1. An infant is diagnosed with a given disorder below. Which of these poses the greatest recurrence risk for this patient’s future siblings?
(B)Cystic fibrosis (CF) is inherited in an autosomal recessive fashion, creating a 25% recurrence risk for subsequent pregnancies. Hirschsprung disease usually is sporadic with a risk of about 3%–5% to siblings of an affected case. There are rare families with Hirschsprung disease transmitted as an autosomal dominant or recessive pattern of inheritance. Ventricular septal defects are also multifactorial in inheritance, the recurrent risk for siblings of a patient with congenital heart disease is 3%–4%. Trisomies are most typically sporadic events and recurrence varies depending on the mother’s age. A small proportion of trisomies are transmitted by a parent as part of a balanced translocation with higher recurrence risks in those families.(Behrman 1239; Brodsky, 165)
2. A term infant with microcephaly, jaundice, and thrombocytopenia is thought to have congenital CMV infection. Your attending physician notes though that 1.5% of all newborns may have asymptomatic congenital cytomegalovirus infection. Which of the following is the most commonly reported sequelae of such infections?
(B)The majority (90%–95%) of newborn infants infected with cytomegalovirus are asymptomatic at birth. Asymptomatic congenital cytomegalovirus infection is a leading cause of sensorineural hearing loss, which can occur in approximately 7% of infants. Hearing loss is often progressive and may not be detected until the patient is older. Sudden loss of residual hearing at age 4–5 years has been associated with congenital cytomegalovirus.(Behrman, 1067, 2129)
3. A 2-year-old infant has acquired sensorineural hearing loss. His mother is asking what the most likely cause could be. What is the least likely etiology of acquired sensorineural hearing loss in a toddler?
(D)Congenital infections with cytomegalovirus, toxoplasmosis, or syphilis may present with delayed onset of sensorineural hearing loss. Hyperbilirubinemia at levels requiring exchange transfusion is also associated with sensorineural hearing loss. Aminoglycosides put an infant at increased risk for hearing loss particularly when used in combination with other ototoxic drugs or when levels are not appropriately monitored with adequate dosing adjustments in response to these levels. Bacterial meningitis also has a strong association with hearing impairment. Although some cheomotherapeutic agents are associated with hearing loss, neuroblastoma does not have a primary association with sensorineural hearing loss.(Behrman, 2130)
4. The pediatric surgeon is requesting an echocardiogram on a hospitalized newborn with a congenital defect of the gastrointestinal tract. Which of the following defects has the highest incidence of associated cardiac defects?
(A)Omphaloceles are among the most common of the abdominal wall defects noted in the newborn and pediatricians must know how to diagnose and provide additional care. In addition, they need to understand the association with other defects. Cardiovascular anomalies occur in 25%–30% of infants with omphaloceles. Omphaloceles also are frequently associated with chromosomal anomalies (50%) and other syndromes including the Beckwith-Wiedemann syndrome (omphalocele, severe hypoglycemia, macrosomia, and macroglossia). Gastroschisis is a defect of the abdominal wall which is often confused with omphalocele. It is characterized by a defect where the intestines are located outside of the abdomen, and exposed to the air. Unlike omphalocele, there is no sac over the intestines (see Figure 3-4). The other lesions listed are not typically associated with chromosomal, syndromic, or other nongastrointestinal anomalies.(Brodsky, 273)
5. You are a practicing pediatrician in a state where cystic fibrosis is not a routine part of newborn screening. Which of the following symptoms in a newborn infant would prompt you to test for cystic fibrosis?
(C)The newborn with cystic fibrosis generally is asymptomatic. The most common manifestation, meconium ileus, occurs in 15%–20% of CF patients. The ileum is completely obstructed with meconium, which results in intestinal obstruction. The meconium plug syndrome also is seen with an increased frequency in infants with cystic fibrosis, but it is less specific than meconium ileus. Sweat chloride testing in suspected cases of cystic fibrosis has always been troublesome in the newborn period but DNAtesting is now available and is 90%–95% sensitive. In the United States, some states have instituted routine newborn screening for cystic fibrosis.(Behrman, 1437)
6. A 3-year-old male child from South America is brought in for an adoption physical examination. He has a 4–5 mm, foamy, mildly vascular, conjuctival lesion next to the cornea on the medial side of both eyes. Which nutrient deficiency is most likely to cause this lesion?
(A) Vitamin A deficiency remains the leading cause of preventable childhood blindness worldwide. Though rare in the United States and other developed countries, this condition is prevalent in developing countries, especially in those with the highest burden of deaths among children under 5 years of age. The lesion described, a Bitot spot, is one of the early classic signs of vitamin Adeficiency. As vitamin A deficiency symptoms progress, the eyes become dry and itchy (conjunctivitis sicca). Corneal ulcers subsequently can form. In the worst cases these ulcers can rupture allowing eye contents to avulse, resulting in permanent blindness. Though most health care providers recognize that vitamin Adeficiency can lead to blindness, most are unaware of the full impact of vitamin A deficiency on children’s health worldwide. Before developing blindness, vitamin A deficient children face a 23% greater risk of dying frominfectious diseases such as measles, malaria, and diarrhea. An estimated 100–140 million children live with vitamin A deficiency worldwide.UNICEF and other organizations are working to reduce this number as they work toward meeting the fourth Millennium Development Goal which is a two-thirds reduction in underfive mortality by 2015. (McMillan, 113; UNICEF Statistics, http://www.childinfo.org/areas/ vitamina; UNICEF, The State of the World’s Children)
7. At a 4-month well child visit, a mother is distressed because her baby’s grandmother believes she should have started feeding her baby solid food at 2 months of age. It is generally recommended that beikost (infant foods other than milk) be introduced into the infant’s diet at about what age?
(D)It is recommended that the introduction of nonmilk foods (beikost) be delayed until the age of 4–6 months. Pancreatic enzymes, such as amylase and lipase, are low early in life but seem adequate to digest most nonmilk foods. The most compelling reason to delay introduction of solids relates to developmental readiness such as disappearance of tongue thrust (extrusor reflex), acquisition of head control, and ability to sit with support. More recently, the avoidance of overfeeding and overweight has become an argument for delaying the introduction of solids until after 4–6 months of age. Admittedly, it often is difficult to convince parents to refrain from introducing solids at an earlier age.(AAP, 103–115)
8. 4 A 23-month-old female is hospitalized for severe malnutrition. Which of the following problems is most likely to be the result of inappropriately rapid treatment of the severely malnourished child?
(D)Congestive heart failure is very easy to precipitate in a severly malnourished child particulary if colloid (blood) or crystalloid (sodium) is infused aggressively. Because the heart is malnourished, contractility and therefore cardiac output is already impaired. By increasing plasma volume which would occur by infusing either of the above substances, the preload to the heart would increase in the face of an impaired pump, resulting in congestive heart failure. During refeeding of severe malnutrition, potassium and phosphate are rapidly taken up by the expanding body cell mass, resulting in low potassium and/or phosphate if not supplemented. Total body water increases in malnutrition resulting in a dilutional hyponatremia which slowly corrects with refeeding. Glycogen stores are depleted in severe malnutrition and hypoglycemia can easily occur if the malnourished child is stressed. (Tsang, 93–95)
9. A pregnant African-American woman plans to breastfeed her baby. She has read of the nutritional, psychologic, and immunologic advantages, but recalled breastfed babies might still require vitamin supplementation. The most current nutritional recommendations indicate she should supplement the baby’s nutrition with which vitamin?
(E) To the best of our current knowledge, formulas are fortified with the necessary vitamins and minerals. Breast milk contains quantitatively small amounts of vitamin D. However, this is sufficient for many babies. Exclusively breastfed infants who are at risk for vitamin D deficiency include infants with inadequate maternal intake of vitamin D (eg, mothers who are strict vegans), infants with inadequate sunlight exposure (eg, dark skin pigmentation, cold climates, urban environments, clothing practices, and more recently the overuse of sunblocking agents), and older infants still exclusively breastfed. Therefore, vitamin D supplementation is recommended for most babies who are exclusively breastfed. Too much vitamin D can be toxic and just as dangerous as too little. The major target organ of vitamin D poisoning is the kidney. (McMillan, 112–116; AAP, 71)
10. 17 A5-month-old male presents with poor weight gain. His diet consists only of goat milk. On examination, he appears tired and is mildly tachycardic. The laboratory value most likely to be elevated is which of the following?
(B) Goat milk contains little folate. Infants fed primarily goat milk are at risk to develop a megaloblastic anemia from folate deficiency. Therefore, the mean corpuscular volume (MCV) will be elevated. The metabolism of folic acid and vitamin B12 is interrelated. Hematologic problems caused by a deficiency in one can be improved with supplementation of either. The neurologic complications of vitamin B12 deficiency, however, will not be improved with treatment with folic acid. Therefore, it is important to carefully sort the child’s deficiencies. Large doses of folic acid should not be given until vitamin B12 deficiency has been excluded. (AAP, 938, McMillan, 1694–1695)
11. A single, 35-year-old pregnant female has not been tested previously for HIV or hepatitis. While awaiting prenatal screening, she requests information regarding breastfeeding. You would most accurately tell her in the United States breastfeeding of infants is contraindicated in which of the following?
(A)The human immunodeficiency virus can be transmitted from mother to baby via breastfeeding. In the United States, where other means of infant nutrition are readily available, HIV-infected women should be advised not to feed their breast milk to babies. According to WHO recommendations, in developing countries, the risk of HIV transmission from breastfeeding must be weighed against the risk of contaminated or nutritionally incomplete replacementfeeding, therefore at the time of this writing, it is still recommended that HIV-positive women from developing countries breastfeed their babies until 6 months of age. UNICEF reports only 37% of babies in developing countries are being breastfed. Suboptimal breastfeeding is responsible for an estimated 1.4 million child deaths worldwide. Although hepatitis B surface antigen has been detected in breast milk, studies indicate this does not significantly increase the risk of transmission of hepatitis among breastfed infants. Transmission of hepatitis C virus via breastfeeding is theoretically possible but not clinically documented in anti-HCV-positive, HIV-negative women. (AAP:Red Book 2006: 126)
12. A new mother asks you how much formula her 3 kg infant should be consuming daily. To give her an idea on how much fluid the child should be taking, you calculate out the approximate daily fluid requirement. Which of the following most closely resembles this child’s daily fluid requirements?
(D)Infants weighing less than 10 kg expend an average of 100 cal/kg of body weight. A 3-kg infant has a basal caloric requirement of 300 calories. The infant needs approximately 100 mLof water per 100 calories metabolized. This translates to a fluid requirement of 300 ml. This concept is an important one to remember since fluid and caloric calculations for adults are different from those for children.(McMillan, 67; Behrman, 242–245)
13. A 30 kg child you are taking care of in the hospital is receiving IV fluids in preparation for surgery. You are trying to determine if the fluids are running at an appropriate rate for daily maintenance. What do you determine is the approximate daily fluid requirement for this child?
(C) There is a simple method for calculating the fluid (and caloric) requirements for an infant or child: 100 mL/kg for the first 10 kg of body weight, 50 mL/kg for the second 10 kg of body weight (between 11 and 20 kg), and 20 mL/kg for each kg of body weight greater than 20 kg. Using this method, the fluid requirements for this child are calculated as follows: For the first 10 kg 100 mL/kg ×10 kg = 1000 mL For the second 10 kg 50 mL/kg ×10 kg = 500 mL For the remaining 10 kg 20 mL/kg ×10 kg = 200 mL This gives the child a total fluid requirement of 1000 mL+ 500 mL+ 200 mL= 1700 mL. Notice that this child does not require 10 times as much fluid as the 3-kg child. (McMillan, 67–68; Behrman, 242–245)
14. A 50 kg child you are taking care of has just received replacement for her fluid deficit. You are now trying to determine the hourly fluid rate needed to supply maintenance fluid requirements. Which number below most accurately reflects the correct mL/h?
(D) Calculate the daily fluid requirements of the patient. For the first 10 kg 10 kg ×100 mL/kg = 1000 mL For the next 10 kg 10 kg ×50 mL/kg = 500 mL For the remainder of the body weight 30 kg ×20 mL/kg = 600 mL Adding these together (1000 mL+ 500 mL+ 600 mL) gives a daily total of 2100 mL. This daily maintenance requirement divided over 24 hours (2100 mL/24 h) gives you 88 mL/h, or approximately 90 mL/h. (Behrman, 242–245)
15. An infant presents with a weight of 8 kg and a 3-day history of diarrhea and vomiting. He appears severely dehydrated with decreased sensorium, sunken fontanelle, poor skin turgor, and decreased urine output. Which of the following most closely estimates the fluid deficit of this child?
(B)The infant described is probably about 15% (severely) dehydrated. In classifying infants and young children, dehydration is divided into mild (5%), moderate (10%), and severe (15%) based on clinical examination. (For an older child and adult, comparable figures would be 3%, 6%, and 9%.) An infant that is mildly (5%) dehydrated has a normal to slightly increased heart rate, slightly dry mucous membranes, poor tear production, and slightly decreased urine output. An infant moderately (10%) dehydrated demonstrates worsening of the previous signs along with decreased skin turgor and sunken anterior fontanelle. An infant with severe (15%) dehydration presents with symptoms of hypovolemic shock with decreased blood pressure, delayed cap refill, Kussmaul respiration, and depressed sensorium. Many students and physicians would calculate a rough estimate of total body fluid deficit as 8 kg ×15% = 1200 mL deficit. However, this calculation is not entirely correct, or accurate, as dehydration and percent dehydration are related to a premorbid weight (wtpre)—in this case, the infant’s weight before he became dehydrated. Current weight = wtpre× (1−percent dehydrated/100). Therefore, the deficit is 15% of 9.4 kg, or 1400 mL. (Note: Total fluid deficit is not the same as total fluid requirement. Daily total fluid requirements in a dehydrated child includes deficit fluid replacement in addition to routine daily fluid requirements and any abnormal ongoing losses such as continued diarrhea.) (Behrman, 245–249)
16. 9 A 10-month-old male infant had multiple episodes of vomiting and diarrhea over the last 24 hours. The infant now has slightly sunken eyes, mildly decreased activity, and dry skin. Vital signs are stable. Which of the following is the generally preferred method for rehydration for this patient?
(A) Infants that present with these physical findings are mildly to moderately dehydrated and are candidates for oral rehydration therapy. Consistent administration of small volumes is effective in correcting dehydration even with continued diarrhea. Composition of the oral replacement fluid should be designed to optimize repletion of the ECF space and provide some carbohydrate to give minimal calories in order to avoid catabolism. The relationshipof sodium concentration to carbohydrate concentration is important for appropriate absorption of sodium without worsening the fluid losses from an osmotic diarrhea caused by overadministered and/or inappropriate carbohydrate solutions. Most household liquids (tea and kool-aid) are inappropriate because of their hypotonic (low sodium) content. However, commercially available rehydration formulas (ie, Pedialyte) are useful. Intravenous therapy is necessary only when the child refuses fluids orally or has severe dehydration with impending circulatory collapse.(Behrman, 246–250)
17. A13-year-old female presents to the emergency department with a 3-day history of fever above 104°F (40°C); vomiting; diarrhea; and diffuse, erythematous rash. She is found to have orthostatic hypotension. Laboratory evaluation reveals decreased platelets and elevated liver and renal function tests. The mother of the child informs you that the child is currently menstruating. You suspect that this child has a toxin mediated infection. What is the most likely etiology of this toxin mediated infection?
(B) Manifestations of staphylococcal toxic shock syndrome, which include fever, mental status changes, conjunctivitis, diffuse macular erythroderma, and multiple organ failure, are caused by a toxin elaborated by the staphylococci rather than by tissue invasion of the organism. The name of the toxin is toxic shock syndrome toxin-1 (TSST-1), and is produced by S aureus. The organism usually can be cultured from skin or mucous membrane and only rarely from the blood. It has been recovered from the vagina and has been associated with the use of tampons, especially those designed to be changed infrequently. Streptococcal toxic shock syndrome is cause by S pyogenes (group Astreptococcus). The incidence is highest among young children, particularly those with concomitant varicella. The organism can be isolated from blood about 50% of the time. BothN gonorrhoeaeandS agalactiaecan be found in the genital tract (the former as a pathogen and the latter as normal flora); neither is associated with toxin-mediated disease. Shiga toxin produced by E colicauses diarrhea and can be associated with hemolytic uremic syndrome. (Long, 110–112; American Academy of Pediatrics, 660–661)
18. What are additional features commonly associated with the toxin-mediated process described in Question 17?
(D)The case definition of staphylococcal toxic shock syndrome includes five to six of the following findings: fever; diffuse rash; desquamation 1–2 weeks after onset; hypotension; if obtained, negative results for blood (except S aureus approximately 5% of the time), throat, and CSF cultures, and negative serologic testing for Rocky Mountain spotted fever, measles, or leptospirosis; and multisystem organ failure. Organ involvement must include three or more of the following: gastrointestinal symptoms, muscular symptoms such as myalgia, mucous membrane involvement such as conjunctival hyperemia, vaginal or oropharyngeal involvement, hepatic dysfunction, renal dysfunction, platelet count less than 100,000/µL, or central nervous system dysfunction such as altered mental status.(American Academy of Pediatrics, 662)
19. Hilar lymphadenopathy is noticed on the chest x-ray obtained for a 6-year-old male known to have mild intermittent asthma. The child is from rural Ohio and lives on a farm with chickens. Tuberculin skin testing is negative and the family denies history of exposure to tuberculosis. You suspect histoplasmosis infection. What is the most likely mode of transmission of the spores?
(C)Histoplasma capsulatumis the most common primary systemic mycosis in the United States, and most often occurs in the Ohio and Mississippi river valleys. The organism grows in moist soil and is facilitated by bird droppings. As in adults, the respiratory tract is the portal of entry for histoplasmosis in essentially all cases in children. Inoculation other than by inhalation is exceedingly rare, and person to person transmission does not occur. (Long, 11198; American Academy of Pediatrics, 371–372)
20. You are seeing a healthy, full-term infant just after delivery. The mother plans on breast-feeding the baby and asks you how long immunity transferred to the baby from the pregnancy would be present. When does passively transferred maternal IgG antibody reach a nadir?
(B)Passively transferred maternal IgG decreases commensurate with the half-life, which is approximately 30 days. Therefore the nadir occurs in infants at the age of 3–6 months.(Long, 92)
21. The mother from Question 3 also tells you that she has read that breast-feeding immunity is different than that acquired in utero. What is the major source of immunity conferred in breast milk?
(D) Human milk provides optimal nutrition for the growing infant. It contains lactose and other carbohydrates that are substrates for protective microflora, such as Bifidobacterium and Lactobacillus spp. The major immunoglobulin present in breast milk is secretory IgA, and is available to act at the mucosal surface of the small intestine. Immunity is conferred against many specific enteropathogens and toxins. It also has been shown to inhibit binding of H influenzaeandS pneumoniaeto pharyngeal cells. (Nelson, 158) Answers
22. A 15-year-old girl was at an overnight rave 24 hours ago and was given Ecstasy by a friend. This morning, she is found comatose and resuscitation is unsuccessful. Most deaths related to Ecstasy have been linked to which of the following?
(C)Raves, or underground all-night parties, typically are attended by adolescents and young adults. Probably the most popular club drug used at raves is Ecstasy, or methlyenedioxymethamphetamine (MDMA). The use of Ecstasy, an amphetamine with hallucinogenic and stimulant properties, results in CNS agitation, tachycardia, hypertension, and diaphoresis. Serotonergic effects of Ecstasy also include enhanced sensual perceptions and blunted perceptions of hunger and thirst. Most Ecstasy-related deaths have been linked to hyperthermia (increased physical activity in enclosed space) or hyponatremia (water intoxication or SIADH). (Poirier, 2002;18:216–218, www.usdoj.gov/ndic)
23. A 2-year-old is found with an opened empty bottle of acetaminophen tablets and has pill fragments in his mouth. The major cause of morbidity and mortality in acute poisoning with acetaminophen is which of the following?
(A) Ingestion of acetaminophen in therapeutic doses typically does not result in side effects. However, ingestion of potentially toxic doses (> 10 g in adults and > 200 mg/kg in children) may result in hepatotoxicity. When present, hepatotoxicity peaks 48–96 hours after ingestion. The use of antidotal therapy with N-acetylcysteine is guided by the serum acetaminophen level drawn no less than 4 hours following ingestion. (Acetaminophen: Consensus Guideline for out of hospital management; Rudolph, 2002;409–411)
24. A4-year-old boy has just fallen off the top rung of the ladder while climbing up to the 3-m diving board at the local swimming pool. He lands on the pavement and is motionless when the lifeguard arrives there in less than a minute. Following closed head injury, which of the following would be most ominous?
(C) Following head trauma, eye changes such as fixed, dilated pupils usually are indicative of increasing intracranial pressure or focal neurologic damage. Ahistory of unconsciousness, irritability and lethargy, amnesia for the event, and/or vomiting are seen commonly in the absence of major intracranial injury. (Rudolph, 348, 2244; Singer, 62:819, 1978)
25. Yearly, over 20,000 individuals younger than 21 years sustain traumatic head injuries while bicycling. Helmet use while bicycling prevents what percent of serious brain injury?
(D) An astounding 88% of serious brain injury sustained while bicycling is prevented with helmet use. Additionally, helmet use prevents an estimated 65% of injuries to the mid and upper face. Two factors have been identified as having a strong association with bicycle helmet use by young children. These are helmet use by an accompanying parent and a state mandatory helmet use law or local ordinance. Communities have successfully raised the rate of helmet use with a variety of programs. (AAP Committee on Injury and Poison Prevention 2001;108:1030–1032)
26. An 18-month-old presents to the emergency department with a 2-day history of lethargy. Blue and yellow bruising over the buttocks and thighs are noted and retinal hemmorhages are seen on fundoscopic examination. Parents deny any history of bleeding or bruising other than what you see. Laboratory studies including a urine analysis, platelet count, bleeding time, and PT/PTT reveal normal values. Which of the following is the most likely diagnosis to explain this child’s findings?
(E) Physical abuse is the leading cause of serious head injury among infants, and studies suggest 95% of serious head injuries in infants under 1 year of age are related to child abuse. The entity “abusive head trauma syndrome (formally referred to as shaken baby syndrome)” typically occurs in infants less than 2 years and was first described as a constellation of findings which included retinal hemorrhages, subdural and/or subarachnoid hemorrhages, and little or no evidence of external cranial trauma caused by “extreme rotational cranial accelerationinduced by violent shaking.” Evidence of other injuries, such as bruises, rib fractures, long-bone fractures, and abdominal injuries are often not present. In up to 90% of cases, unilateral or bilateral retinal hemorrhages are present. In cases of leukemia and idiopathic thrombocytopenic purpura, hematologic abnormalities generally are present and suggestive of the diagnosis. HenochSchöenlein purpura is a systemic vasculitis typically manifest by a triad of arthritis, abdominal pain (related to small bowel edema and inflammation and occasionally to intussusception), and a classic purpuric rash which appears on the buttocks and legs of the child; neurologic manifestations may occur but are not characterized by retinal hemorrhage. (AAP Committee on Injury and Poison Prevention, July 2001;108(1):206–210; Kliegman, 2007)
27. An 18-month-old male toddler presents with pallor. He drinks 64 oz of cow milk per day. The examination is significant only for an obese and playful male with pallor. Stool is negative for blood. Which laboratory test would most likely reveal the diagnosis?
(C) Given the history of excessive intake of milk, a food known to be low in iron, and the presentation of pallor, initial testing should focus on the hemoglobin and iron status. The reticulocyte count and the mean corpuscular volume (MCV) generally are low in iron deficiency. Chest radiography and stool smears for ova and parasites are not indicated. Serum haptoglobin is low in state of hemolysis, but that is not the most likely cause of anemia in this case. Abone marrow biopsy is not indicated at this time. (Behrman, 2014–2016)
28. An 18-month-old male toddler presents with pallor. He drinks 64 oz of cow milk per day. The examination is significant only for an obese and playful male with pallor. Stool is negative for blood. Testing reveals a mean corpuscular volume of 60 fL(nL72–86 fL) and an elevated red cell distribution width. The most likely diagnosis is
(D) In iron deficiency anemia, the red blood cells are smaller than normal and are variable in size; therefore a decreased MCV and elevated red cell distribution width (RDW) are classic with this history. Vitamin B12 deficiency from a poor diet or intrinsic factor deficiency presents with an elevated MCV. No blasts indicating leukemia or stippling suggesting hemosiderosis were noted on the smear. Additionally, there is no evidence of sickled cells. (Behrman, 1469–1471)
29. An 18-month-old male toddler presents with pallor. He drinks 64 oz of cow milk per day. The examination is significant only for an obese and playful male with pallor. Stool is negative for blood. Appropriate therapy is started for this patient. When should reticulocytosis peak?
(C)When iron deficiency anemia is suspected, elemental iron at a dose of 6 mg/kg/day divided into two or three doses should be initiated. Appetite will return to normal in 12–24 hours. Bone marrow response will begin in 36–48 hours. Reticulocytosis will peak around 5–7 days. Repletion of stores will occur in 1–3 months depending on the severity of the anemia. Contrary to common belief, iron does not constipate patients. Increasing vitamin C intake via diet or supplementation can increase iron absorption. Parents should be counseled regarding the importance of a diverse diet. Milk intake should be limited to 16–24 oz/day. (Behrman, 1469–1471)
30. Among children, short stature and infertility are most commonly associated with which of the following?
(C) Both Turner syndrome and Pierre Robin sequence are associated with short stature; however, Turner syndrome is also associated with gonadal dysgenesis and infertility. Children with Klinefelter syndrome and Marfan syndrome typically have long extremities, and children with Beckwith-Wiedemann syndrome typically have gigantism. (Rudolph CD,745, 762, 2091)