Pediatric Examination and Board Review (191 page)

(D) a thorough history from the caretakers is warranted to assess whether there is an adequate explanation for this injury

(E) sternal fractures are the most common abusive injury in infants

12.
On examination you note 2 healing lesions. They are dime-sized, scabbed over “mirror images” on each buttock. You are worried these are cigarette burns. The mother denies smoking or hurting her child. Which of the following statements is false?

(A) skin conditions such as impetigo can mimic abusive lesions

(B) “accidental” contact burns are often brushed burns and not ovoid

(C) intentional cigarette burns are ovoid and firstdegree burns

(D) the healing patterns of intentional cigarette burns differ from the scars that result from skin infection

(E) abusive burns are found more often in younger children; they are more serious and require longer hospital stays

13.
Four months after you evaluated and reported a child for suspected child abuse, you receive a subpoena to appear in juvenile court. Which of the following is true?

(A) the standard of proof is equal to criminal proceedings

(B) the standard of proof is preponderance of evidence

(C) subpoena duces tecum is a subpoena that requires you to testify only

(D) you should prepare an opinion for the court as to what your findings were

(E) you are obligated to contact the family and inform them of your testimony

14.
The 4-month-old gains weight in the hospital. His siblings, who are 2 and 4 years of age, are evaluated and found to have mild malnutrition but have not seen a physician in more than a year. With regard to neglect, all of the following are true except

(A) neglect is a failure to meet a child’s needs with regard to food, shelter, or clothing, and medical, emotional, and educational needs

(B) neglect has variable manifestations

(C) often neglect is defined in terms of acts of omission by the caretaker

(D) harm or potential injury as a result of omission is often the basis for laws defining neglect

(E) lack of supervision is not a category of neglect

15.
Medical conditions that will interfere with caloric intake and retention include all of the following except

(A) GI conditions

(B) infections (eg, parasitic GI tract infestation or urinary tract infection)

(C) renal tubular acidosis

(D) HIV

(E) prenatal exposure to marijuana and cocaine

16.
Effective management of child neglect must rely on a systematic and thorough approach by the clinician. Which of the following is a false statement regarding the management of child neglect?

(A) to initiate an intervention, the clinician must convey to the family his or her specific concerns and show an interest in assisting the family

(B) early engagement of the child welfare system will ensure intervention

(C) the clinician must recognize that intervention often requires long-term investment, support, and case tracking

(D) early efforts by the clinician should include an assessment of the family, community support systems and available services

(E) development of a care plan with the family outlining efforts needed by the family and concrete plans for follow-up involving the family’s input and agreement is a fundamental management step

17.
Your patient required a short admission and your final diagnosis was FTT. Your understanding of the etiology of this case had to do with social factors affecting safety and access to appropriate food and medical care. The mother now has a protective order, has moved to a shelter, and the children have all been assessed as well. Which of the following is a true statement about disposition of children with FTT?

(A) most infants with FTT require transitional placement in foster care until the caretaker can demonstrate ability to care for the child

(B) assessment of the family’s willingness, ability, and insight determine the disposition of the child with regard to child welfare contact and home disposition

(C) child welfare systems have well-developed interdisciplinary interventional models that include medical expertise, case management, and legal and mental health services to provide longitudinal interventional services for children with FTT

(D) children with FTT do not benefit from early interventional services as a result of the brain development insults from starvation

(E) catch-up growth often requires nasogastric or gastrostomy tube placement and feedings

18.
Which of the following require an immediate report to child welfare?

(A) a 15-month-old who has missed his last 2 immunization visits

(B) a 9-month-old who rolled off the bed and sustained a bruise to his forehead when his mother fell asleep

(C) a 12-year-old with Ewing sarcoma who has failed 2 rounds of chemotherapy. His prognosis for recovery with an experimental regimen is poor and the parents refuse treatment

(D) a 10-year-old with sickle cell disease presents in aplastic crisis with a hemoglobin of 3 g/dL. The parents refuse transfusion because they are Jehovah’s Witnesses

(E) a 2-year-old admitted for ingestion of his grandmother’s cardiac medication

ANSWERS

1.
(C)
This baby has FTT that warrants immediate evaluation, which includes a review of family history, including assessment for potentially growthretarding family illnesses such as cystic fibrosis (CF), celiac, inflammatory bowel disease or lactose intolerance, and HIV risk. The parent’s height and weight and any family history of growth delay should be elucidated. A psychosocial assessment should also be obtained looking for stressors, domestic violence, or mental illness and a review of access resources. Prenatal and perinatal issues (eg, low birthweight, drug or alcohol exposure) are known to be predictors of FTT.

2.
(A)
To assess the child’s current growth status it is important to obtain all available prior growth measurements. Measurements are used to identify children with growth failure, guide treatment, and also aid prognostically. It is very important that measurements are performed appropriately (eg, the same scale for weights). Infants and toddlers should be weighed without clothing and older children weighed in underwear. Growth measurements at one time point are difficult to interpret; what is most important is to assess growth over time or lack of it. The rest of the diagnostic evaluation must be guided by history and physical examination once FTT has been established. The most important guides to evaluation are the history and physical findings. The other answer choices are potentially correct based on the initial findings (eg, a pre-albumin would be helpful in assessment of a severely malnourished infant, the ferritin level may be indicated in an iron-deficient child, a bone age is appropriate in a child with short stature, and electrolytes are most often useful when a child is clinically dehydrated). In severe malnourishment, hypokalemia can be seen.

3.
(D)
Weight for age reflects multiple factors including current and past growth problems and is the single most powerful predictor of mortality compared with other measurements. Depressed weight for height reflects more acute nutritional deprivation, and a depressed height reflects chronic malnutrition. Growth chart adjustment for prematurity depends on both the severity of the prematurity and which growth index is being adjusted. Correction for prematurity may take up to 3 years of age. Adjustment for weight often takes 2 years postnatally and head circumference can take 18 months; length can take up to 40 months.

4.
(A)
An FTT evaluation must be directed by history and physical examination findings. There is no standard screening protocol. It is important to focus the workup to diagnose occult diseases and to assess any metabolic derangements causing FTT. All children should have a CBC, consideration for lead exposure, and a urinalysis to assess possible renal tubular acidosis. Metabolic testing—for example, electrolytes, glucose, blood urea nitrogen (BUN), and creatinine— should be considered in children with vomiting and diarrhea. Children who are severely malnourished should have a total protein, albumin, calcium, alkaline phosphatase (low in zinc deficiency), and a phosphorus level if rickets is of concern. Consideration of HIV, cystic fibrosis, or GI tract infection should be considered in “at-risk” populations, and food allergies should be considered in children with skin manifestations (eg, urticaria or other rashes). If a child has unexplained respiratory symptoms, a GI evaluation for reflux should be considered. Children with medical diagnoses associated with FTT or children who have swallowing dysfunction warrant an oral motor evaluation.

5.
(D)
Unfortunately, there is a belief among some providers that demonstration of growth in the hospital is diagnostic of “nonorganic” FTT, that children with chronic and serious medical diseases do not grow, and that those with “environmental FTT” will grow in the hospital. In reality, those inferences are too simplistic and imprecise. Growth is expected for most children with FTT if given appropriate nutrition and administration. Therefore growth in the hospital is not a definitive test to distinguish between nonorganic versus organic FTT. It is important for the medical community to self-educate and to train the child welfare community that the diagnosis of FTT is more complex than demonstrating growth, and that demonstrating growth is a poor discriminator of major organic disease from purely “environmental” causes of FTT. FTT is usually defined as a child whose growth is less than expected, with the weight falling below the 5th percentile, weight for height falling below the 10th percentile, or the weight falling across 2 major percentiles over time. The proximate issue with children with FTT is that they are malnourished. The etiology of this growth failure must be considered from a nutritional, medical, developmental, and social perspective. It is imperative that catch-up growth is considered along with required daily intake. Expected growth is based on age. An infant is expected to grow 25-30 g daily, a 3- to 6-month-old 17-18 g daily, a 6- to 9-month-old 12-13 g daily, a 9- to 12-month-old 9 g daily, and a 12+ month old 7-9 g daily. In most circumstances children need 1.5-2 times their expected oral intake to catch up. It is known that heavy prenatal exposure to alcohol is associated with microcephaly and short stature.

6.
(C)
All of the family characteristics are important to assess in children with a FTT diagnosis. Effective treatment should incorporate this information by addressing the stressors that incite or hinder growth. A psychosocial perspective should be a core component of an FTT evaluation.

7.
(D)
The most common form of child maltreatment is neglect, based on national reporting data collected by the National Child Abuse and Neglect Data System (Child Welfare Information Gateway 2009).

8.
(D)
Based on national data, 3 million children are reported to the child welfare system annually, and about a third of these reports are substantiated. Nearly 56% of the reports were made by a mandated reporter.

9.
(B)
It is incorrect to state that all children with FTT must be reported to child welfare. There are many children who have growth-limiting illnesses who by definition fit the diagnosis of FTT. It is very important to assess the family’s strengths and ability to provide a child with the necessary environment to improve growth. If, in the judgment of the clinical team, a child requires out-of-home placement because the child is in jeopardy or if monitoring by child welfare and obtaining services and support would enhance compliance and therefore growth, child welfare referral and reporting are indicated.

10.
(B)
Poverty is the single most common risk factor associated with neglect and therefore FTT. The other factors listed are associated as well, but less strongly.

11.
(D)
Assessing findings on a skeletal survey must include a review of past medical history to elucidate if this was a documented and evaluated injury with treatment in the past. The relative suspicion for an injury to be associated with abuse is based on the child’s age and the injury (eg, a clavicular fracture in a toddler with a history of a fall is low suspicion unless there are mitigating issues). Conversely, a sternal fracture is rare and would absolutely warrant a meticulous evaluation.