Полезные материалы за все 6 курсов / Учебники, методички, pdf / Kaplan Pediatrics USMLE 2CK 2021
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USMLE Step 2 CK λ Pediatrics
Stature-for-age percentiles:
Girls, 2 to 20 years
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Chapter 3 λ Growth and Nutrition
Constitutional Delay
BA<CA
Adapted from CDC.gov/National Center for Health Statistics
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USMLE Step 2 CK λ Pediatrics
Growth Hormone Deficiency
BA<CA
Adapted from CDC.gov/National Center for Health Statistics
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Chapter 3 λ Growth and Nutrition
Familial Short Stature
BA=CA
Adapted from CDC.gov/National Center for Health Statistics
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USMLE Step 2 CK λ Pediatrics
Note
Suspect Turner syndrome in females with pathologic short stature.
Suspect craniopharyngioma if short stature and vision problems.
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DISORDERS OF GROWTH
Height
Short stature
A father is worried that his 13-year-old son is short. The child has been very healthy. He is below the 5th percentile for height and has been all his life. Physical exam is normal. Father is 6 foot 3; mother is 5 foot 10. Father was a “late bloomer.”
•Constitutional growth delay—child is short prior to onset of delayed adolescent growth spurt; parents are of normal height; normal final adult height is reached; growth spurt and puberty are delayed; bone age delayed compared to chronological age.
•Familial short stature—patient is parallel to growth curve; strong family history of short stature; chronologic age equals bone age.
•Pathologic short stature—patient may start out in normal range but then starts crossing growth percentiles. Differential diagnosis: craniopharyngioma, hypothyroidism, hypopituitarism, nutritional problems, and other chronic illnesses.
Table 3-1. Growth Velocity
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Normal |
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Abnormal |
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Bone age = |
Ideal |
• Genetic |
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chronological age |
Genetic (familial) short stature |
• Chromosomal |
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Bone age < |
Constitutional delay |
• Chronic systemic disease |
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chronological age |
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• Endocrine related |
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Bone age ≥ |
Obesity (tall) |
• Precocious puberty |
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chronological age |
Familial tall stature |
• Congenital adrenal |
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hyperplasia |
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• Hyperthyroidism |
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Tall stature
•Usually a normal variant (familial tall stature)
•Other causes—exogenous obesity, endocrine causes (growth hormone excess [gigantism, acromegaly], androgen excess [tall as children, short as adults])
•Syndromes—homocystinuria, Sotos, Klinefelter
Weight
Organic failure to thrive
A baby weighs 16 pounds at 1 year of age. Birth weight was 8 pounds. He has irritability, diarrhea, and abdominal distension. He was doing well until age 9 months when he started to eat the food that the rest of the family eats. His length curve is just starting to flatten.
Chapter 3 λ Growth and Nutrition
•Causes include malnutrition, malabsorption (infection, celiac disease, cystic fibrosis, disaccharide deficiency, protein-losing enteropathy), allergies, immunodeficiency, and chronic disease
•Initial diagnostic tests (when organic causes are suspected)—document caloric intake, CBC, urinalysis, liver function tests, serum protein, sweat chloride, stool for ova and parasites
Clinical Recall
An 8-year-old boy has been under the 2nd percentile for height all of his life. Hand x-ray for bone age assessment reveals a bone age of 8 years. Which of the following is the most likely diagnosis?
A.Hypothyroidism
B.Constitutional growth delay
C.Familial short stature
D.Chronic illness
E.Poor nutritional status
Answer: C
Courtesy of Tom D. Thacher, M.D.
Figure 3-1. Kwashiorkor
Note generalized edema secondary to low serum albumin.
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USMLE Step 2 CK λ Pediatrics
Non-organic failure to thrive
A 4-month-old infant presents to the emergency department because of upper respiratory symptoms. The patient is <5th percentile in weight and length. He is 3.5 kg. Birth weight was 4.2 kg. The mother states that the child takes 16 oz of infant formula per day with cereal added. Physical exam reveals a baby with little subcutaneous fat, long dirty fingernails, impetigo, and a flat occiput.
•Emotional or maternal deprivation plus nutritional deprivation leads to neglect (psychosocial deprivation); also look at socioeconomic and intelligence issues of parents
•Clinically, children are thin and wasted-appearing and may have poor hygiene; developmental delays, social delays (no eye contact, no expression); feeding aversion
•Major emphasis of diagnosis is not on medical testing but on showing that child can gain appropriate weight with good care (may need hospitalization)
•Report all cases with respect to maternal neglect to Child Protective Services (CPS); require long-term intervention
Obesity
•Risk factors—predisposition, parental obesity, family/patient inactivity, feeding baby as response to any crying, and rarely associated in syndromes (Prader-Willi; Down)
•Presentation—tall stature in some, abdominal striae, associated obesity of extremities; increased adipose tissue in mammary tissue in boys, large pubic fat pad, early puberty
•Diagnostic tests—BMI >85% signifies overweight to obese
•Complications—Obese infants and children are at increased risk of becoming obese adults (the risk is greater with advanced age of onset); cardiovascular (hypertension, increased cholesterol), hyperinsulinism, slipped capital femoral epithesis, sleep apnea, type 2 diabetes, acanthosis nigricans.
•Treatment—exercise and balanced diet; no medications
FEEDING
A normal newborn has sufficient stores of iron to meet requirements for 4–6 months, but iron stores and absorption are variable. Breast milk has less iron than most formula, but has higher bioavailability.
•Formula is supplemented with vitamin D; breastfed infants must be supplemented from birth (400 IU/d)
•Vitamin K is routinely given intramuscularly at birth, so no supplementation needed
•Both breast milk and formula are 90% H2O, so no additional H2O needed
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Chapter 3 λ Growth and Nutrition
Breastfeeding
A nursing mother asks if her 3-month-old baby requires any vitamin supplementation.
Most infants can breastfeed immediately after birth and all can feed by 4–6 months. The feeding schedule should be by self-regulation; most establish by 1 month.
•Advantages
–Psychological/emotional—maternal-infant bonding
–Premixed; right temperature and concentration
–Immunity— protective effects against enteric and other pathogens; less diarrhea, intestinal bleeding, spitting up, early unexplained infant crying, atopic dermatitis, allergy, and chronic illnesses later in life; passive transfer of T-cell immunity
–Decreased allergies compared to formula fed
–Maternal—weight loss and faster return to preconceptional uterine size
•Contraindications: HIV; HBV; CMV; HSV (if lesions on breast); acute maternal disease if infant has no disease eg, tuberculosis, sepsis; breast cancer; substance abuse
–Drugs: (absolute contraindications) antineoplastics, radiopharmaceuticals, ergot alkaloids, iodide/mercurials, atropine, lithium, chloramphenicol, cyclosporin, nicotine, alcohol
–Drugs (relative contraindications) neuroleptics, sedatives, tranquilizers, metronidazole, tetracycline, sulfonamides, steroids
–No contraindication with mastitis
Clinical Recall
For which of the following new mothers may breastfeeding be recommended?
A.A woman with HIV
B.A woman with mastitis
C.A woman taking lithium for bipolar disorder
D.A woman with breast cancer on chemotherapy
E.A woman suspected to be using drugs of abuse
Answer: B
Note
Mothers with HBV infection are free to breastfeed after the neonate has received the appropriate recommended vaccinations against HBV.
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USMLE Step 2 CK λ Pediatrics
Table 3-2. Breast Milk Versus Cow Milk
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Component |
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Human Milk |
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Cow Milk |
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Water/solids |
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Same |
Same |
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Calories |
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20 cal/oz |
20 cal/oz |
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Protein |
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1–1.5% (whey dominant) |
3.3% (casein dominant) |
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Carbohydrate |
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6.5–7% lactose |
4.5% lactose |
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Fat |
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high in low chain fatty acids |
high in medium chain fatty acids |
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Minerals |
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Iron better absorbed |
Low iron and copper |
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Vitamins |
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Diet dependent, low in K |
Low in C, D |
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Digestibility |
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Faster emptying |
Same after 45 days |
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Renal solute load |
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Low (aids in renal function) |
Higher |
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Note
Do not give cow milk to infants age <1.
Formula Feeding
•Infant formulas. Formula feeding is used to substitute or supplement breast milk. Most commercial formulas are cow-milk–based with modifications to approximate breast milk. They contain 20 calories/ounce. Specialty formulas (soy, lactose-free, premature, elemental) are modified to meet specific needs.
•Cow milk (whole milk) should not be introduced until after the full first year of life. Introduction of cow milk <1 yr promotes iron-deficiency anemia (low Fe in cow milk plus low bioavailability; also causes erosion of GI mucosa, leads to blood loss and therefore Fe loss).
•Advanced feeding—Stepwise addition of foods (one new food every 3−4 days)
SOLIDS
•Iron-fortified cereal only at 4-6 months (when infant is developmentally able to take cereal by spoon)
•Step-wise introduction of strained foods (vegetables and fruits), then dairy, meats (6-9 months; stage I pureed and stage II chunkier)
•Table foods at 9-12 months
•No honey in first year of life—infant botulism
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Development 4
Chapter Title
Learning Objective
Explain information related to primitive reflexes and developmental milestones
OVERVIEW
Development includes 5 main skill areas: visual-motor, language, motor, social, and adaptive.
•Assessment is based on acquisition of milestones occurring sequentially and at a specific rate: each skill area has a spectrum of normal and abnormal
–abnormal development in one area increases likelihood of abnormality in another area, so careful assessment of all skills is needed
–developmental diagnosis is a functional description/classification and does not specify an etiology
•Developmental delay is performance significantly below average, i.e., developmental quotient (developmental age/chronologic age × 100) of <75; may be in ≥1 areas; 2 assessments over time are more predictive than a single assessment
•Major developmental disorders
–Intellectual disability: IQ <70–75 plus related limitation in ≥2 adaptive skills, e.g., self-care, home living, work, communication
–Communication disorders (deficits of comprehension, interpretation, production, or use of language)
–Learning disabilities, one or more of (defined by federal government; based on standardized tests): reading, listening, speaking, writing, math
–Cerebral palsy
–Attention deficit/hyperactivity disorder
–Autism spectrum disorders
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