Developmental Milestones
At approximately what age should most children begin walking independently?
12–15 months.
Teaching Pearl:
Walking after 15 months warrants developmental evaluation but can still be normal until 18 months depending on the overall clinical picture.
A healthy newborn is delivered at term without complications. Which vaccine should be administered before hospital discharge?
Hepatitis B vaccine.
Teaching Pearl:
All medically stable infants ≥2,000 g born to HBsAg-negative mothers should receive the first Hepatitis B vaccine within 24 hours of birth.
A previously healthy 2-year-old suddenly develops a barking cough, hoarse voice, and inspiratory stridor after several days of URI symptoms. What is the most likely diagnosis?
Croup.
Teaching Pearl:
Dexamethasone should be given to all patients with croup. Nebulized epinephrine is reserved for moderate to severe disease.
A school-aged child has honey-colored crusted lesions around the nose and mouth.
Impetigo
Teaching Pearl:
Usually caused by Staphylococcus aureus or Group A Streptococcus.
A healthy 2-month-old is brought in for a well-child visit. The parents ask how their baby should sleep to reduce the risk of sudden infant death syndrome (SIDS).
Alone, on their back, in a crib or bassinet with a firm mattress and no loose blankets or toys.
Teaching Pearl:
Remember the ABCs of Safe Sleep: Alone, Back, Crib.
Which developmental milestone is most concerning if absent in an 18-month-old?
A. Running
B. Pointing to objects
C. Using spoon
D. Scribbling
B. Pointing to objects.
Teaching Pearl:
Lack of pointing (joint attention) is an early sign concerning for autism spectrum disorder.
A child develops a low-grade fever the evening after receiving routine immunizations. Should future vaccines be withheld?
No.
Teaching Pearl:
Mild fever and local reactions are expected and are not contraindications to future doses.
A febrile infant appears pale, tachycardic, and has delayed capillary refill. What type of shock should be assumed until proven otherwise?
Septic shock.
Teaching Pearl:
Children often maintain blood pressure until late shock.
A 6-year-old has palpable purpura on the lower extremities, abdominal pain, and swollen knees.
IgA vasculitis (Henoch-Schönlein Purpura)
Teaching Pearl:
Monitor for renal involvement with urinalysis and blood pressure checks.
A family asks when sunscreen should first be used routinely.
At 6 months of age.
Teaching Pearl:
For infants younger than 6 months, prioritize shade and protective clothing; use small amounts of sunscreen only when shade and clothing are inadequate.
During a 9-month visit, an infant still demonstrates a persistent Moro reflex. Why is this concerning?
It may indicate an underlying neurologic disorder.
Teaching Pearl:
The Moro reflex typically disappears by 4–6 months.
A 2-month-old is diagnosed with severe combined immunodeficiency (SCID). Which routine vaccine is contraindicated?
Rotavirus vaccine.
Teaching Pearl:
Rotavirus is a live vaccine and is contraindicated in infants with SCID.
A child with DKA develops headache, bradycardia, hypertension, and altered mental status after several hours of treatment. What complication has occurred?
Cerebral edema.
Teaching Pearl:
Treat immediately with hypertonic saline or mannitol. Do not delay treatment for CT imaging.
A 12-year-old obese adolescent presents with knee pain but has a normal knee examination. Hip internal rotation is painful and limited.
Slipped capital femoral epiphysis (SCFE)
Teaching Pearl:
Always examine the hips in adolescents presenting with knee pain.
A 2-year-old is still drinking multiple bottles of milk each night. What nutritional safety concern is most important?
Iron deficiency anemia and dental caries.
Teaching Pearl:
Prolonged bottle use can contribute to excess milk intake, poor iron intake, and tooth decay.
A 4-year-old cannot jump on one foot, cannot copy a cross, and has unintelligible speech. Which type of delay is most likely?
Global developmental delay.
Teaching Pearl:
Delays across multiple domains warrant comprehensive developmental assessment.
A 6-year-old with functional asplenia due to sickle cell disease is up to date on routine immunizations. Which additional vaccines should be considered?
Additional pneumococcal vaccination (PPSV23), meningococcal vaccines (MenACWY and MenB when age-appropriate), and annual influenza.
An infant has persistent SVT despite vagal maneuvers. What medication is administered next, and how should it be given?
Rapid IV adenosine followed immediately by a saline flush.
Teaching Pearl:
Because of its extremely short half-life, adenosine must reach the heart quickly to be effective.
A child has severe nighttime bone pain, fever, refusal to bear weight, and elevated inflammatory markers.
Acute hematogenous osteomyelitis
Teaching Pearl:
MRI is the preferred imaging modality for early diagnosis.
A teenager reports vaping nicotine because it is "safer than cigarettes." What is the best counseling response?
Vaping is not safe for adolescents and is associated with nicotine addiction, impaired brain development, and lung injury risk.
Teaching Pearl:
Screen all adolescents for vaping and nicotine use during preventive visits.
During a developmental evaluation, a child loses previously acquired language skills between 18 and 24 months. What is the most concerning feature of this history?
Developmental regression.
Teaching Pearl:
Regression is never considered a normal variant and warrants urgent evaluation.
A 12-month-old exposed to measles is incompletely immunized and presents within 72 hours of exposure. What is the preferred post-exposure prophylaxis?
MMR vaccine within 72 hours of exposure (if eligible and not otherwise contraindicated).
Teaching Pearl:
Immune globulin is reserved for certain high-risk individuals or later presentations.
What medication should be administered immediately for torsades de pointes??
Magnesium sulfate.
Teaching Pearl:
Magnesium is first-line therapy even if the serum magnesium concentration is normal.
A 7-year-old has recurrent skin abscesses caused by Staphylococcus aureus, eczema, and markedly elevated IgE levels.
Hyper-IgE (Job) syndrome
Teaching Pearl:
Think of primary immunodeficiency when severe infections recur with characteristic clinical findings.
A 2-year-old is found chewing on a colorful laundry detergent pod. He begins coughing and vomiting. What is the immediate recommendation?
Call Poison Control immediately and seek emergency medical evaluation if symptoms are present. Do not induce vomiting.
Teaching Pearl:
Laundry detergent pods can cause caustic injury and airway compromise.