37: Infant female well-child visits (2, 6, and 9 months)

A 36-month-old presents for a well child visit. The parents would like to know if the child's development is progressing appropriately. The child passed a hearing test at birth, and other than a few URIs, has been generally healthy. The child has not had any hospitalizations or serious illnesses. The child is able to run well, walk up stairs, walk slowly down stairs, uses more words than the parents are able to count, but can only use them in short, two or three-word sentences. The child's speech is understandable and the child can draw a circle, but not a cross. Neurological examination reveals normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the next best step in management of this child? A. Perform a brain-stem auditory evoked potential hearing screen B. Perform a screening exam for autism C. Reassure the parents that the boy's development appears normal D. Refer the child to a developmental specialist for comprehensive evaluation E. Refer the child to a specialist for evaluation of his delayed motor development

C. A. A brain-stem auditory evoked potential hearing test (BAER) may be indicated in infants who fail to meet language milestones if they cannot cooperate with other more comprehensive testing. A 36-month-old should be able to cooperate with behavioral audiometry, so a BAER is not indicated. In addition, this child has no evidence of language delay and does not require referral at this point. B. Autism is an increasingly diagnosed cause of developmental delay, but this child is not delayed and no mention is given of any autistic features, such as a lack of symbolic play, repetitive movements, or poor sociability. C. The developmental milestones mentioned in the vignette are within the range of normal for a 36-month-old child. In the absence of any other evidence of significant impairment, there is no indication for referral at this point. D. If there are reasons for concern on developmental screening tests, a referral may be indicated. However, the developmental milestones mentioned in the vignette are within the range of normal for a 36-month-old child. E. This child's motor milestones are not delayed, and no referral is indicated.

Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy's age to be based upon his developmental milestones? A. 12 months B. 15 months C. 18 months D. 30 months E. 36 months

C. A. At age one year, gross motor skills include pulling to stand, standing alone, and perhaps first steps. Fine motor skills including putting a block in a cup and banging 2 cubes held in hands. At this age a child should be able to imitate vocalizations/sounds and babble. The majority of children this age will know 1 or 2 words in addition to "mama" and "dada." Social-emotional milestones at age one year are waving bye-bye and playing pat-a-cake. Running, building towers of blocks, removing clothing, and a 6-word vocabulary are more advanced skills than a 12-month-old would be expected to have. B. At 15 months of age, a child should be able to stoop and recover, walk well, put a block in a cup, have a vocabulary of a few words, wave bye-bye, and drink from a cup. Running, building towers of blocks, removing clothing, and a 6-word vocabulary are more advanced skills than a 15-month-old would be expected to have. C. At 18 months, a child should be able to walk backward, and 50-90% of children can run at this stage. An 18-month-old should be able to scribble, build a tower of 2 cubes, have 3-6 words in her or his vocabulary, and be able to help in the house and remove garments. D. At 2 ½ years of age, kids can jump up and throw a ball overhand. They can build a tower of 6-8 cubes, point to 6 body parts, name 1 picture, put on clothing, and wash and dry their hands. Sammy is only able to build a tower of 2 cubes, can remove his clothing but does not yet put clothing on, and his vocabulary is limited to 6 words-leading us to believe he is younger than 2 ½ years old. E. At age 3, children can balance on each foot for 1 second, wiggle their thumbs, name 4 pictures, name 1 color, name a friend, and brush their teeth with help. Sammy's vocabulary is only 6 words, he is not able to name a friend, he is only able to stack 2 cubes, and he has just starting running, but is unable to balance on each foot for 1 second.

A 9-month old comes to the clinic for a well-child visit. The child is at the 50th percentile for weight, length, and head circumference and is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit? A. Hep B, DTaP, IPV B. Hep B, IPV, and MMR C. Influenza, Hep B, IPV D. Influenza, Hep B, IPV, DTaP E. Influenza, IPV

C. A. Hep B, DTaP, IPV is incorrect. All three doses of DTaP have been given and the patient now needs a yearly flu shot starting at 6 months of age. B. Hep B, IPV, and MMR is incorrect. The patient also needs a yearly flu shot starting at 6 months of age and MMR is not given before 12 months of age. C. Influenza, Hep B, IPV is correct. The patient needs a third Hep B, a third IPV, and a yearly flu shot starting at 6 months of age. D. Influenza, Hep B, IPV, DTaP is incorrect. All three doses of DTaP have been given. E. Influenza, IPV is incorrect. The patient needs the third Hep B shot.

An asymptomatic, healthy 9-month-old is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child? A. Children who are older than 12 months have a better prognosis than younger children B. Favorable histology does not play a role in prognosis C. Lymph node involvement is a poor prognostic factor D. Non-amplification of the n-myc gene is a favorable prognostic factor E. Prognosis of neuroblastoma is predictable

D. A. In infants less than one year of age, neuroblastoma tumors may spontaneously regress. Stage 4S neuroblastoma is a special category that is reserved for infants less than 12 months who have resectable primary tumors and metastases to the liver, skin, and bone marrow. Overall survival is over 85 percent for babies over 6 weeks of age with Stage 4S. B. Favorable histology is a good prognostic factor in neuroblastoma, and is based on the differentiation of the cells involved. C. Due to the effectiveness of chemotherapy, neuroblastomas with lymph node involvement are still considered favorable, especially in the setting of other favorable factors, such as young age and differentiating histology. Though distant metastasis is a significant poor prognostic factor, regional lymph nodes do not significantly affect the outcome. D. Non-amplification of the n-myc gene is one of the favorable genetics in neuroblastoma. E. Neuroblastoma has a broad spectrum of clinical courses. Some tumors may spontaneously regress, some may mature to a benign type, and yet other tumors can be very aggressive with metastases. Age plays a role in the prognosis, as most infants have a good prognosis even with disseminated disease, while infants over 18 months of age do not do as well.

A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? A. Enlarged cells with intranuclear inclusion bodies B. Hypersegmented neutrophils C. Sheets of lymphocytes with interspersed macrophages D. Small round blue cells with dense nuclei forming small rosettes E. Stacks of RBCs

D. A. This describes the classic "owl's eyes" seen in CMV and other viral infections. B. Hypersegmented neutrophils are characteristic of megaloblastic anemia, a condition associated with a vitamin B12 and/or folate deficiency, not malignancy. C. This is incorrect, as sheets of lymphocytes with interspersed macrophages are associated with Burkitt lymphoma. D. This is the correct response. In addition to neuroblastoma, other tumors associated with small blue cells include Ewing's sarcoma and medulloblastoma, both of which tumors are seen in children. E. Stacks of RBCs suggest rouleaux formation, a phenomenon seen in multiple myeloma, a condition not seen in young infants.

A 5-month-old male is brought to the urgent care clinic with a 3 day history of rhinorrhea and non-productive cough. At birth the baby was large for gestational age and exam at the time was notable for macrocephaly, macroglossia, and hypospadias. Vital signs are stable on physical exam at this time. There is copious nasal discharge, but lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? A. Hepatoblastoma B. Renal cell carcinoma C. Teratoma D. Wilms' tumor

D. A. While children with Beckwith-Wiedemann syndrome can have hepatoblastoma (in addition to other types of tumors), this is not the most common tumor in this genetic condition. Note that hepatoblastoma may also be associated with familial adenomatous polyposis. B. Renal cell carcinomas are much more common in adulthood. Risk factors include cigarette smoking and obesity. C. Teratomas are congenital tumors that are present at birth. These benign tumors are often identified incidentally, or may become symptomatic due to mass effect of the lesion within the abdominal cavity. The aggressiveness of the tumor depends on the degree of differentiation. D. Wilms' tumor is commonly associated with Beckwith-Wiedemann syndrome, a genetic overgrowth syndrome. Other features that may be seen in children with this syndrome include omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features.