Pediatric Examination and Board Review (209 page)

(A) maternal vascular disease

(B) fetal chromosomal disorder

(C) in utero infection

(D) maternal fibroids

(E) all of the above

2.
The presence of 1 major anomaly and how many minor anomalies would suggest the possibility of a major chromosomal defect?

(A) 1

(B) 2

(C) 3

(D) 4

(E) 5

3.
This SGA baby born to a teenage mother has some petechiae on the face and trunk. You do the following

(A) send evaluative tests for CMV

(B) send a serologic evaluation for toxoplasmosis

(C) send a blood culture to detect possible occult bacteremia

(D) A, B, and C

(E) none of the above

4.
All are risk factors for congenital toxoplasmosis except

(A) eating steak tartare

(B) having a cat who lives indoors

(C) gardening

(D) exposure of a pregnant woman to an infant with toxoplasmosis

(E) all of the above

5.
The differential diagnosis of a newborn who is SGA with a normal physical examination includes

(A) CMV

(B) rubella

(C) toxoplasmosis

(D) varicella

(E) A and C

6.
Neonatal herpes skin lesions are most likely to be seen on day

(A) 1

(B) 3

(C) 5

(D) 8

(E) 21

7.
What percentage of women with neonates who develop herpes simplex virus (HSV) are asymptomatic or have no history of having had herpes?

(A) less than 1%

(B) 1-5%

(C) 5-20%

(D) 60-80%

(E) more than 95%

8.
Congenital toxoplasmosis has a prevalence in the United States of about

(A) 1:100

(B) 1:1000

(C) 1:10,000

(D) 1:100,000

(E) 1:1,000,000

9.
With regard to treatment of congenital toxoplasmosis, all of the following statements are true except

(A) prenatal treatment decreases transmission rate

(B) prenatal treatment of an infected fetus decreases fetal and newborn clinical manifestations

(C) postnatal treatment for 1 year is needed for infected symptomatic children

(D) postnatal treatment for 1 month is needed for infected asymptomatic children

(E) all of the above

10.
A baby diagnosed with congenital CMV infection passes the hearing screening test. Which of the following statements are true?

(A) the baby is fortunate; there will be no hearing loss

(B) the baby is still at risk for progressive hearing loss and will require repeat testing in the future

(C) the baby needs to see an audiologist for more advanced testing

(D) the auditory brainstem response (ABR) must have been done incorrectly

(E) none of the statements are true

11.
An SGA term baby is at risk for

(A) hypoglycemia

(B) polycythemia

(C) hypothermia

(D) A, B, and C

(E) none of above

12.
SGA neonates should have glucose levels followed for up to how long after birth?

(A) 2 hours

(B) 12 hours

(C) 24 hours

(D) 3 days

(E) 1 week

13.
In SGA infants, the most important predictor of future growth and development is

(A) weight at birth

(B) head size at birth

(C) length at birth

(D) body mass index (BMI)

(E) body surface area (BSA)

ANSWERS

1.
(E)
The causes of intrauterine growth retardation can be divided into three main categories:

• Systemic disease or causes in the mother that affect uteroplacental function. Examples include chronic hypertension, severe diabetes, lupus, and preeclampsia.

• Fetal causes (ie, those that inhibit the growth potential of the fetus). Examples include chromosomal disorders like trisomy 18 or congenital infections.

• Local uterine causes such as large fibroids, bicornuate uterus, or multiple uterine occupants, eg twins, that impair the growth of the fetus secondary to space constraints.

2.
(B)
An infant that has 2 minor anomalies and 1 or more major anomaly is likely to have an underlying genetic diagnosis.

3.
(E)
Petechiae on the face, trunk, and in the groin area can occur in normal infants. The platelet count should be checked. If the platelet count and the rest of the examination is normal, there is no need to perform additional evaluations. However, if there are petechiae on an SGA baby who also has hepatosplenomegaly, this infant should be evaluated further for intrauterine infections such as CMV or rubella. In this instance, there should be associated thrombocytopenia.

4.
(D)
Toxoplasma gondii
is a protozoan that is acquired through ingestion of undercooked or raw meat containing the tissue cyst stage of the parasite or exposure to other food materials that are contaminated by oocysts excreted in the feces of infected cats. There is no person-to-person transmission.

5.
(E)
Ninety percent of newborns congenitally infected with CMV are asymptomatic at delivery, and 10% will have signs and symptoms. Affected infants may be SGA. They may also have microcephaly, intracranial calcifications, hepatosplenomegaly, petechiae, thrombocytopenia, or hearing loss. In this baby, the examination is normal, although the baby is SGA. The diagnosis of congenital CMV can be made by PCR of blood or viral culture of urine obtained within the first 3 weeks of life. Infants with congenital toxoplasmosis are asymptomatic in 70-90% of cases.

6.
(D)
The incidence of neonatal HSV infection is approximately 1:3000 to 1:7000 live births. HSV infection may occur transplacentally, intrapartum, or postpartum. Most infected neonates acquire the virus at delivery. Only 30-50% of babies present with skin lesions that commonly appear around 7-10 days but can appear at any time.

7.
(D)
About 60-80% of women with neonates who develop HSV are asymptomatic or have no history of ever having herpes.

8.
(C)

9.
(D)
Treatment of the mother during pregnancy decreases the transmission rate to the fetus. If the mother and fetus are both infected, treatment of the mother with pyrimethamine and sulfadiazine decreases fetal clinical manifestations. Symptomatic or asymptomatic infected babies should be treated with pyrimethamine and sulfadiazine for 1 year.

10.
(B)
Ninety percent of babies with congenital CMV are asymptomatic at birth. Sensorineural hearing loss is the most common late sequela.

11.
(D)
SGA babies are at risk for hypoglycemia secondary to decreased glycogen stores, decreased gluconeogenesis, and increased sensitivity to insulin. They are at risk for hypothermia secondary to decreased subcutaneous fat and a large surface area to body weight ratio. They are at risk for polycythemia secondary to chronic hypoxia.

12.
(D)
Blood sugar should be monitored in an SGA baby for up to 3 days. Glycogen stores generally take 2-3 days to develop.

13.
(B)

S
UGGESTED
R
EADING

Martin R, Fanaroff AA, Walsh M.
Fanaroff and Martin’s Neonatal-Perinatal Medicine Diseases of the Fetus and Infant.
8th ed. Chicago, IL: Elsevier Mosby; 2006.

CASE 119: A 36-WEEK-GESTATION NEONATE’S MOTHER WANTS AN EARLY DISCHARGE

A 2300-g birthweight, 36-week gestation baby is now 40 hours old. The mother is all set to take him home.

SELECT THE ONE BEST ANSWER

1.
The American Academy of Pediatrics (AAP) guidelines for consideration of early discharge (<48 hours) of the healthy neonate specify that the baby must be at least how many weeks’ gestation?