question]
By age 4 years, children should be able to speak in three- to four-word sentences with
complete intelligibility. Minor developmental articulation and grammatical errors (eg, She
runned home after school) are expected. Four-year-olds should be able to play interactively
with peers and have progressed to copying block designs such as a gate or steps. They have
long since mastered towers and are more likely to want to make something with blocks and tell
you what it is. Children who are 4 years old cannot copy a triangle, tie their shoelaces, or print
their first names.
Critique 27.
Preferred Response: E
[View Question]
A birthweight and crown-heel length that are below normal accompanied by a head
circumference that is relatively normal is consistent with asymmetric growth restriction. This
pattern of intrauterine growth is seen typically in a newborn whose mother has had pregnancyinduced hypertension. In a pregnancy complicated by hypertension, progressive placental
insufficiency results in decreased transplacental transfer of nutrients to the fetus, which affects
primarily the gain in body weight. Unless the placental insufficiency is severe or prolonged,
brain growth is relatively spared, which accounts for the normal head circumference.
In a normal pregnancy, the fetus gains body weight linearly until about the 32nd week
of gestation and exponentially thereafter. The weight gain is greatest in the third trimester of
pregnancy and is estimated to be approximately 15.0 g/kg per day. In contrast, the fetal gain in
crown-heel length and head circumference occurs linearly throughout pregnancy, and each is
estimated to be approximately 0.9 cm/wk in the third trimester.
An infant who has a chromosomal abnormality, such as trisomy 13 or trisomy 18, has a
pattern of intrauterine growth consistent with symmetric growth restriction. Body weight,
crown-heel length, and head circumference all are below normal. This pattern of intrauterine
growth reflects an overall loss of growth potential from the chromosomal abnormality.
Fetal growth arrest, resulting in symmetric growth restriction, frequently is seen in
pregnancies complicated by viral infection. Viruses that can cause fetal growth arrest include
rubella, cytomegalovirus, and herpes. The growth arrest in congenital viral infection may result
from several factors, including altered fetal growth potential from viral growth inhibitory factors
and altered substrate delivery caused by placental villus inflammation.
Another cause of symmetric growth restriction in a newborn may be a limited growth
potential from hereditary causes. These infants are healthy but small for gestational age. Their
parents typically are of small constitution.
In a pregnancy that is complicated by gestational diabetes, maternal hyperglycemia
often results in fetal hyperglycemia, which causes hypertrophy of the fetal pancreatic islets
and beta cells and increased secretion of insulin. The fetal hyperinsulinemia results in
macrosomia and an increase in adipose tissue. The infant of a mother who has gestational
diabetes, therefore, typically is large for gestational age.
Critique 47.
Preferred Response: C
[View Question]
Developmental milestones represent average or low-average accomplishments at a given age

and are intended to trigger further evaluation if delayed. Direct examination of the boy
described in the vignette is reassuring. Low muscle tone is a subjective impression at times
and can occur independent of language, cognitive, gross motor, fine motor, and
social/adaptive functioning. Isolated low muscle tone rarely is a serious problem without
associated findings. Accordingly, the mother can be assured that her son has normal motor
development.
Muscular dystrophy is a disorder resulting in muscle weakness, not just low tone.
Adrenoleukodystrophy often presents with neurobehavioral symptoms or adrenal insufficiency;
spasticity rather than hypotonia is a feature of more advanced disease. Brain imaging is
indicated in progressive neurologic disorders, especially with spasticity, but it is not indicated
in the child described in the vignette. Physical therapy is not effective for isolated low muscle
tone.
Formal screening using a standardized instrument would be appropriate before
considering any referral or determining eligibility for special education services.
Critique 67.
[View Question]
At birth, the average head circumference of a term male infant is 34.8 cm (13.57 in).
Accordingly, the head circumference of the infant described in the vignette, who appears
healthy and average in size, would be closest to 35 cm. Head circumference increases by 0.5
cm/wk during the first 2 months of life and by 0.25 cm/wk from 2 to 6 months of life.
Other growth parameters measured at the time of birth are weight and length. The
average term infant is 50 cm (19.5 in) in length at birth. The length normally increases by 50%
at 1 year of life, doubles by 4 years, and triples by 13 years. The average weight of a term
infant at birth is 3.25 kg (7.18 lb). Newborns lose approximately 10% of birthweight in the first
several days of life, but usually regain the original birthweight by 2 weeks of age. Birthweight
typically is doubled by 5 months of age and tripled by age 1 year.
Critique 88.
Preferred Response: B
[View Question]
In an active and alert state, normal motor milestones for a 2-month-old include the ability to
raise the head and shoulders off the surface of the table in the prone position and to fix and
follow past the midline. The infant described in the vignette appears to be doing well, is alert
and responsive, and is making appropriate vocalizations. It is helpful to know when he had his
last meal and last nap because alertness, interest, and motor performance can vary
throughout the day. Intentional reaching and grasping develops later. A 2-month-old would not
be expected to sustain a sitting position without support, his hands would be open most of the
time, and he should be able to grasp a rattle that is placed in his hand. Persistent fisting is a
sensitive sign of cortical dysfunction and should prompt further assessment. The Moro reflex
often (but not always) is extinguished by this age. Most infants will not be able to roll over until
3 to 4 months of age.
Critique 107.
[View Question]
Anthropometric measurements (height, weight, head circumference) can be assessed crosssectionally or longitudinally. If only one measurement is available, growth for age can be
assessed by comparing this measurement with appropriate reference charts. Measuring a child
more than once provides growth velocity data, which can be used to assess growth rate. When
plotted on a growth chart, an individuals growth can be expected to remain in the same
percentile range for the first 2 to 9 years of life. However, the physiologic change from
intrauterine influences on a persons genetic potential can account for shifts among growth
curve percentiles during early infancy. The growth curve percentiles also may change during
puberty due to the adolescent growth spurt. Weight, length, and head circumference should be
obtained and plotted during each health supervision visit to follow growth and alert the
pediatrician to any potential problems. Growth curves unique to certain populations (eg, Down
syndrome, preterm infants, or certain ethnic groups) should be used when appropriate.
Knowing that the growth parameters of the child described in the vignette were
unchanged since birth, that there were no prenatal or perinatal problems, and that current
findings on physical examination are normal should allow the pediatrician to reassure the
mother that her childs growth parameters are consistent with normal growth.
Inadequate caloric intake and a malabsorptive disorder present with weight decreasing
initially, then length. Endocrine disorders often present with short stature, but normal weight,
and chromosomal abnormalities frequently are characterized by microcephaly and dysmorphic
features.
Critique 127.
[View Question]
The length and weight of the girl described in the vignette was at the 50th percentile at birth.
Children generally double their birth length by the time they reach 4 years of age. Most 4-yearolds are approximately 102 cm (40 in) tall and weigh 18 kg (40 lb). The girl described has a
height of 90 cm (<5th percentile), which is much lower than expected. Her weight is at the
25th percentile, and although it has crossed one percentile line, it is not affected as severely as
her height. Of the causes listed, the most likely etiology of this childs short stature and
relatively spared weight is an endocrine disorder, such as growth hormone deficiency.
Children who have classic growth hormone deficiency grow at subnormal growth
velocities (<5 cm/y) and have significant retardation of skeletal maturation. Growth hormone
deficiency may be idiopathic or organic, and it can be due to a hypothalamic or pituitary tumor.
Affected children may present with complaints of headache, visual abnormalities, or other
neurologic symptoms. Children in whom growth hormone deficiency is suspected should
undergo growth hormone testing. Evaluation for other pituitary hormone deficiencies also
should be made.
A common normal variant of growth is constitutional growth delay. Born at normal
weight and length, affected children may grow at slower rates throughout infancy. After
infancy, their growth rates return to normal, and they grow parallel to the lower percentiles of
standard growth curves. There is often a positive family history for constitutional growth delay.
The short stature of the girl described in the vignette is more severe than would be expected in
constitutional growth delay.
Metabolic abnormalities, such as rickets, can cause poor growth. Many children who
have metabolic abnormalities experience a deceleration in the rate of growth in weight and
length in the first years of life. No physical abnormalities are described in the vignette that
would suggest a metabolic abnormality. Common physical findings in children who have rickets
include rachitic rosary (thickening of the costochondral junction), wrist enlargement, bowed
legs, frontal bossing, and craniotabes.
Poor nutrition and parental neglect are relatively common causes of poor growth. This
childs weight for height is greater than 90%, which indicates adequate nutrition. The growth
pattern seen in most children who are receiving poor nutrition or parental neglect is a
deceleration of weight and height, with weight being affected first and more severely than
height.
Critique 150.
Preferred Response: A
[View Question]
Term infants normally lose 10% of their bodyweight during the first several days of life, but
they should regain it by 2 weeks of age. Although the 2-week-old infant described in the
vignette weighs 0.23 kg less than birthweight, the mother reports good milk production,
frequent nursing, and frequent wet diapers, all of which suggest that breastfeeding is going
well. Other indications of adequate milk production include leaking in the opposite breast and
empty breast after feeding with refilling. Accordingly, it is most appropriate for the mother to
continue breastfeeding and return in 1 week to determine whether the infant's weight is
increasing.
Every major national and international organization for the promotion of childrens
health agrees that breastfeeding is the best way to feed a baby. The incidence of breastfeeding
peaked in 1982; the years since have seen a steady decline in initial and prolonged
breastfeeding. A common reason for stopping breastfeeding is the misconception that the
infant is failing to thrive due to breastfeeding.
Supplementing breastfeeding with formula or stopping breastfeeding and switching to
formula are not indicated for the infant described in the vignette. Supplementing with formula
will hinder the mothers milk production and suggests to her that something is wrong with
her milk, which is not supported by any findings in the vignette.
Because the infant has not regained his birthweight, he should be evaluated again in 1
week; waiting until the 2-month evaluation to recheck the infants weight is not recommended
because adequate weight gain from breastfeeding has not yet been demonstrated.
Hospitalization is not indicated for an infant who has no signs or symptoms suggesting an
underlying infection, metabolic disorder, or dehydration. Hospitalization only rarely may be
indicated for breastfed infants who show signs or symptoms of significant dehydration because
this will disrupt the mothers ability to breastfeed in a calm, quiet environment and may result
in decreased milk production and possibly discontinuation of breastfeeding.
Critique 168.
[View Question]
Microcephaly is defined as a head circumference that measures more than 3 standard
deviations below the mean for age and gender. It most often is the result of a small brain; the
skull generally grows in response to brain growth. Microcephaly can be categorized as primary
(genetic) or secondary (acquired or nongenetic). Infants who have primary microcephaly have
small head circumferences at birth. The infant described in the vignette had a normal head
circumference at birth, which eliminates primary causes of microcephaly.
The decrease in this infants head circumference suggests that a significant neurologic
injury has occurred since birth. Bacterial meningitis is one cause of acquired microcephaly.
Infants who develop meningitis in the first few months of life, as might have occurred with this
infant at 3 weeks of age, can have complications, including cerebral infarcts, cystic cavitations,
and loss of neurons, which can lead to microcephaly.
Maternal hypertension during pregnancy is a risk factor for intrauterine growth
retardation, which may be associated with a small head circumference at birth. Infants of
women who have diabetes often are large for gestational age and have large head
circumferences at birth.
Although poor nutrition may be a cause of microcephaly, the weight and height of
poorly nourished infants are affected before any decrease in the rate of growth of the brain is
noted. Infants from families that have a history of microcephaly typically have small head
circumferences at birth. If there is a suspicion of familial microcephaly, it may be of benefit to
measure the head circumferences of the parents and any siblings of the infant.
Critique 190.
[View Question]
Most research on the development of preterm infants shows that the majority of effects of
prematurity on growth and development do not disappear in healthy babies until 2 years of
age. Accordingly, it is good practice to correct for prematurity when assessing the growth and
development of children who are younger than age 2, such as the infant described in the
vignette. Therefore, a 2-month-old child who was born 2 months preterm should be compared
with term newborns for purposes of developmental assessment.
The term newborn has the ability to fixate on a face and follow it briefly, but he or she
is not expected to follow objects consistently to midline. Volitional reaching and grasping
occurs after 3 months of age in a term infant, as do babbling and cooing vocalizations. The
Moro reflex should be present in all newborns. Its absence or asymmetry should prompt an
investigation to rule out entities such as cerebral palsy and paralysis (congenital or acquired).
Critique 210.
[View Question]
Anticipatory guidance about normal development affords the clinician a good opportunity to
promote development and parenting skills. Most 15-month-old children are able to drink from a
cup, so this is a good opportunity to encourage parents to offer a cup instead of a bottle. Few
children of this age can throw a ball overhand or walk without tripping. All developmentally
normal 15-month-olds should have progressed beyond babbling and started using individual
words and gestures and responding to a few words. Few will have achieved a vocabulary of 50
words. Children normally cannot draw a circle until 3 years of age.
The 12-month-old childs emerging mobility, interest in exploration, and manual skills
can be exciting but also treacherous. This health supervision visit provides a good opportunity
to reinforce child safety information. It is also worthwhile to ask the parents if they or anyone
else are concerned about the childs development in case a question about expectations is an
indirect expression of concern.
Critique 230.
[View Question]
Speech and language delay is common, and pediatricians are correct to pay special attention
to this area of development because it correlates most closely with cognitive development and
later school function. In contrast to receptive language delay or mixed receptive and
expressive language delay, expressive language delay can be an isolated finding with a good
prognosis. Speech articulation problems can occur independently of receptive or expressive
language delays.
Assessing the degree of intelligibility requires a good sample of language, and it is
easiest to assess during play or with a standardized test such as the Goldman-Fristoe Test of
Articulation, which usually is performed by a speech-language pathologist. Having ageappropriate toys and books available in the office makes it easier for the pediatrician to assess
speech and language development. The child described in the vignette shows appropriate
communication functions for a 36-month-old. By age 4 years, almost all of her speech should
be intelligible, although some articulation errors (r and th sounds) are expected at this age.
Because the child described in the vignette has normal language development, further testing
and a follow-visit in 3 months is unnecessary.
Routine use of a screening questionnaire focusing on possible parental concerns can
help avoid parental surprise and improve detection of children who have developmental
delays. If there are other risk factors, such as a history of hearing loss, recurrent ear infections,
or excessive frustration on the childs part related to speaking, consultation might be
considered. Knowledge of normal language development and common variations is important;
equally important is the ability to communicate this to families.
Critique 252.
[View Question]
Five-year-old children can communicate their thoughts and feelings. They also have a rapidly
developing ability to assimilate new information and follow simple rules. They enjoy board and
card games with their enhanced ability to count and take turns. They also are not above
cheating and making up their own rules and are not always good losers. They know more than
three to four colors and have progressed beyond pointing to pictures in books. They often can
pick out words and pretend to read books that they have memorized. Their speech is clear,
and they frequently relate long, fanciful stories; fantasy and reality are not completely
distinguishable. Speech with only 50% intelligibility and a 3-minute attention span are more
typical of a 3-year-old child.
I. Growth and development
Question 1.
Answer.
You are precepting a group of medical students during a structured observation at a local child
care center.
Of the following motor milestones, the one that is MOST typical of a 24-month-old child is
A.
building a tower of two cubes
B.
copying a circle
C.
scribbling
D.
throwing a ball overhand
E.
walking backwards
Question 53.
Answer.
During a routine health supervision visit, you pull an infant to a sitting position. She has no
head lag and maintains the sitting position with her arms propped forward on the table. She is
able to reach for objects and transfer them from hand to hand.
Of the following, these motor skills are MOST likely to emerge at age
A.
4 months
B.
6 months
C.
8 months
D.
10 months
E.
12 months
During a health supervision visit, an infant turns when her name is called and looks to her
father for reassurance when frightened. Although silent in the office, her parents report that
she says "mama" and "dada" in a nonspecific way.
These milestones are MOST typical of a child who is
A.
5 months old
B.
7 months old
C.
9 months old
D.
11 months old
E.
13 months old
During an office visit, the child you are observing trips. Getting up from the floor, he
announces, "John fall!" His mother reports that he uses a spoon well at mealtimes and wakes
up dry in the morning.
These developmental skills are MOST consistent with those of a child who is
A.
12 months old
B.
18 months old
C.
24 months old
D.
30 months old
E.
36 months old
As part of a kindergarten visit, a pediatric resident sits at a table and draws with the children.
Of the following, the MOST advanced fine motor skill he typically should observe in this group
of 5-year-olds is their ability to copy a
A.
circle
B.
cross
C.
diamond
D.
square
E.
vertical line
Both the weight and height parameters of a 6-month-old girl have dropped to substantially
below the 5th percentile for age. Until 2 months of age, she had maintained growth at the 50th
percentile. At that time, her mother returned to work and the grand-mother assumed her care.
She has received iron-fortified formula since birth and currently ingests 6 oz every 4 hours.
Of the following, the best INITIAL step in management of this child is to
A.
determine how the formula is mixed
B.
obtain a creatinine level
C.
obtain a sweat test
D.
obtain thyroid function studies
E.
reassure the mother that this is a normal growth pattern
Answers
Critique 1
[View Question]
Achievement of fine motor milestones during the second year of life requires evolution beyond
the neat pincer grasp that is present at 12 months of age. With improved cortical control of the
upper extremities and better truncal balance, the hands are more available, and the child can
learn to manipulate objects during functional play.
Throwing a ball with an overhand motion is most typical of a 24-month-old child. The
ability to build a tower of two cubes emerges at 14 months of age; by 24 months, the tower
should be six or more blocks tall. Imitative scribbling appears at 16 months; spontaneous
scribbling appears at 18 months. The ability to copy a circle usually is not seen until 3 years of
age. Walking backwards is an appropriate milestone for a 16-month-old child; an ability to walk
down steps holding onto the rail better describes the gross motor abilities of a 24-month-old.
Other normal motor milestones for 24 months of age include the ability to wash and dry hands,
remove clothing, put on a hat, kick a ball, and jump with two feet off the floor.
Critique 53
[View Question]
Focused observation of a child during routine examinations provides an enormous amount of
developmental information. In many cases, it is superior to handling the infant directly and
confirms the milestone reports from the parents.
Gross motor skills require a balance between extensor and flexor tone; a decline in
obligatory primitive reflexes; and the development of righting, protective, and equilibrium
responses. In most cases, infants learn to maintain new positions long before they can achieve
them voluntarily.
Head lag begins to disappear by 4 months of age, but sitting in an armed-propped

position, as described for the infant in the vignette, is more typical of a 6-month-old child. This
is replaced at 7 to 8 months with upright sitting and an ability to achieve a sitting position
independently. A 6-month-old also should be able to roll over in both directions, demonstrate
an immature raking grasp, reach for objects, and transfer them from hand to hand.
Critique 107
[View Question]
Assessment of language development includes observation as well as consideration of history
provided by the parents. Receptive language progresses more quickly than expressive
language and is characterized by an increasing ability to localize sounds by 5 months of age.
This skill is followed by the ability to attach meaning to specific sounds (eg, turning when
name is called) by 9 months of age. Expressive language advances from musical-like vowel
sounds (3 months) into repetitive consonant sounds (6 to 7 months). The use of these words
by the infant does not take on specific meaning or symbolic use until approximately 12 months
of age. The production of meaningful speech is the result of cognitive, oral-motor, and social
processes. It is the most sensitive to caretaking practices of any sensorimotor skill.
Social cognition is part of language development. The infant must learn to distinguish
familiar faces from strangers. When fully developed, facial images take on emotional meaning,
as demonstrated by anxiety with strangers or protests over separation (stranger anxiety). A
young infant (eg, 5 to 7 months old) will not seem anxious when held by the examiner or
protest separation from the parent. By 9 months, an infant will seek reassurance from a parent
or caretaker by making eye contact when frightened.
Critique 160
[View Question]
The child described in the vignette is demonstrating a spectrum of abilities that are typical for
a 24-month-old child. Referring to himself by name (John) is consistent with a developmental
age of 24 months. The ability to use language to describe an immediate experience is typical
for this age and precedes the exponential explosion in expressive language that occurs
between 24 and 36 months.
The neat use of a spoon requires the development of purposeful wrist supination and is
characteristic of the fine motor skills that develop late in the second year of life. This skill
precedes the neat use of a fork to eat, which generally occurs between 30 and 36 months.
By 24 months, most children will remain dry overnight and may begin to communicate
an urge to urinate. This dryness is more a function of an awareness of bladder fullness than
volitional toilet training. The ability to void or inhibit voiding voluntarily develops later in the
second and third years of life.
Critique 213
[View Question]
The actions of children in play situations reflect their social, cognitive, fine motor, visualperceptual, and gross motor skills. Observing children during pencil and paper tasks also
reveals much about their attention span and temperament, their experience with such
activities, and their progression though the range of normal skill acquisition.
Asking children to copy the Gesell figures has been used by pediatricians for many
years because of the well-described normative values of this test. For a child to complete more
mature drawings, he or she must have developed a mature pencil grasp that allows him or her
to close objects (circle), add isolated branches (cross, square), and change directions while
drawing (triangle, diamond). This progression forms the motor basis for the evolving people
drawings produced by children. Most 2-year-olds will be able to copy a vertical line, and most
3-year-olds can copy a circle. A 4-year-old can reproduce a cross reasonably well, whereas 5year-olds can copy a square, and a 6-year-old can copy a diamond.
Critique 266
[View Question]
The infant described in the vignette is receiving approximately 36 oz of formula daily.
Appropriate weight gain should occur if the formula contains at least the standard
concentration of 20 kcal/oz. Accordingly, the first step in management is to ascertain how the
formula is being mixed. This should be done before any diagnostic studies are obtained. The
only change in the infant's routine has been the mother's return to work. It is possible that the
grandmother, who is doing most of the feedings, is mixing the formula incorrectly. A common
mistake is to mix two cans of water with one can of the formula concentrate, resulting in a
decreased caloric content. Although a 6-month-old child should be eating some solid food,
failure to provide solid foods would not completely account for this infant's failure to thrive.
Sometimes caretakers who are facing financial difficulties are forced to knowingly dilute the
formula to make it last longer. Parental neglect or inexperience also can lead to undernutrition
from low caloric intake despite an apparently adequate volume of formula.
Chronic renal insufficiency can lead to poor growth, and it is possible for hereditary and
acquired renal diseases to present at the age of 6 months. If a thorough history and physical
examination does not yield any clue to the diagnosis in an infant who is failing to thrive, a
serum creatinine concentration should be considered. A sweat test will confirm the diagnosis of
cystic fibrosis and would be an appropriate investigation if loose stools and recurrent
pulmonary infections have been present. Evaluation of thyroid function also should be
considered in any child who has no obvious cause of growth failure based on the history or
physical examination. A growth pattern such as the one described for the infant in the vignette
never should be considered normal.
I.
Growth and development
II.
Question 1.
Answer.
Three stimulant medications (methylphenidate, dextroamphetamine, pemoline) are used
frequently to treat patients who have attention deficit hyperactivity disorder.
Of the following, the statement you are MOST likely to include in a discussion with residents
concerning the use of these medications is that
A.
common side effects include insomnia and decreased appetite
B.
lack of response to one stimulant predicts lack of response to all stimulants
C.
long-term use of stimulants results in decreased adult height
D.
only 25% of children will respond to medication
E.
the most serious side effect is weight loss
Question 88.
Answer.
Of the following fine motor milestones, the one that is MOST characteristic of a 12-month-old
child is the ability to
A.
build a tower of four blocks
B.
release a raisin into a bottle
C.
scribble spontaneously
D.
transfer objects between hands
E.
use a neat pincer grasp to attain a raisin or pellet
A mother brings her 5-year-old son to your office before he starts kindergarten. She asks that
you check his development to be sure he is ready to attend school.
Of the following, the BEST use of a preschool developmental screening test is to
A.
determine school readiness
B.
diagnose learning disabilities
C.
diagnose mental retardation
D.
identify children who require a more formal evaluation
E.
predict school success
Answers
Critique 1
[View Question]
Approximately 80% of children diagnosed with attention deficit hyperactivity disorder (ADHD)
will derive benefit from one of the frequently used stimulant medications. Recently it has
become clear that a child who does not respond favorably to one stimulant may respond to
another. When all stimulants are tried sequentially, the rate of positive benefit approaches
95%.
Commonly reported side effects of the stimulants include insomnia, decreased
appetite, irritability or other mood changes, headache, and abdominal pain. Of note, many of
these effects also are reported by patients receiving placebo. The most serious side effect of
stimulant use is the appearance of motor tics. Fewer than 1% of children who have ADHD
develop a tic disorder; in 13% of cases, stimulants appear to exacerbate a pre-existing
disorder. Long-term studies of children who received stimulants for ADHD have shown no
appreciable difference in eventual adult height or weight compared with those who have not
received stimulants.
The management of a child who exhibits attention deficits must be multimodal.
Although other drugs have proved beneficial in certain children who have ADHD, only
stimulants have demonstrated a consistent improvement in sustained attention. Effective
medical management requires the clinician to allow an adequate amount of time to discuss
and evaluate the issue of medication side effects and its impact on current social and adaptive
behaviors, academic performance, and attention span. Stimulant medications alone are not
curative, and successful management requires close involvement of the clinician, school
personnel, family, and child.
Critique 88
[View Question]
The development of fine motor skills in the 12-month-old infant demonstrates several general
concepts about neurodevelopment. Over time, children progress from having obligatory
symmetric reactions to developing voluntary, asymmetric, and precise movements.
Development proceeds in a cephalic to caudal as well as a proximal to distal direction. The
final goal of every step of developmental progression is a move from dependence to
independence.
The highlight of fine motor development in the first year of life is the development of
the pincer grasp. By the age of 12 months, most children should be able to use this pincer
grasp to attain a raisin or pellet. Achieving this milestone requires the use of the upper
extremities to make the transition from primarily assisting with balance and positioning to
using the pincer grasp as manipulative instruments that can help explore the nearby
environment.
At the same time, the typical 12-month-old child will begin to take a few independent
steps, will attempt to build a tower of two blocks, will follow a single step command with an
accompanying gesture, will cooperate with dressing, and will drink from a cup with assistance.
The ability to transfer an object between hands appears initially at 6 months of age,
and building a tower of four blocks and accurately releasing a raisin into a bottle are fine motor
skills that are seen at 16 to 19 months. Spontaneous scribbling is a skill achieved by the typical
18-month-old child.
Critique 186
[View Question]
"School readiness" implies that a child is prepared to participate successfully in formal
schooling. This requires that the child demonstrate the physical, developmental, and
behavioral skills necessary for formal schooling. School readiness tests were designed to
measure an individual child's preparedness for academic achievement and to identify children
who need early preventive intervention and further testing. However, school readiness tests
never should be used as the only determinant of a child's readiness for school. Unfortunately,
they are used for a wide variety of purposes, some of which are inappropriate and vary from
the original intent of the test designers.
Many of these school readiness tests are limited significantly in their reliability, validity,
sensitivity, specificity, and standardization sample. This is especially true of some
"homegrown" screening instruments. Despite these limitations, up to 50% of children who are
eligible to enter kindergarten are not enrolled because of their scores on readiness tests.
The limited number of standard academic skills apparent at the age of the screening
forces the use of preacademic and perceptual-motor skills that correlate only moderately with
later school success or achievement. It is also difficult to define "academic difficulties" in a
preschool child. Preschool developmental screening instruments are not designed to diagnose
mental retardation or learning disabilities or to predict school success. Further, when concerns
are raised about the results of a preschool developmental screening test, referral for a more
formal assessment should be made.
I. Growth and development
Question 36.
Answer.
In deciding if a child's growth is normal, important information can be obtained by plotting the
rate of growth (growth velocity) on a growth curve chart.
In the prepubertal boy, the average growth rate (in cm/y) is CLOSEST to
A.
2
B.
5
C.
8
D.
11
E.
14
Question 71.
Answer.
During the health maintenance examination of a 3-year-old girl, her mother expresses concern
about the child's "talking."
Of the following, the information from the mother that is MOST reassuring to you that the girl's
language development is normal is that she
A.
combines two words into one sentence
B.
knows 200 words
C.
points to one body part
D.
points to three named pictures in a book
E.
understands two prepositions
Question 93.
Answer.
The BEST method to assess age-appropriate visual development in an 8-week-old infant is to
observe for
A.
blinking as an object approaches the infant
B.
circular tracking of a suspended object through 360 degrees
C.
horizontal tracking of a suspended object through 180 degrees
D.
smiling recognition of a familiar face
E.
visual fixation while the child is held 8 to 12 in from the examiner's face
Of the following socioemotional behaviors, the one that would be MOST characteristic of a 28week-old infant is to
A.
bring feet to mouth while supine
B.
play peek-a-boo
C.
point to desired object
D.
recognize strangers
E.
smile spontaneously
Which of the following behaviors is MOST likely to appear at 8 weeks of age?
A.
Following a visual stimulus just to midline
B.
Regarding a face
C.
Regarding own hand
D.
Turning head toward a rattling sound
E.
Turning toward a familiar voice
A mother is concerned that her 5-year-old son is excessively clumsy.
Among the following, the skill MOST likely to emerge in a 5-year- old child is
A.
hopping on one foot
B.
riding a tricycle
C.
skipping
D.
walking on his toes
E.
walking up stairs
Among the following, the skill that is MOST likely to emerge at 18 months of age is
A.
building a tower of four cubes
B.
cutting paper with scissors
C.
imitating the drawing of a vertical line
D.
scribbling spontaneously with a crayon
E.
turning the pages of a book one at a time
The head size of a 6-month-old boy is at the 95th percentile. At birth, his head size was at the
50th percentile. His overall development has been normal.
Of the following, the MOST helpful method for distinguishing between benign macrocephaly
and hydrocephaly is to
A.
examine the fundi
B.
measure fontanelle size
C.
measure the parents' head size
D.
obtain plain radiography of the skull
E.
plot the head circumference on a growth chart
Answers
Critique 36
[View Question]
Measuring growth velocity or rate of growth (cm/y) is an extremely important part of every
health supervision visit. A child may present with what is considered a normal height and
weight but have an abnormal growth rate that indicates a need for evaluation. Evidence of an
abnormal growth pattern in children who have congenital growth hormone deficiency may
become apparent by 3 to 6 months of age. From the age of 1 year through the preadolescent
age, the lower limit of normal growth is approximately 5 cm/y. Most children will double their
birth length by the age of 4 years and triple it by 13 years, with an annual growth velocity after
the age of 2 years that usually will be at least 5 cm (2 in)/y. Children growing less than 5 cm/y
may require further evaluation for conditions such as growth hormone deficiency or
hypothyroidism.
Critique 71
[View Question]
The acquisition of language skills is thought of as an orderly sequence of milestones, but there
is some variability in this fluid process. Language development correlates with later cognitive
development. However, language development can be affected by environment,
temperament, and innate cognitive abilities of the child. Identifying children whose individual
language differences still fall within the range of normal can be problematic between 20 and
26 months of age. However, it is important to make this distinction because language delay is
the most common presentation of a developmental disorder in children aged 2 to 4 years. A
hearing test is warranted for every child in whom there is a concern about language.
The best assessment of language reviews not only what is being said, but the ability of
such communication efforts to express the child's needs and the child's understanding of
language directed toward him or her. Accordingly, both receptive and expressive language
skills should be evaluated to assess age-appropriate development.
Comprehension of prepositions, use of grammatically correct sentences, and an 800word vocabulary is the best description of the expected language abilities for a 3-year-old
child. Pointing to more than one body part is a skill attained by 90% of children by 22 months.
Most will combine two words in a sentence by 24 months and can point to three named
pictures in a book by 28 months. By 3 years of age, the number of words in a child's
vocabulary often is difficult to assess, but if the vocabulary of a 30-month-old is small enough
for the parents to count (eg, 150 to 200 words), it is probably too small.
Critique 93
[View Question]
The assessment of vision in young children requires not only an intact visual system in the
child, but use of a developmentally appropriate method of assessment by the examiner. The
majority of anatomic and physiologic changes in the visual system occur in the first few
months of life. Visual development progresses through a predictable series of milestones that
involve integration of certain nonvisual abilities, such as head control and use of upper
extremities. Additionally, many developmental tasks either are motivated by vision or their
performance is enhanced by visual abilities. Studies have demonstrated a relationship
between a child's visual abilities and upper extremity movements as prereaching skills (eg,
purposeful movement) and hand-to-mouth coordination develop.
The initial development components of visual function involve involuntary reflexive
patterns. Pupillary reactions are rapid to strong light in the newborn period, however, response
to weak light is not present until about 6 months of age. The consensual reflex means that
stimulation of one pupil results in an equal response in both pupils. When a bright light is
directed into the infants eyes, eyelid reflexes cause flinching, frowning, blinking and tight
eyelid closure. The newborn also responds to visual threats by blinking.
Subsequent visual behaviors are voluntary eye movements which are cognitively
directed including localization (or visual approach), fixation (or visual grasp), and ocular pursuit
(or visual tracking). The process of localization is associated with the development of head
control. Indifference to faces, which incorporates both movement and sound, is typical of the
newborn. A reciprocal social smile generally appears at 6 weeks of age. In contrast, a
spontaneous social smile in response to a familiar face usually appears by 4 months of age.
Visual fixation and pursuit skills develop rapidly in an infant. Horizontal visual tracking
progresses from 30 degrees at birth through 120 degrees at 4 weeks of age and reaches 180
degrees in the 8- to 10-week-old infant. Circular tracking of an object suspended through 360
degrees requires smooth pursuit movements (no saccades) and appears by 16 weeks. Visual
tracking with a focal length (the distance at which objects are most clear) of 8 to 12 in is
present in the newborn. The newborn also responds to visual threats by blinking. This visual
ability progresses to a reciprocal social smile at 6 weeks of age. In contrast, a spontaneous
social smile in response to a familiar face usually appears by 16 weeks.
Critique 103
[View Question]
In general, the 28-week-old infant can sit independently and upright on the table and babble
with vowel-dominated sounds, often in imitation. Additionally, the infant can change position
with good body control and, while supine, bring feet to mouth. Having achieved this reasonably
stable position with good hand control to feed himself or herself and purposefully hold two
items, the child is prepared to interact with the environment in every way possible.
A spontaneous smile appears soon after birth and develops further for use in social
situations by 2 months of age. Most infants can differentiate strangers by 3 to 4 months of age,
but will not demonstrate true stranger anxiety until 8 to 9 months. By 8 to 9 months of age,
the child typically has perfected reciprocal games like peek-a-boo. However, it is not until 12
months, when the child successfully combines age-appropriate social, language, and fine
motor abilities, that he or she can point to a desired object.
Critique 134
[View Question]
Eight-week-old infants are adapting rapidly to the surrounding world. At the same time that
they are developing improved coordination of the eyes, head, and upper extremities, they also
must overcome primitive reflexes, replacing them with more functional and useful purposeful
movements.
Infant traits observed early in life, such as visual alertness, tracking, and attentiveness,
lay the groundwork for more advanced skills. The simple skill of regarding a face appears
shortly after birth and progresses to following a visual stimulus to the midline by 2 to 4 weeks
and past the midline by 8 weeks of age. At the same time, use of the upper extremity improves
as the grasp and fisting reflexes disappear. Most infants will begin to regard their own hands
for at least several seconds at 8 weeks. The ability to grasp and retain an object briefly, such
as a rattle placed in the hand, emerges at 8 to 12 weeks of age. The ability to reach
purposefully for an object at 4 months of age combines all of these previously learned abilities.
Similarly, auditory behaviors of simple alerting are replaced with searching and
localization skills as the child matures. Recognition of a familiar voice becomes apparent by 4
months of age. Localization of sound by directly turning the head emerges by 5 months.
Critique 171
[View Question]
Gross motor milestones are the abilities best known, remembered, and reported by parents
and medical professionals. These milestones may be achieved within the expected time range
in many children despite significant delays in other areas. Therefore, screening that
concentrates only on gross motor milestones is inadequate. However, abnormalities in
attaining these motor skills signal the need to search for delays in other developmental areas,
including a careful neuromuscular examination.
The typical 5-year-old child can tandem walk backwards, skip with alternating feet, and
hop in place up to 10 times. These abilities are built on the skills, balance, coordination, and
practice that are demonstrated in earlier milestones, such as walking up stairs (average age,
17 months), purposefully walking on toes and riding a tricycle (average age, 36 months), and
hopping on one foot (average age, 43 months).
Critique 203
[View Question]
Any sequence of developmental milestones describes an average or typical child; there is a
range of variability among individuals of the same age. The accepted normal or typical range
also may be affected by the intended purpose of the task, whether it is for screening or
diagnosis. Accordingly, a child's failure to perform a single item within a number of expected
developmental milestones should not be considered sufficient to make a diagnosis or label a
child.
Gesell assessed development along five streams: gross motor, fine motor, visuomotorproblem solving, expressive and receptive language, and social adaptive. As one of the five
streams of development, visuomotor milestones encompass fine motor and problem solving
skills. At 18 months of age, nearly 50% of normal children can stack four blocks to create a
tower, an activity that requires visuomotor maturity, upper extremity coordination, and
judgment concerning balance. On average, children typically demonstrate a spontaneous
scribble by 15 months, the ability to turn single pages in a book by 24 months, the imitation of
drawing vertical and horizontal lines by 24 months, and the effective use of scissors by 36
months of age.
Critique 238
[View Question]
Macrocephaly. If a parent has a large head, the other areas of the child's development are
normal, and there are no signs of increased intracranial pressure, the infant's large head
usually is a result of benign familial macrocephaly.
Signs of increased intracranial pressure suggesting hydrocephalus or an intracranial
mass include irritability or somnolence, loss of appetite, vomiting, a bulging fontanelle,
strabismus, impairment of upward gaze, and increased tendon reflexes and hypertonicity.
Progressive hydrocephalus with increased intracranial pressure is the most common pathologic
cause of a rapidly enlarging head. Other causes include subdural effusions and intracranial
cysts.
Fontanelle size is too variable to be helpful in distinguishing between benign
macrocephaly and hydrocephaly. A large fontanelle is worrisome only if it is bulging or
enlarging serially, features of increased intracranial pressure. However, it is worthwhile to
measure and record the fontanelle size (eg, 4 x 5 cm) serially to assure that it is getting
smaller over a period of time.
Infants who have chronic increased intracranial pressure due to hydrocephalus rarely
develop papilledema because the soft brain tissue and loose sutures allow venting of the
increased pressure. In contrast, an acute increase in intracranial pressure, as seen following
nonaccidental trauma, may cause papilledema and retinal hemorrhages in infancy.
Plotting the serial measurements of head size on a growth chart occasionally may
reveal worrisome changes from low to high percentiles in a normal situation. For example, in a
preterm infant who is recovering from a difficult newborn course, catch-up brain growth rather
than a pathologic situation may explain such changes.
If there is concern about progressive hydrocephalus, ultrasonography performed
through the fontanelle is an excellent method of determining the ventricular size. However,
this evaluation should be performed in a laboratory experienced in obtaining and interpreting
ultrasonography. If ultrasonography is not available or the infant has a closed fontanelle,
computed tomography may be necessary. Serial imaging over a period of months may be
necessary to determine whether mild ventriculomegaly is static or progressively enlarging.
Changes on radiography (eg, separated sutures) are late, rather than early, findings in patients
who have increased intracranial pressure.
I.Growth and development
Question 20.
Answer.
While evaluating a child, you note that he pulls to a stand, cruises around furniture, and walks
with one hand held. When presented with cubes, he tries to make a tower but has difficulty
letting go of the cubes; he can, however, release a cube into a cup. He uses a pincer grasp to
pick up a pellet but is unable to release it into a bottle.
The abilities described are MOST consistent with those of a child who has just reached the age
of
A.
10 months
B.
12 months
C.
14 months
D.
16 months
E.
18 months
Question 41.
Answer.
Of the following developmental skills, the one that is accomplished MOST consistently by a 24month-old child is
A.
aligning two or more cubes to make a train
B.
copying a circle
C.
drawing a person with three parts
D.
reciting nursery rhymes
E.
repeating three digits
Question 63.
Answer.
A 10-year-old girl has moderate exogenous obesity.
This child's height and bone age are MOST likely to be related as follows:
A.
B.
C.
D.
E.
Height Bone Age

<25th percentile
<25th percentile
50th percentile Normal
>75th percentile
>75th percentile
Advanced
Normal
Advanced
Normal
Question 87.
Answer.
A 15-month-old girl who was placed in foster care recently has had poor growth over the past 6
months. Her weight is markedly below the 5th percentile for her age and has plateaued since
the age of 9 months. Length and head circumference are at the 25th and 50th percentiles,
respectively. Development is normal, although she still uses a bottle rather than a cup.
The findings in this patient are MOST likely due to
A.
B.
C.
an intrauterine insult
D.
constitutional growth failure
E.
inadequate intake of calories
Of the following skills, the one that is accomplished MOST consistently by a 4-year-old child is
A.
building steps with cubes
B.
copying a triangle
C.
drawing a person with 10 parts
D.
repeating five digits
E.
understanding four prepositions
Symmetric growth retardation is a common finding in infants who have a genetic or
chromosomal syndrome or congenital infection or who have been exposed to alcohol or other
drugs in utero.
Of the following, the finding that is MOST suggestive of symmetric growth retardation in a term
newborn is a(n)
A.
absence of the posterior fontanelle
B.
anterior fontanelle less than 1 cm in diameter
C.
occipitofrontal circumference of 31 cm
D.
overlapping of the coronal sutures
E.
weight-length ratio less than the 10th percentile
You are seeing a 4-year-old boy, who is new to your practice, for a preschool evaluation. His
birth records reveal that his weight, length, and head circumference were all at the 50th
percentile. He now weighs 18 kg (10th percentile) and has a height of 85 cm (<5th percentile).
Findings on physical examination are normal.
The MOST likely cause of this boy's poor growth is
A.
B.
C.
inadequate caloric intake
D.
increased fluid intake
E.
intrauterine growth retardation
Of the following language skills, the one that is demonstrated MOST consistently by an 18month-old child is
A.
B.
C.
D.
E.
following two directional commands

having a 50-word vocabulary
naming 10 pictures
using "I," "me," and "you" appropriately
using two- to three-word sentences

Of the following gross motor skills, the one that is accomplished MOST consistently by an 18month-old child is
A.
jumping in place with both feet off the floor
B.
kicking a ball without demonstration
C.
running well without falling
D.
seating self in a small chair
E.
walking up and down stairs alone using a handrail
You are evaluating a 4-month-old boy who was born at 28 weeks' gestation. The infant's
neonatal course was complicated by chronic lung disease, a grade III intraventricular
hemorrhage, and periventricular leukomalacia.
Which of the following findings would be MOST suggestive of an increased risk for neurologic
deficits in this child?
A.
Abnormal brainstem auditory evoked response
B.
Decrease in head circumference from the 50th to the 3rd percentile
C.
Irritability and poor sleeping habits
D.
Mild-to-moderate truncal hypotonia
E.
Performance level of a 6-week-old on developmental screening
During a health maintenance visit for her son, a mother tells you that the boy recently began
to sit without support. You support him in standing and note that he bears weight and bounces
actively.
This boy is demonstrating gross motor milestones MOST consistent with a child aged
A.
3 months
B
5 months
C.
7 months
D.
9 months
E.
11 months
While evaluating a child, you note that he follows a command that is accompanied by a
gesture; says "mama," "dada," "bye-bye," and "baba" for bottle; and cooperates with dressing.
The abilities described are MOST consistent for a child aged
A.
10 months
B.
12 months
C.
14 months
D.
16 months
E.
18 months
Answers
Critique 20
[View Question]
Typically, it is not until 12 months of age that an infant can accomplish all of the skills
described in the vignette. A 10-month-old infant is beginning to cruise around furniture
sideways while holding on with both hands for support. One month later, he or she will hold on
with only one hand, which allows cruising around furniture in a forward direction. However, at
this age the caregiver must hold both of the infant's hands to provide adequate balance and
support while walking. At 11 months of age, infants also can pick up a pellet with the tips of
the fingers, but they must rest their arm and hand on the table for support. They cannot
accurately release a cube into a cup, much less a pellet into a tiny hole.
At 12 months of age, infants can walk with only one hand held. The pincer grasp is fully
perfected. They now can release a cube into a cup, although they still cannot release a pellet
into a small container. They may attempt to make a tower, but they usually will fail.
Infants who are 14 months old walk alone but with outstretched arms (ie, "high guard")
and a wide-based gait to enhance balance. Although it is done clumsily, they can release a
pellet into a small container and build a tower of two cubes. They are enchanted with putting
objects into and taking them out of containers, which often will keep them occupied for long
periods of time. Finally, they are becoming interested in shapes and will attempt to insert a
round form into a round formboard.
At 16 months of age, children have sufficient balance to narrow the base of support while
walking; in addition, their arms are down by their sides or engaged in carrying objects while
walking. They rarely fall and can stoop and pick up an object from the floor without losing
balance. Other skills include the ability to build a tower of three cubes, scribble, dump a pellet
from a bottle on command, and replace the pellet into a bottle. Lastly, they can successfully
place a round form into a formboard that has a single round opening.
At 18 months of age, children run stiffly and climb onto furniture. Intrigued by these
new locomotive skills, they are always "on the go." Although it may take some effort to get
them to sit quietly, they do enjoy putting pegs in and out of a pegboard and turning the pages
of a book. They can build a tower of four cubes and selectively insert a round form into a
formboard that also contains square and triangular openings. They may find the correct
opening for the square form, but usually will have difficulty inserting it.
Critique 41
[View Question]
By 24 months of age, a child should be able to align at least two cubes to make a train. Vertical
building skills are learned before horizontal building skills; accordingly, the 24-month-old child
also should be able to build a tower of 6 to 8 cubes. It is not until 30 months of age that
children can combine vertical and horizontal skills to make, for example, a train with a stack.
The mastery of vertical before horizontal building is paralleled by the development of drawing
skills. At 18 months of age, most children can imitate a vertical stroke. A few months later,
they can imitate a horizontal stroke, and at 36 months, they can combine the two motions to
draw a cross.
All of the other skills listed in the vignette are not accomplished until at least 3 years of
age. Although the 2-year-old may be able to scribble using a circular motion, he or she cannot
copy a circle until 3 years of age. Children should be able to copy a square at 4 years of age.
This milestone is easily remembered by associating the ability to draw a square with "4 sides
at 4 years".
The average 3-year-old can draw a "head" (ie, a single circle). If presented with a
partially drawn stick figure, he or she may add some parts, such as a missing arm or eye. At 4
years of age, children can draw a person with four to six parts, and at 5 years, they can draw a
person with eight to 10 parts. Having a child draw a picture of a person provides a crude
assessment of cognitive ability; simplified scoring procedures can be found in most pediatric
handbooks. When the figure is scored using detailed and precise standards, such as those
found in psychometric testing manuals, it correlates well with sophisticated tests of nonverbal
intelligence. However, fine motor deficits that adversely affect drawing ability may limit the
child's success in completing this task in spite of normal cognitive skills.
Reciting nursery rhymes and repeating digits are verbal skills. At about 3 years of age,
children typically enjoy reciting nursery rhymes with adults. They also can construct threeword sentences with up to six syllables. The 30-month-old may be able to repeat two digits,
but it is not until 3 years of age that he or she can repeat three digits. This skill may be
influenced adversely by impulsivity or poor attention.
Critique 63
[View Question]
The National Center for Health Statistics reports that the proportion of children aged 6 to 17
years who are overweight increased over the past 25 years from 5% to 11%.
Children who have moderate exogenous obesity due to excessively high caloric intake
typically are tall for age and have advanced bone age as a result of early prepubertal increases
in androgens. Thus, the child presented in the vignette is most likely to have a height that is
greater than the 75th percentile and an advanced bone age. In contrast, children who are
obese because of hormonal abnormalities (eg, Cushing syndrome) typically are short (<5th
percentile) and have a delayed bone age.
The definition of obesity remains controversial. Some authorities define it as 120% or
more of "normal" body weight for age. However, more recently the Expert Committee on
Clinical Guidelines for Overweight in Adolescent Preventive Services has recommended the use
of the body mass index (BMI), which is defined as weight/stature squared (kg/M). A BMI of
greater than 30 kg/M or greater than the 95th percentile for age indicates that a child is
overweight.
Successful intervention requires the prompt recognition of moderate exogenous
obesity by the clinician. Interventions aimed at preventing the numerous complications
associated with adult obesity should be instituted as early as possible.
Critique 87
[View Question]
The 15-month-old girl presented in the vignette has grown poorly since 9 months of age;
weight gain has been affected most significantly. Her development is normal, and no abnormal
physical findings are described. In the majority of patients who have this clinical picture, the
etiology of the growth failure is the result of complex interactions between biologic and social
factors leading to inadequate intake of calories, rather than due to an organic etiology. The fact
that this child still obtains most of her liquid intake from a bottle suggests that she may be
drinking excessive amounts of juice, water, or whole milk that satiate her before an adequate
caloric intake is reached. Liquid intake should be restricted to determine if her weight increases
once adequate calories from other food sources are provided. Continued poor growth despite
adequate caloric intake would suggest the need for additional evaluation (eg, in-hospital
supervision of intake and monitoring of growth parameters).
Unlike the child described in the vignette, children who have poor growth due to
chromosomal abnormalities usually exhibit growth retardation in head circumference and
length as well as weight. Development also may be delayed, and other characteristic
abnormalities can be found on physical examination. Children who have endocrine disorders
causing growth failure usually present with isolated short stature because height is affected
most significantly.
Problems during pregnancy such as chronic hypertension can interfere with the
placental transfer of nutrients to the fetus, but the effect of such an intrauterine insult should
be apparent at birth rather than at age 9 months. Constitutional growth failure, also known as
familial delayed growth, is characterized by poor gains in both height and weight.
Critique 107
[View Question]
A 4-year-old child usually will understand four prepositions such as in, under, on, and beside.
Other cognitive skills that are typical of children this age include the ability to draw a foursided figure (ie, a square), count to 4, identify four colors, say a four- to five-word sentence,
and draw a picture of a person with at least four parts. These children also comprehend "same"
versus "different" and can tell a story. When it is demonstrated, they can build a gate with
cubes. Strangers should be able to understand most of their speech. In fact, a convenient
mnemonic to assist the clinician in remembering language intelligibility is based on this
finding: a child's language should be 50% (2/4's) intelligible at 2 years, 75% (3/4's) intelligible
at 3 years, and 100% (4/4's) intelligible at 4 years.
All the other choices offered as answers to the vignette are skills that are not mastered
until at least 5 years of age. That is, the average 5-year-old can draw a triangle, count to 10,
repeat a 10-syllable sentence, and draw a picture of a person with 8 to 10 parts.
Children who are 6 years old usually can build a 10-cube staircase from memory, know
number concepts to 10 (ie, 10 cubes are more than 5 cubes), and can perform simple addition.
When asked to draw a person, they will include 12 to 15 parts.
The ability to repeat five digits is typical of a 7-year-old. However, this ability may be
impaired by a short attention span, such as that seen in children who have attention deficit
hyperactivity disorder. The average 7-year-old also can repeat three digits backward, can draw
a diamond shape, and can draw a person that has 18 to 22 parts.
Critique 130
[View Question]
Growth potential and size are determined genetically, with the major contribution being
maternal rather than paternal. Intrauterine growth retardation (IUGR) is the term used to
signify failure of the fetus to attain predicted size at birth.
Most forms of IUGR reflect late gestational events, such as preeclampsia or pregnancyinduced hypertension. Vascular disease impairs placental growth and function and slows fetal
growth. This decrease in growth velocity affects fetal weight first, then fetal length, and, lastly
and uncommonly, fetal brain volume (head circumference). The form of IUGR that affects
weight more than length and head circumference is termed asymmetric growth retardation
and can lead to an abnormal weight-to-length ratio (eg, <10th percentile).
Early gestational events (ie, those that occur in the embryonic period) frequently affect
all growth parameters-weight, length, head circumference-equally. Typically, each parameter is
depressed below the 10th percentile. Maternal drug and alcohol abuse, chronic hypertension,
renal disease, collagen vascular disease, fetal viral infection, and a broad range of genetic
syndromes all can lead to symmetric growth failure.
In the term infant, the mean (50th percentile) head circumference is 34 cm; 32 cm is
two standard deviations below the mean (<5th percentile) and 36 cm is two standard
deviations above the mean (>95th percentile). Accordingly, an occipitofrontal circumference of
31 cm would be less than the 5th percentile and, of the options presented, would be most
suggestive of symmetric growth retardation.
Fetal growth retardation affects the growth of all bones, not simply long bones.
Therefore, thinned cranial bones with wide suture lines and widely open anterior and posterior
fontanelles are seen in many infants who have severe IUGR; absent or small fontanelles or
overlapping sutures are not characteristic. Rarely, however, bones become softened and a
"ping-pong ball" sensation will be felt when the occiput is depressed (craniotabes); this is a
common finding in infants who have advanced intrauterine hydrocephalus or rickets.
Critique 151
[View Question]
Children generally double their birth length by the time they reach 4 years of age; the boy
described in the vignette, who had normal growth parameters at birth, would be expected to
have reached a height of about 104 cm at 4 years of age. Accordingly, his height of 85 cm
(<5th percentile) is substantially lower than expected. His weight (10th percentile) also has
crossed several percentile lines, but is not affected as severely as his height. Of the options
mentioned, the most likely cause of this child's short stature and relatively spared weight is an
endocrine disorder.
In cases of intrauterine growth retardation (IUGR), the infant is born small, and the rate
of growth continues to be retarded throughout infancy and early childhood. All growth
parameters are affected. Causes of IUGR include congenital infections (eg, toxoplasmosis,
rubella virus, cytomegalovirus, herpes simplex virus), teratogens (eg, alcohol, certain
medications), and intrauterine events (eg, placental insufficiency).
One of the nutritional causes of poor growth is inadequate caloric intake due to
inappropriate feeding regimens, poor food choices, or increased fluid intake. For example,
excessive intake of juice, water, and milk causes early satiety before an adequate caloric
intake is reached. Feeding regimens that do not provide enough total calories will result in poor
growth, even if growth parameters at birth were normal. For example, a 2-month-old infant fed
a 4 oz bottle three times a day will not have adequate growth. In general, the growth pattern
of a child who is receiving inadequate nutrition shows a deceleration in rate of weight and
height growth, with weight affected more than height.
Chromosomal abnormalities also can cause poor growth. Many children who have
genetic syndromes experience a deceleration in the rate of growth in length, weight, and head
circumference in the first years of life. However, most chromosomal abnormalities are
associated with distinctive facies or stigmata, which would help identify the underlying
syndrome; these are not present in the child described in the vignette.
Critique 174
[View Question]
An 18-month-old child should be able to follow, without an accompanying gesture, at least two
directional commands such as "Give the book to daddy" or "Bring the cup to mommy." The 2year-old child will be able to follow four different types of directional commands (eg, "give,"
"bring," "show," "get"). Occasionally, the clinician may confuse prepositional commands with
directional commands. The ability to follow a command involving prepositions (eg, "in," "on,"
"under") requires higher cognitive skills. A child usually will be able to follow two or three
prepositional commands at about 36 months of age.
At 12 months, an infant usually will say one or two words in addition to "mommy" and
"daddy"; by 18 months, he or she will use 15 to 25 words spontaneously. Although 18-month-
old children may repeat many more words on request, they will not use 50 words functionally
until about 2 years of age. Until a functional vocabulary of 50 words has been achieved, it may
be helpful to ask parents to record all of their child's words. Beyond this point, expressive
language skills increase so rapidly that parents will find it difficult to keep track of new words.
At that time, monitoring sentence structure becomes a more reliable indicator of expressive
language skills.
Although an 18-month-old infant may point to a few body parts, familiar persons, or
objects on request, the ability to point to a picture on request reflects a higher level of mental
processing. Accordingly, at 18 months, the infant may point to one picture on request, but it is
not until 24 months that he or she can point to three pictures. The ability to identify 10 pictures
is a skill that usually is attained between 2 and 3 years of age.
By 12 months of age, infants usually understand the concept of self, realizing that they
are different from all others and preferentially responding to their own name. However, they do
not use the three pronouns "I," "me," and "you" appropriately until 24 to 30 months of age.
Infants typically do not begin to combine two words into phrases (noun-noun) or short
sentences (noun-verb) until they have mastered a vocabulary of at least 50 words. Prior to this
time, they may say "giant words" (two-word combinations that they hear repeatedly and
perceive as one word, such as "thank you" and "ice cream"). When they say these phrases,
they really are treating the two words as a polysyllabic single word. The individual words rarely
appear separately or in combination with other words.
Critique 195
[View Question]
Being able to seat one's self in a small chair is the only skill of those listed in the vignette that
typically is accomplished by an 18-month-old child. At this age, children also can climb onto
adult furniture and turn around to sit facing forward.
Although an 18-month-old may attempt to jump in place, the feet will not leave the
floor. It is at 24 months of age that a child can jump in place after demonstration and jump
from the bottom step leading with one foot.
The 18-month-old child will walk into a ball or step on it when asked to kick it, even
after a demonstration. With practice and improved balance, most children can kick a ball
without demonstration at about 24 months of age.
The 18-month-old runs stiffly but is always "on the go." Such constant activity and
practice improves both balance and speed, so that the 24-month-old runs well and falls only
rarely.
Children's climbing abilities vary, depending on whether they have been exposed to
stairs. Once a child is allowed to maneuver stairs, the skills unfold in a relatively predictable
fashion. Abilities used to ascend stairs usually are mastered prior to those needed to descend.
For example, a child will let go of the adult's hand and use the handrail when ascending stairs
several months before using the same action when descending stairs. Thus, going both up and
down stairs using a handrail usually is not accomplished until about 24 months of age. The
following table shows the ages at which major stair climbing skills are acquired.
STAIR CLIMBING SKILLS
=========================================================
============
Age
Up
Down
--------------------------------------------------------------------15 months
Creeps upward
18 months
Walks up with one hand
held, bringing both feet
to the same step
Creeps backward
20-22
months
Walks up using rail,
bringing both feet to the
same step
Walks down with one hand
held, bringing both feet
to the same step
24 months
Walks down using rail,
bringing both feet to the
same step
30 months
Walks up using
rail, alternating feet
36-48
months
Walks up without using
rail, alternating feet Walks down using
48-60
months
Walks down without using
Critique 217
[View Question]
Survival of infants born at 28 weeks' gestation has become the norm in most areas of the
United States. However, approximately 20% to 25% of these infants will have significant
neurologic sequelae, including blindness, hydrocephalus, paralysis, weakness, cerebral palsy,
deafness, behavior problems, learning disorders, and attention deficit hyperactivity disorder.
Although weight gain and linear growth in very preterm infants lag behind that of their
more mature preterm counterparts, head growth usually follows a normal curve throughout
infancy. Thus, a substantial decrease in the head circumference suggests that significant
neurologic injury occurred previously and may herald the development of cerebral atrophy and
eventual microcephaly (ie, head circumference, at least 2 standard deviations [SD] below the
mean). Acquired microcephaly may result from infection (eg, toxoplasmosis, syphilis, human
immunodeficiency virus infection) late in the third trimester or during the perinatal period,
from hypoxic-ischemic insults, or from metabolic derangements (eg, hypothyroidism,
aminoaciduria). As noted for the infant in the vignette, the head circumference is normal at
birth; microcephaly, resulting from postnatal impairment of brain growth, becomes apparent
after several months.
In most infants, head circumference reflects brain volume and a small skull usually is
due to a small brain. Similarly, the smaller the head, the less likely it is that intelligence will be
normal. Among infants who have a head circumference that is 2 to 3 SD below the mean, the
incidence of moderate-to-severe mental retardation is 33%; this increases to 62% among
infants who have a head circumference more than 3 SD below the mean. Exceptions to this
general rule include infants who have microcephaly associated with an abnormally shaped
head, familial microcephaly, or growth retardation due to an underlying condition (eg,
malabsorption, congenital heart disease).
The incidence of hearing impairment is higher in the very-low-birthweight infant
compared with the term or large preterm infant, but there is no direct correlation between this
finding and most other neurologic injuries. Truncal hypotonia is a common nonspecific finding
during the first few months of life; in the absence of other objective neurologic abnormalities or
the persistence of primitive reflexes, this finding cannot be used to predict later neurologic
functioning. Until 18 postnatal months of age it is appropriate to correct for gestational age
(eg, for a 28-week-old infant, subtract 12 weeks from the chronologic age) when
developmental testing results are reported.
Critique 241
[View Question]
The skills of the boy presented in the vignette are most consistent with those of a 7-month-old
child. At 3 months of age, infants require truncal support to sit, and the head will bob. They
prefer to be prone or supine and can push up on their forearms or bat at objects from these
respective positions. At 4 months of age, infants can keep the head in midline while supine.
Fine motor skills have improved to the point that objects can be grasped and brought to the
midline for exploration with both hands; objects also can be brought to the mouth for oral
exploration. Infants this age enjoy being held in a sitting position; they can keep the head
steady, but the body usually is tipped forward.
Five-month-old infants sit straighter and need only pelvic support for balance.
Development of a frontwards protective instinct is heralded by the appearance of the
parachute reaction. The reaction can be elicited by holding the child in ventral suspension and
quickly lowering the body toward a surface. Infants will reflexively extend their arms in the
direction of the surface to brace against the impending impact. At 6 months of age, this
protective reaction should be intact, allowing the infant to sit independently with a rounded
back and arms outstretched in a propped position. Lifting one arm may cause the infant to fall
because the sidewards protective reactions are not yet developed.
At 7 months of age, an infant, such as the one described in the vignette, will be able to
sit independently for seconds to 1 or more minutes. The infant also will bear weight, bounce, or
lift one leg when supported in a standing position. Independent sitting is facilitated by the
development of side protective reactions, which allow infants to brace or prevent a fall.
However, infants this age still are at risk of falling backwards because backwards protective
reactions do not develop until later. For this reason, a 7-month-old infant should not be left
alone in a sitting position, and it is wise to place supports behind him or her during these early
attempts to sit independently.
Nine-month-old infants can sit well with the back straight, balancing for long periods at
a time. Their hands are free to manipulate and explore objects while maintaining a sitting
position, and they can get into and out of the sitting position by transferring in and out of the
quadruped position. They may creep on hands and knees and pull themselves to a standing
position.
By 11 months, all sitting skills are perfected. Infants can rotate and pivot, and they do
not lose balance when reaching upwards for an object. Backwards protective reactions are
intact and prevent backwards falls. The 11-month-old infant is mobile, can creep at a rapid
pace, cruise around furniture holding on with one hand for support, walk with only one hand
held, and possibly stand independently for a few moments. If the infant takes any independent
steps at this time, the steps usually are widely based, and the walking is only for short
distances between caregivers.
Critique 261
[View Question]
Following a command (eg, "give me") that is accompanied by a gesture (eg, an outstretched
arm), saying two words in addition to "mama" and "dada", and cooperating with dressing are
skills typical of a 12-month-old child. Socially, these children offer a ball to a mirror image.
They also are beginning to "jargon" (use sentence-like intonation and rhythm), although the
sounds are not recognizable. Parents often report that the infant seems to be "speaking in a
foreign language."
Some 10-month-old children may stop an activity momentarily when told "no" sternly.
They also may say "mama" or "dada" appropriately; however, children usually do not say their
first "real" (functional) words until 11 months of age.
By 14 months, children can follow a command without a gesture, have a functional
vocabulary of four to five words (in addition to "mama" and "dada"), and can remove their hat
and socks.
The 16-month-old infant can follow a command to fetch a familiar object from another
room. However, successful execution of this receptive language task also depends on memory
span and the ability to carry an object while walking. Additional receptive language skills
typical of this age include pointing to a body part and to a familiar object. The average 16month-old will use 5 to 10 words spontaneously and will begin to insert these words into
sentence-like "jargoning." When words become recognizable in jargoning, the speech pattern is
termed "mature jargoning."
The 18-month-old infant will point to three body parts and possibly to one familiar
picture in a book. Most children this age also will have mastered a 10- to 25-word vocabulary
that may include one or two "giant words" (two-word combinations, such as "thank you" or
"let's go," that the child hears repetitively and interprets as a single, polysyllabic word). The
child does not use either of the two words in the giant word in combination with other words.
The 18-month-old infant may be able to remove a loose garment that has no buttons or
zippers, but it is not until 24 months of age that he or she can unzip and remove most articles
of clothing.

Growth and Devlopment Prep

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Growth and Devlopment Prep

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I.

Growth and development

Of the following, your MOST appropriate response is to

Developmental milestones represent average or low-average accomplishments at a given age

Head lag begins to disappear by 4 months of age, but sitting in an armed-propped

Height Bone Age

following two directional commands

Question 195. Answer.

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