A 6-week-old baby presents to the office. His weight is still near birth weight. He had a normal birth and delivery and has not had any signs of infection or illness. The physical examination does not reveal any significant abnormalities except for his thin appearance. A diagnosis of failure to thrive is made.
Which of the following is indicated?
Correct Answer B:
Increasing caloric density of feedings and careful frequent follow-up of weight gain is a good first step. If there is no improvement with good caloric intake, then consider hospitalization.
A. This is an expensive approach and usually unnecessary.
C. This child is too young to start solid foods and the caloric content of solid foods is lower.
D. This approach is too aggressive without more information and evidence of neglect.
E. Switching to another cow’s milk based formula is no significant change and would not provide additional calories.
A 15-month-old male is brought to the pediatrician’s office because he seems much smaller than his two older brothers were at that age. His mother states that he has been generally healthy except for two episodes of otitis media and an occasional “cold”. He began walking at 11.5 months and can now say “mama”, “dada”, “byebye”, and the names of his brothers and dog.
What is the most appropriate first step in evaluating his size?
Correct Answer D:
To make the diagnosis of failure to thrive (FTT), it is important to plot height and weight on standard growth curve (choice D) and especially important to compare these to previous values if they are known. FTT refers to growth < 3rd or 5th %ile on >1 occasion in a child < 2 years old; a child < 2 years whose weight is < 80% of the ideal weight for age; or a child < 2 years whose weight crosses two major percentiles.
→ According to the history, this child is meeting his developmental milestones appropriately (choice A).
→ A 3-day food diary (choice B) is an important component of an FTT workup, but FTT must be established first.
→ The child’s previous illness are minor and would not result in growth problems or warrant an immune workup (choice C).
→ Cystic fibrosis (choice E) is one cause of FTT, but this is not the initial step.
Organic causes in the differential diagnosis of recurrent abdominal pain in children include:
Correct Answer E:
Recurrent abdominal pain (RAP) is common in children especially in pre-school children and adolescents. Recurrent abdominal pain is an expression of physiological mala-djustments in response to family or school problems in predisposed children. Contrary to this belief, many studies have found organic causes of RAP to be more common. The occurrence of nocturnal pain is considered an important indicator of an organic (disease based). Night pain or pain on awakening suggests a peptic origin, while pain that occurs in the evening or during dinner is a feature of constipation.
Organic causes include (but are not limited to) gastrointestinal disease, urinary tract infections, parasite infestation and esophagitis/gastritis.
A 10-year-old presents with a 1-year history of abdominal pain which is “always there”, but waxes and wanes. She is an “A” student and competes on a state level in figure skating. Mom describes her as a happy child who doesn’t seem to be stressed.
Most likely diagnosis:
The duration of the symptoms, history of being an “A” student, and type A competitive personality all make chronic abdominal pain most likely. As stress is internalized and somaticized, stress often is not shown outwardly.
A. The history is too chronic to be typical for appendicitis.
B. There is no history of diarrhea or blood in the stools, and no history of bloating/gaseous pain.
C. IBD tends to have a more chronic history of diarrhea with blood in the stools, and progressive worsening of the disease.
E. Gallbladder disease is unlikely in pediatrics unless there is a history of hemoglobinopathy, chronic TPN, or other underlying illnesses.
A 15-year-old female presents with sudden onset of mild left lower quadrant pain. She denies any history of trauma or fever or sexual activity. There is no loss of appetite and no change in bowel habit. She is in the middle of her menstrual cycle. Physical exam is unremarkable.
What is the most likely diagnosis?
Given this patient history and presentation the most likely cause of her abdominal pain is Mittelschmerz or midcycle pain. One-sided pain that is lasting minutes to a few hours which is usually sharp, cramping and distinctive that may switch sides from month to month or from one episode to another and begins midway through the menstrual cycle suggests mittelschmerz.
→ Patients with appendicitis classically present with visceral, vague, poorly localized, periumbilical pain. Within 6 to 48 hours, the pain becomes parietal as the overlying peritoneum becomes inflamed; the pain then becomes well localized and constant in the right iliac fossa. Note: bilateral pelvic pain suggests PID, but nausea and vomiting and pain migration from periumbilical area to right lower quadrant of abdomen suggests appendicitis.
→ Use of an IUD and a history of PID or tubal ligation increase the risk of ectopic pregnancy. If a post-menarcheal girl presents with abnormal vaginal bleeding and adnexal mass and hypotension, ectopic pregnancy should be suspected but this patient's physical exam is unremarkable.
→ A patient who develops sudden onset of severe, intermittent, and unilateral pain associated with nausea and vomiting may have ovarian torsion.
→ PID is unlikely to be diagnosed in this patient due to lack of risk factors for PID such as multiple sexual partners, multiple sexual partners, a history of prior STIs, a history of sexual abuse, and IUD use.
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