I. Growth and Development2002

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2002 Self-Assessment Exercise —
I. Growth and development
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Questions
Question 50. Answer.

Two months ago an infant girl began to smile in response to her mother. She now laughs out
loud and initiates social interaction.
Of the following, her present age MOST likely is:
A. 2 months
B. 4 months
C. 6 months
D. 8 months
E. 10 months

A 6-year-old girl can write her name and can count 10 objects.
Of the following, the MOST likely additional activity of which she is capable is:
A. hitting a baseball
B. knowing her right hand from her left
C. making a simple meal
D. printing neatly in small letters
E. sounding out words while reading

A 12-year-old girl is at the 5th percentile for height. She is an otherwise healthy child. The
bone age is greater than two standard deviations below the chronologic age.
Of the following, the MOST likely cause of this patient's short stature is:
A. constitutional growth delay
B. genetic short stature
C. growth hormone deficiency
D. hypothyroidism
E. ulcerative colitis

I. Growth and development, Self-Assessment Exercise by Category
PREP® Archive on CD-ROM. Copyright © 2003, American Academy of Pediatrics.
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A boy speaks six specific words in addition to "mama" and "dada." He is able to follow
one-step commands without a gesture.
His age is CLOSEST to:
A. 12 months
B. 15 months
C. 18 months
D. 21 months
E. 24 months

In answer to your questions during a health supervision examination, a mother reports that
her son dresses himself and brushes his teeth without help. When you ask him, he copies a
circle and cross, draws a simple figure of a person, walks up and down steps, hops on one
foot, and balances on one foot for 3 seconds.
This boy's developmental age is CLOSEST to:
A. 3 years
B. 4 years
C. 5 years
D. 6 years
E. 7 years

According to the mother of a 2-year-old boy, he has a vocabulary of more than 50 words,
points to pictures of objects that she names, and combines words into two- and three-word
phrases.
Of the following, he MOST likely also can:
A. ask “why” questions
B. recognize colors
C. sing nursery rhymes
D. use “I,” “me,” and “mine” appropriately
E. use plural nouns
Answers
Critique 50. Preferred Response: B

[View Question]
At 2 months of age, infants begin to appreciate the power of a smile to elicit parental
response and to maintain proximity. The newborn can perform facial expressions such as
happiness, sadness, surprise, interest, disgust, fear, and anger, but these expressions are much
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more obvious at age 2 to 3 months. Two-month-olds can identify the facial expressions and
vocalizations of their caregivers and smile responsively and spontaneously coo.
In the next stage of language and social development, the infant begins to initiate the
social interaction with caregivers instead of simply responding. At 3 months of age, infants
respond to parental displays of pleasure by cooing, smiling, and moving. As this response
matures at age 4 months, infants begin to initiate the interactions and anticipate parents’
response. Language maturation is marked by squeals and laughs that invite interaction with
caregivers, as described for the infant in the vignette.
By 6 months of age, the infant has a preference for his or her primary caretakers and
begins to look to those people for clues on how to respond to different situations. Language
skills vary, but there is continued maturation of skills, with babbling, blowing bubbles, and
imitation of sounds such as a cough. At 8 to 9 months, infants begin to develop stranger
anxiety and protest separation from a primary caretaker. They enjoy social games such as
peek-a-boo and pat-a-cake. They continue to imitate sounds and begin polysyllabic babbling
such as nonspecific “dada.”
References:
Bowlby J. Beginnings of attachment behaviour. In: Attachment and Loss: Volume I:
Attachment. New York, NY: Basic Books, Inc; 1969:265-298
Brazelton TB. Six to eight weeks. In: Touchpoints: Your Child’s Emotional and Behavioral
Development. Reading, Mass: Addison-Wesley Publishing Co; 1992:68-82
Johnson C, Blasco P. Infant growth and development. Pediatr Rev. 1997;18:224-242
Zuckerman BS, Frank DA, Augustyn M. Infancy and toddler years. In: Levine DL, Carey
WB, Crocker AC, eds. Developmental-Behavioral Pediatrics. 3rd ed. Philadelphia, Pa: WB
Saunders Co; 1999:24-37

[View Question]
At age 6 years (finishing kindergarten or starting first grade), a child has mastered the simple
skills needed for an academic base. Children at this age demonstrate a transition from
“preoperational” thinking to “operational” thinking, as described by Piaget. Preoperational
thinking is characterized by magical and egocentric thinking. The child who has
preoperational skills is very centered in his or her perspective and finds it difficult to
understand that other people can look at things differently. In contrast, concrete operational
thought is characterized by the ability to consider multiple variables, understand serial
relationships (alphabet, word formation) and classification systems (handedness), and
perform mental operations relating to objects (counting). Accordingly, the child described in
the vignette most likely knows her right hand from her left.
Most 6-year-olds do not yet have the visuomotor coordination to hit a baseball,
although they may be able to play t-ball. These children may be able to obtain a drink or open
a packaged meal, but they cannot yet organize and cook a meal. Letter formation is still
awkward at this age, with large letters. Reading is primarily by word recognition, although
6-year-old children may be starting to use phonetics.
Developmental evaluation should be included in health supervision visits at this time
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to assess a child’s school readiness and probability of academic success. Verbal skills and
general knowledge can be appraised through general questions such as “Where do you go to
school?” and “What is your telephone number?”. Asking the child to copy a cross
(4-year-old), square (5-year-old), triangle (6-year-old), or diamond (7-year-old) can evaluate
handedness, graphomotor skills, and visual-perceptual skills. Asking the child, “What makes
the sun come up in the morning?” and “What really happens to the people on television who
fly or get hurt?” can assess his or her beliefs regarding causality and capacity to distinguish
between reality (concrete operational thinking) and fantasy (preoperational thinking).
References:
Dixon SD, Stein MT. Encounters With Children: Pediatric Behavior and Development. 3rd
ed. St Louis, Mo: Mosby, Inc; 2000
Piaget J. The Origins of Intelligence in Children. New York, NY: International Universities
Press; 1952
Smith PK, Cowie H. Understanding Children’s Development. 2nd ed. Cambridge, Mass:
Blackwell Publishers; 1991
Critique 118. Preferred Response: A

[View Question]
Assessment of bone age is useful in the diagnosis and treatment of growth disorders. The
most frequently used method for assessing bone age, developed by Greulich and Pyle,
compares radiographs of the patient’s left hand and wrist with established standards. The
criteria for defining a certain bone age vary by gender and race, and separate tables are used
for males and females. In general, females have more advanced skeletal maturity than males
of the same age. In addition, African-American children have more advanced skeletal
maturity than Caucasian children.
A comparison of bone age with chronologic age allows for assessment of the growth
rate. During adolescence, those whose bone ages are advanced relative to their chronologic
ages are considered early developers; those who have bone ages that are delayed relative to
their chronologic ages are late developers.
The child described in the vignette most likely has constitutional growth delay.
Affected children grow normally in early infancy, but then their growth rate declines.
Typically, such children lag 2 to 4 years behind their peers in height age, bone age, and
sexual development. Frequently, similar growth patterns can be documented in parents,
siblings, and other family members. Most children who have constitutional growth delay
attain normal adult heights when their growth is complete.
Genetic short stature is a common cause of short stature. Affected children usually
have a height at or below the 3rd percentile, but bone age is comparable to chronologic age,
and growth rate is normal.
Short stature due to hypothyroidism is accompanied by other symptoms, such as
constipation, dry skin, cold intolerance, and puffiness (myxedema). Laboratory evaluation
reveals elevated thyroid-stimulating hormone and low thyroxine levels. Determination of
bone age documents a delay in bone maturation.
Ulcerative colitis can retard growth and may delay bone development. Many affected
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children experience poor growth for several years before the onset of the classic symptoms of
diarrhea and bloody stools.
Growth hormone deficiency is a relatively rare cause of short stature that should be
considered if other conditions have been excluded. Affected children are often chubby, and
boys may have small genitalia. Hypoglycemia may be present. It is associated with a
significant delay in bone age compared with chronologic age. The diagnosis can be
confirmed by inadequate release of growth hormone following stimulation with arginine or
insulin.
References:
Linder B, Cassorla F. Short stature: etiology, diagnosis and treatment. JAMA.
1988;260:3171-3175
Loder RT, Estle DT, Morrison K, et al. Applicability of the Greulich and Pyle skeletal age
standards to black and white children of today. Am J Dis Child. 1993;147:1329-1333
Mahoney CP. Evaluating the child with short stature. Pediatr Clin North Am.
1987;34:825-849
Rosenfield RL. Essentials of growth diagnosis. Endocrinol Metab Clin North Am.
1996;25:743-758
Vogiatzi MG, Copeland KC. The short child. Pediatr Rev. 1998;18:92-99

[View Question]
At 12 months of age, children are able to speak one specific word in addition to a specific
word for their caregivers. They will look at a named object and follow a one-step command
that is accompanied by a gesture. Much of their efforts still are applied to gross motor skills,
and they are very interested in the task of walking.
Children who are 15 months of age will be able to speak four to six specific words in
addition to naming caregivers and close family members, as demonstrated by the boy in the
vignette. They also can point to one body part. The majority are very verbal, with most
language in the form of jargon that resembles a typical speech pattern. They can follow a
one-step simple command, such as “get your shoes” or “close the door” without the aid of a
gesture.
By 18 months of age, most children’s vocabularies have increased to 10 to 20 words,
and they can identify three body parts. Socially, they imitate performing household chores
such as sweeping, washing dishes, and gardening. They are beginning to understand cause
and effect and are consolidating their concept of object permanence. At 21 months of age,
they can identify six body parts, and their vocabulary approaches 50 words. At 24 months,
most children have a vocabulary of more than 50 words and are beginning to form two-word
phrases and use the personal pronouns “I,” “me,” and “you.”
References:
Colson ER, Dworkin PH. Toddler development. Pediatr Rev. 1997; 18:255-259
Johnson CP, Blasco PA. Infant growth and development. Pediatr Rev. 1997;18:224-242

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[View Question]
The motor developmental milestones described for the boy in the vignette are most consistent
with a 4-year-old child. In addition to walking up and down stairs with alternating feet, other
motor skills likely to be present at this age include the ability to perform a broad jump of
several feet and to catch a large ball. He probably can hold a crayon well, use scissors, and
use all table utensils well except for a knife. He also may be able to copy a square.
In contrast, a 3-year-old will be able to climb stairs with alternating feet, but will not
be able to descend with alternating feet. He will be able to stand on one foot briefly and may
be able to copy a circle and a cross. A 5-year-old child will be able to copy a circle, cross,
and square as well as a triangle. He also should be able to print some letters. He will be able
to stand on one foot for 10 seconds and may be able to skip. The motor skills of children ages
6 and 7 focus on increasing speed and accuracy. They will print letters consistently, although
their letters may be large and irregular.
References:
ed. St Louis, Mo: Mosby, Inc; 2000:383-399
Sturner RA, Howard BJ. Preschool development. 1: Communicative and motor aspects.
Pediatr Rev. 1997;18:291-301
Critique 218. Preferred Response: D

[View Question]
The cognitive and developmental skills of a 2-year-old include those reported in the vignette
as well as the use of personal pronouns (“I, me, mine”). A 2-year-old’s speech is
approximately 25% intelligible to a stranger, and he or she speaks in the present tense. At this
age, children can point to more than six body parts on themselves or a doll.
At 3 years of age, a child’s speech is 75% intelligible to a stranger, and he or she uses
plurals and pronouns and can relate his or her age. Children of this age begin to use “what”
and “who” questions in sentences of three to four words. They may be able to identify two
colored blocks, but they will have difficulty naming the color.
At 4 years of age, children’s speech will be 100% intelligible to a stranger, and the
children can describe experiences using present and past tense. They can sing nursery
rhymes, give their first and last names, and identify their gender and the gender of others.
They ask “why” questions in sentences of four to five words and are starting to speak in
paragraphs. They name five or six colors.
References:
Brazelton TB. Two years. In: Touchpoints: Your Child’s Emotional and Behavioral
Development. Reading, Mass: Addison-Wesley Publishing Co; 1992:180-199
ed. St Louis, Mo: Mosby, Inc; 2000:383-399

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Sturner RA, Howard BJ. Preschool development. 1: Communicative and motor aspects.
Pediatr Rev. 1997;18:291-301

Questions [Print Directions](1)
Question 5. Answer.
A reporter for the local newspaper is interviewing you for an article on preschoolers. He asks
you to list some normal milestones for 4-year-olds.
Of the following, the MOST typical milestone for a 4-year-old is to
A. copy a square and triangle
B. prefer solitary or parallel play
C. print his or her first name
D. speak clearly in sentences
E. tie his or her shoelaces

A male infant is born at an estimated gestational age of 34 weeks. His measurements at birth
are: weight, 1,200 g (<10th percentile); crown-heel length, 40 cm (10th percentile); and head
circumference, 31.5 cm (50th percentile).
Of the following, the MOST likely explanation for the growth pattern of this infant is
A. chromosomal abnormality
B. congenital viral infection
C. gestational diabetes
D. hereditary constitution
E. pregnancy-induced hypertension

The mother of a 3-year-old boy reports that a neighbor thinks that her son has poor muscle
tone and needs therapy. On evaluation, the boy stacks eight cubes, copies a circle, does a
broad jump, and stands on one foot briefly. Physical examination reveals normal reflexes,
muscle palpation, muscle strength, movement, posture, and range of motion. During the
examination, he points to the otoscope and asks, "What's that for?"
Of the following, the MOST appropriate next step is to

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A. measure creatine phosphokinase concentration to rule out muscular dystrophy
B. obtain magnetic resonance imaging of the brain to rule out adrenoleukodystrophy
C. reassure the mother that her son has normal motor development
D. refer the boy to a physical therapist for exercises to increase his muscle tone
E. refer the boy to determine eligibility for special education services

You are examining a term newborn in the nursery. His weight is 3.27 kg (50th percentile),
and his length is 50.5 cm (50th percentile). The pregnancy, labor, and delivery were
unremarkable. There are no significant findings on physical examination.
The MOST likely head circumference in this child, if it is consistent with his other growth
parameters, is
A. 31 cm
B. 33 cm
C. 35 cm
D. 37 cm
E. 39 cm

During a health supervision visit for their 4-year-old daughter, a couple asks you to examine
their 2-month-old son. They place him supine on the examining table where he smiles
responsively and gurgles.
Of the following, you would expect this 2-month-old to be MOST able to
A. exhibit the Moro reflex
B. raise his head off the table when prone
C. reach for a rattle
D. roll over
E. transfer objects from hand to hand

You are examining a girl at her 1-year health supervision visit. Her weight, length, and head
circumference all were at the 10th percentile at birth. There were no pregnancy, labor,
delivery, or nursery complications. Physical examination reveals her weight, length, and head
circumference are at the 5th percentile.
Of the following, this child's growth parameters MOST likely represent
A. a chromosomal abnormality
B. a malabsorptive disorder
C. an endocrine disorder
D. inadequate caloric intake
E. normal growth
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You are examining a 4-year-old girl for the first time at a health supervision visit. Her mother
reports that the child was at the 50th percentile for weight and height at birth. Physical
examination reveals her weight to be 15 kg (25th percentile) and her height to be 90 cm (<5th
percentile). Family growth history is unremarkable. Findings on the remainder of the physical
examination are unremarkable.
The MOST likely cause of this girl's poor growth is
A. constitutional growth delay
B. growth hormone deficiency
C. parental neglect
D. poor nutrition
E. rickets

A 2-week-old infant whose birthweight was 3.23 kg now weighs 3.0 kg. The mother is
breastfeeding and reports good milk production. The infant nurses every 2 to 3 hours and has
eight wet diapers per day. Findings on physical examination are unremarkable.
Of the following, the BEST advice for this mother is to
A. continue to breastfeed and return to the office in 1 week to recheck the infant's weight
B. hospitalize the infant for an evaluation of failure to thrive
C. return to the office for the 2-month health supervision visit
D. stop breastfeeding and change to formula
E. supplement breastfeeding with formula

You are examining a 4-month-old boy, who is brought in by his foster mother for his first
health supervision visit. His weight, length, and head circumference were at the 50th
percentile at birth. You now note a decrease in the head circumference from the 50th to the
10th percentile, although his weight and height remain at the 50th percentile. The infant was
delivered at term. The mother reports that the boy had an infection at 3 weeks of age.
Of the following, the MOST likely cause of his microcephaly is
A. familial microcephaly
B. maternal diabetes
C. maternal hypertension
D. meningitis
E. poor nutrition

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A healthy 2-month-old infant was born at 32 weeks' gestation. She has grown well since
birth.
On physical examination of this infant, the MOST likely finding is
A. ability to fixate on a face and follow it briefly
B. ability to reach and grasp a rattle
C. ability to watch an object and follow it to midline
D. absence of the Moro reflex
E. babbling and cooing vocalizations

The parents of a healthy term baby ask you at the 12-month health supervision visit what they
should expect of the baby developmentally by the 15-month visit.
Of the following, the milestone MOST likely to be met by 15 months of age is
A. drawing a circle
B. drinking from a cup
C. having a vocabulary of at least 50 words
D. throwing a ball overhand
E. walking well without tripping

A cheerful, energetic 36-month-old girl bursts into the room at her health supervision visit
and begins talking. Her mother explains what the girl says because you can understand only
about 50% of her speech. The girl does answer some questions about a playmate. When you
question the mother about her daughter's speech, she seems surprised and asks if something is
wrong.
Of the following, your MOST appropriate response is to
A. ask her to keep a list of all the words her daughter uses
B. assure her that the girl's speech development is normal
C. refer the girl for brainstem auditory evoked response testing
D. refer the girl for evaluation of language delay
E. request a follow-up visit in 3 months to follow the girl's speech development

You are planning to spend the weekend with a group of 5-year-old children.
Of the following, the milestone that can help you BEST plan activities for the group is
A. an attention span of 2 to 3 minutes
B. naming three or four colors
C. playing board or card games
D. pointing to pictures in books
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E. speaking in three-word sentences with 50% intelligibility
Answers

[View Question]
By age 4 years, children should be able to speak in three- to four-word sentences with
complete intelligibility. Minor developmental articulation and grammatical errors (eg, “She
runned home after school”) are expected. Four-year-olds should be able to play interactively
with peers and have progressed to copying block designs such as a gate or steps. They have
long since mastered towers and are more likely to want to make something with blocks and
tell you what it is. Children who are 4 years old cannot copy a triangle, tie their shoelaces, or
print their first names.
References:
Sturner RA, Howard BJ. Preschool development. Part 1: communicative and motor aspects.
Pediatr Rev. 1997;18:291-301
Sturner RA, Howard BJ. Preschool development. Part 2: psychosocial/behavioral
development. Pediatr Rev. 1997;18:327-336
Critique 27. Preferred Response: E

[View Question]
A birthweight and crown-heel length that are below normal accompanied by a head
circumference that is relatively normal is consistent with asymmetric growth restriction. This
pattern of intrauterine growth is seen typically in a newborn whose mother has had
pregnancy-induced hypertension. In a pregnancy complicated by hypertension, progressive
placental insufficiency results in decreased transplacental transfer of nutrients to the fetus,
which affects primarily the gain in body weight. Unless the placental insufficiency is severe
or prolonged, brain growth is relatively spared, which accounts for the normal head
circumference.
In a normal pregnancy, the fetus gains body weight linearly until about the 32nd week
of gestation and exponentially thereafter. The weight gain is greatest in the third trimester of
pregnancy and is estimated to be approximately 15.0 g/kg per day. In contrast, the fetal gain
in crown-heel length and head circumference occurs linearly throughout pregnancy, and each
is estimated to be approximately 0.9 cm/wk in the third trimester.
An infant who has a chromosomal abnormality, such as trisomy 13 or trisomy 18, has
a pattern of intrauterine growth consistent with symmetric growth restriction. Body weight,
crown-heel length, and head circumference all are below normal. This pattern of intrauterine
growth reflects an overall loss of growth potential from the chromosomal abnormality.
Fetal growth arrest, resulting in symmetric growth restriction, frequently is seen in
pregnancies complicated by viral infection. Viruses that can cause fetal growth arrest include
rubella, cytomegalovirus, and herpes. The growth arrest in congenital viral infection may
result from several factors, including altered fetal growth potential from viral growth
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inhibitory factors and altered substrate delivery caused by placental villus inflammation.
Another cause of symmetric growth restriction in a newborn may be a limited growth
potential from hereditary causes. These infants are healthy but small for gestational age.
Their parents typically are of small constitution.
In a pregnancy that is complicated by gestational diabetes, maternal hyperglycemia
often results in fetal hyperglycemia, which causes hypertrophy of the fetal pancreatic islets
and beta cells and increased secretion of insulin. The fetal hyperinsulinemia results in
macrosomia and an increase in adipose tissue. The infant of a mother who has gestational
diabetes, therefore, typically is large for gestational age.
References:
Ehrenkranz RA, Younes N, Lemons JA. Longitudinal growth of hospitalized very low birth
weight infants. Pediatrics. 1999;104:280-289
Sparks JW, Ross JC, Cetin I. Intrauterine growth and nutrition. In: Polin RA, Fox WW, eds.
Fetal and Neonatal Physiology. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1998:267-290
Critique 47. Preferred Response: C

[View Question]
Developmental milestones represent average or low-average accomplishments at a given age
and are intended to trigger further evaluation if delayed. Direct examination of the boy
described in the vignette is reassuring. Low muscle tone is a subjective impression at times
and can occur independent of language, cognitive, gross motor, fine motor, and
social/adaptive functioning. Isolated low muscle tone rarely is a serious problem without
associated findings. Accordingly, the mother can be assured that her son has normal motor
development.
Muscular dystrophy is a disorder resulting in muscle weakness, not just low tone.
Adrenoleukodystrophy often presents with neurobehavioral symptoms or adrenal
insufficiency; spasticity rather than hypotonia is a feature of more advanced disease. Brain
imaging is indicated in progressive neurologic disorders, especially with spasticity, but it is
not indicated in the child described in the vignette. Physical therapy is not effective for
isolated low muscle tone.
Formal screening using a standardized instrument would be appropriate before
considering any referral or determining eligibility for special education services.
References:
Pediatr Rev. 1997;18:291-301

[View Question]
At birth, the average head circumference of a term male infant is 34.8 cm (13.57 in).
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Accordingly, the head circumference of the infant described in the vignette, who appears
healthy and average in size, would be closest to 35 cm. Head circumference increases by 0.5
cm/wk during the first 2 months of life and by 0.25 cm/wk from 2 to 6 months of life.
Other growth parameters measured at the time of birth are weight and length. The
average term infant is 50 cm (19.5 in) in length at birth. The length normally increases by
50% at 1 year of life, doubles by 4 years, and triples by 13 years. The average weight of a
term infant at birth is 3.25 kg (7.18 lb). Newborns lose approximately 10% of birthweight in
the first several days of life, but usually regain the original birthweight by 2 weeks of age.
Birthweight typically is doubled by 5 months of age and tripled by age 1 year.
References:
Needleman RD. The first year. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson
Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:32-38
Overby KJ. Physical growth. In: Rudolph AM, ed. Rudolph's Pediatrics. 20th ed. Stamford,
Conn: Appleton & Lange; 1996:3-9

[View Question]
In an active and alert state, normal motor milestones for a 2-month-old include the ability to
raise the head and shoulders off the surface of the table in the prone position and to fix and
follow past the midline. The infant described in the vignette appears to be doing well, is alert
and responsive, and is making appropriate vocalizations. It is helpful to know when he had
his last meal and last nap because alertness, interest, and motor performance can vary
throughout the day. Intentional reaching and grasping develops later. A 2-month-old would
not be expected to sustain a sitting position without support, his hands would be open most of
the time, and he should be able to grasp a rattle that is placed in his hand. Persistent fisting is
a sensitive sign of cortical dysfunction and should prompt further assessment. The Moro
reflex often (but not always) is extinguished by this age. Most infants will not be able to roll
over until 3 to 4 months of age.
References:
Illingworth RS. Normal Child: Some Problems of the Early Years and Their Treatment. 10th
ed. New York, NY: Churchill-Livingstone; 1991
Zuckerman BS, Frank DA, Augustyn M. Infancy and toddler years. In: Levine MD, Carey
Critique 107. Preferred Response: E

[View Question]
Anthropometric measurements (height, weight, head circumference) can be assessed
cross-sectionally or longitudinally. If only one measurement is available, growth for age can
be assessed by comparing this measurement with appropriate reference charts. Measuring a
child more than once provides growth velocity data, which can be used to assess growth rate.
When plotted on a growth chart, an individual’s growth can be expected to remain in the
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same percentile range for the first 2 to 9 years of life. However, the physiologic change from
intrauterine influences on a person’s genetic potential can account for shifts among growth
curve percentiles during early infancy. The growth curve percentiles also may change during
puberty due to the adolescent growth spurt. Weight, length, and head circumference should
be obtained and plotted during each health supervision visit to follow growth and alert the
pediatrician to any potential problems. Growth curves unique to certain populations (eg,
Down syndrome, preterm infants, or certain ethnic groups) should be used when appropriate.
Knowing that the growth parameters of the child described in the vignette were
unchanged since birth, that there were no prenatal or perinatal problems, and that current
findings on physical examination are normal should allow the pediatrician to reassure the
mother that her child’s growth parameters are consistent with normal growth.
Inadequate caloric intake and a malabsorptive disorder present with weight
decreasing initially, then length. Endocrine disorders often present with short stature, but
normal weight, and chromosomal abnormalities frequently are characterized by microcephaly
and dysmorphic features.
References:
Committee on Nutrition. Anthropometry. In: Pediatric Nutrition Handbook. 4th ed. Elk
Grove Village, Ill: American Academy of Pediatrics;1998:166-170
Needleman RD. Assessment of growth. In: Behrman RE, Kliegman RM, Jenson HB, eds.
Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:57-61

[View Question]
The length and weight of the girl described in the vignette was at the 50th percentile at birth.
Children generally double their birth length by the time they reach 4 years of age. Most
4-year-olds are approximately 102 cm (40 in) tall and weigh 18 kg (40 lb). The girl described
has a height of 90 cm (<5th percentile), which is much lower than expected. Her weight is at
the 25th percentile, and although it has crossed one percentile line, it is not affected as
severely as her height. Of the causes listed, the most likely etiology of this child’s short
stature and relatively spared weight is an endocrine disorder, such as growth hormone
deficiency.
Children who have classic growth hormone deficiency grow at subnormal growth
velocities (<5 cm/y) and have significant retardation of skeletal maturation. Growth hormone
deficiency may be idiopathic or organic, and it can be due to a hypothalamic or pituitary
tumor. Affected children may present with complaints of headache, visual abnormalities, or
other neurologic symptoms. Children in whom growth hormone deficiency is suspected
should undergo growth hormone testing. Evaluation for other pituitary hormone deficiencies
also should be made.
A common normal variant of growth is constitutional growth delay. Born at normal
weight and length, affected children may grow at slower rates throughout infancy. After
infancy, their growth rates return to normal, and they grow parallel to the lower percentiles of
standard growth curves. There is often a positive family history for constitutional growth
delay. The short stature of the girl described in the vignette is more severe than would be
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expected in constitutional growth delay.
Metabolic abnormalities, such as rickets, can cause poor growth. Many children who
have metabolic abnormalities experience a deceleration in the rate of growth in weight and
length in the first years of life. No physical abnormalities are described in the vignette that
would suggest a metabolic abnormality. Common physical findings in children who have
rickets include rachitic rosary (thickening of the costochondral junction), wrist enlargement,
bowed legs, frontal bossing, and craniotabes.
Poor nutrition and parental neglect are relatively common causes of poor growth. This
child’s weight for height is greater than 90%, which indicates adequate nutrition. The growth
pattern seen in most children who are receiving poor nutrition or parental neglect is a
deceleration of weight and height, with weight being affected first and more severely than
height.
References:
Committee on Nutrition. Assessment of nutritional status. In: Pediatric Nutrition Handbook.
4th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1998:165-184
Dubowitz H, Giardino A, Gustavson E. Child neglect: guidance for pediatricians. Pediatr
Rev. 2000;21:111-116
Needleman RD. Assessment of growth. In: Behrman RE, Kliegman RM, Jenson HB, eds.
Vogiatzi MG, Copeland KC. The short child. Pediatr Rev. 1998;19:92-99

[View Question]
Term infants normally lose 10% of their bodyweight during the first several days of life, but
they should regain it by 2 weeks of age. Although the 2-week-old infant described in the
vignette weighs 0.23 kg less than birthweight, the mother reports good milk production,
frequent nursing, and frequent wet diapers, all of which suggest that breastfeeding is going
well. Other indications of adequate milk production include leaking in the opposite breast
and empty breast after feeding with refilling. Accordingly, it is most appropriate for the
mother to continue breastfeeding and return in 1 week to determine whether the infant's
weight is increasing.
Every major national and international organization for the promotion of children’s
health agrees that breastfeeding is the best way to feed a baby. The incidence of breastfeeding
peaked in 1982; the years since have seen a steady decline in initial and prolonged
breastfeeding. A common reason for stopping breastfeeding is the misconception that the
infant is failing to thrive due to breastfeeding.
Supplementing breastfeeding with formula or stopping breastfeeding and switching to
formula are not indicated for the infant described in the vignette. Supplementing with
formula will hinder the mother’s milk production and suggests to her that something is
“wrong” with her milk, which is not supported by any findings in the vignette.
Because the infant has not regained his birthweight, he should be evaluated again in 1
week; waiting until the 2-month evaluation to recheck the infant’s weight is not
recommended because adequate weight gain from breastfeeding has not yet been
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demonstrated. Hospitalization is not indicated for an infant who has no signs or symptoms
suggesting an underlying infection, metabolic disorder, or dehydration. Hospitalization only
rarely may be indicated for breastfed infants who show signs or symptoms of significant
dehydration because this will disrupt the mother’s ability to breastfeed in a calm, quiet
environment and may result in decreased milk production and possibly discontinuation of
breastfeeding.
References:
Breastfeeding: A Guide for the Medical Professional. 4th ed. St Louis, Mo: Mosby-Year
Book, Inc; 1994
Committee on Nutrition. Breastfeeding. In: Pediatric Nutrition Handbook. 4th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 1998:3-20
Curran JS, Barness La. Breast-feeding. In: Behrman RE, Kliegman RM, Jenson HB, eds.

[View Question]
Microcephaly is defined as a head circumference that measures more than 3 standard
deviations below the mean for age and gender. It most often is the result of a small brain; the
skull generally grows in response to brain growth. Microcephaly can be categorized as
primary (genetic) or secondary (acquired or nongenetic). Infants who have primary
microcephaly have small head circumferences at birth. The infant described in the vignette
had a normal head circumference at birth, which eliminates primary causes of microcephaly.
The decrease in this infant’s head circumference suggests that a significant neurologic
injury has occurred since birth. Bacterial meningitis is one cause of acquired microcephaly.
Infants who develop meningitis in the first few months of life, as might have occurred with
this infant at 3 weeks of age, can have complications, including cerebral infarcts, cystic
cavitations, and loss of neurons, which can lead to microcephaly.
Maternal hypertension during pregnancy is a risk factor for intrauterine growth
retardation, which may be associated with a small head circumference at birth. Infants of
women who have diabetes often are large for gestational age and have large head
circumferences at birth.
Although poor nutrition may be a cause of microcephaly, the weight and height of
poorly nourished infants are affected before any decrease in the rate of growth of the brain is
noted. Infants from families that have a history of microcephaly typically have small head
circumferences at birth. If there is a suspicion of familial microcephaly, it may be of benefit
to measure the head circumferences of the parents and any siblings of the infant.
References:
Haslem RHA. Microcephaly. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson
Rios A. Microcephaly. Pediatr Rev. 1996;17:386-387

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[View Question]
Most research on the development of preterm infants shows that the majority of effects of
prematurity on growth and development do not disappear in healthy babies until 2 years of
age. Accordingly, it is good practice to correct for prematurity when assessing the growth and
development of children who are younger than age 2, such as the infant described in the
vignette. Therefore, a 2-month-old child who was born 2 months preterm should be compared
with term newborns for purposes of developmental assessment.
The term newborn has the ability to fixate on a face and follow it briefly, but he or
she is not expected to follow objects consistently to midline. Volitional reaching and
grasping occurs after 3 months of age in a term infant, as do babbling and cooing
vocalizations. The Moro reflex should be present in all newborns. Its absence or asymmetry
should prompt an investigation to rule out entities such as cerebral palsy and paralysis
(congenital or acquired).
Reference:

[View Question]
Anticipatory guidance about normal development affords the clinician a good opportunity to
promote development and parenting skills. Most 15-month-old children are able to drink
from a cup, so this is a good opportunity to encourage parents to offer a cup instead of a
bottle. Few children of this age can throw a ball overhand or walk without tripping. All
developmentally normal 15-month-olds should have progressed beyond babbling and started
using individual words and gestures and responding to a few words. Few will have achieved
a vocabulary of 50 words. Children normally cannot draw a circle until 3 years of age.
The 12-month-old child’s emerging mobility, interest in exploration, and manual
skills can be exciting but also treacherous. This health supervision visit provides a good
opportunity to reinforce child safety information. It is also worthwhile to ask the parents if
they or anyone else are concerned about the child’s development in case a question about
expectations is an indirect expression of concern.
References:
Illingworth RS. Normal Child: Some Problems of the Early Years and Their Treatment. 10th
ed. New York, NY: Churchill-Livingstone; 1991

[View Question]
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Speech and language delay is common, and pediatricians are correct to pay special attention
to this area of development because it correlates most closely with cognitive development
and later school function. In contrast to receptive language delay or mixed receptive and
expressive language delay, expressive language delay can be an isolated finding with a good
prognosis. Speech articulation problems can occur independently of receptive or expressive
language delays.
Assessing the degree of intelligibility requires a good sample of language, and it is
easiest to assess during play or with a standardized test such as the Goldman-Fristoe Test of
Articulation, which usually is performed by a speech-language pathologist. Having
age-appropriate toys and books available in the office makes it easier for the pediatrician to
assess speech and language development. The child described in the vignette shows
appropriate communication functions for a 36-month-old. By age 4 years, almost all of her
speech should be intelligible, although some articulation errors (“r” and “th” sounds) are
expected at this age. Because the child described in the vignette has normal language
development, further testing and a follow-visit in 3 months is unnecessary.
Routine use of a screening questionnaire focusing on possible parental concerns can
help avoid parental surprise and improve detection of children who have developmental
delays. If there are other risk factors, such as a history of hearing loss, recurrent ear
infections, or excessive frustration on the child’s part related to speaking, consultation might
be considered. Knowledge of normal language development and common variations is
important; equally important is the ability to communicate this to families.
References:
Pediatr Rev. 1997;18:291-301

[View Question]
Five-year-old children can communicate their thoughts and feelings. They also have a rapidly
developing ability to assimilate new information and follow simple rules. They enjoy board
and card games with their enhanced ability to count and take turns. They also are not above
cheating and making up their own rules and are not always good losers. They know more
than three to four colors and have progressed beyond pointing to pictures in books. They
often can pick out words and pretend to read books that they have memorized. Their speech
is clear, and they frequently relate long, fanciful stories; fantasy and reality are not
completely distinguishable. Speech with only 50% intelligibility and a 3-minute attention
span are more typical of a 3-year-old child.
References:
Pediatr Rev. 1997;18:291-301
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Question 1. Answer.
You are precepting a group of medical students during a structured observation at a local
child care center.
Of the following motor milestones, the one that is MOST typical of a 24-month-old child is
A. building a tower of two cubes
B. copying a circle
C. scribbling
D. throwing a ball overhand
E. walking backwards

During a routine health supervision visit, you pull an infant to a sitting position. She has no
head lag and maintains the sitting position with her arms propped forward on the table. She is
able to reach for objects and transfer them from hand to hand.
Of the following, these motor skills are MOST likely to emerge at age
A. 4 months
B. 6 months
C. 8 months
D. 10 months
E. 12 months

During a health supervision visit, an infant turns when her name is called and looks to her
father for reassurance when frightened. Although silent in the office, her parents report that
she says "mama" and "dada" in a nonspecific way.
These milestones are MOST typical of a child who is
A. 5 months old
B. 7 months old
C. 9 months old
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D. 11 months old
E. 13 months old

During an office visit, the child you are observing trips. Getting up from the floor, he
announces, "John fall!" His mother reports that he uses a spoon well at mealtimes and wakes
up dry in the morning.
These developmental skills are MOST consistent with those of a child who is
A. 12 months old
B. 18 months old
C. 24 months old
D. 30 months old
E. 36 months old

As part of a kindergarten visit, a pediatric resident sits at a table and draws with the children.
Of the following, the MOST advanced fine motor skill he typically should observe in this
group of 5-year-olds is their ability to copy a
A. circle
B. cross
C. diamond
D. square
E. vertical line

Both the weight and height parameters of a 6-month-old girl have dropped to substantially
below the 5th percentile for age. Until 2 months of age, she had maintained growth at the
50th percentile. At that time, her mother returned to work and the grand-mother assumed her
care. She has received iron-fortified formula since birth and currently ingests 6 oz every 4
hours.
Of the following, the best INITIAL step in management of this child is to
A. determine how the formula is mixed
B. obtain a creatinine level
C. obtain a sweat test
D. obtain thyroid function studies
E. reassure the mother that this is a normal growth pattern
Answers

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Critique 1 Preferred Response: D
[View Question]
Achievement of fine motor milestones during the second year of life requires evolution
beyond the neat pincer grasp that is present at 12 months of age. With improved cortical
control of the upper extremities and better truncal balance, the hands are more available, and
the child can learn to manipulate objects during functional play.
Throwing a ball with an overhand motion is most typical of a 24-month-old child. The
ability to build a tower of two cubes emerges at 14 months of age; by 24 months, the tower
should be six or more blocks tall. Imitative scribbling appears at 16 months; spontaneous
scribbling appears at 18 months. The ability to copy a circle usually is not seen until 3 years
of age. Walking backwards is an appropriate milestone for a 16-month-old child; an ability to
walk down steps holding onto the rail better describes the gross motor abilities of a
24-month-old. Other normal motor milestones for 24 months of age include the ability to
wash and dry hands, remove clothing, put on a hat, kick a ball, and jump with two feet off the
floor.
References:
Capute AJ, Accardo PJ. The infant neurodevelopmental assessment: a clinical interpretive
manual for CAT-CLAMS in the first two years of life, Part 1. Curr Probl Pediatr.
1996;26:238-257
1996;26:279-306
Needlman RD. Developmental assessment and biologic variation. In: Behrman RE, Kliegman
RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB
Needlman RD. The second year. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson
Critique 53 Preferred Response: B

[View Question]
Focused observation of a child during routine examinations provides an enormous amount of
developmental information. In many cases, it is superior to handling the infant directly and
confirms the milestone reports from the parents.
Gross motor skills require a balance between extensor and flexor tone; a decline in
obligatory primitive reflexes; and the development of righting, protective, and equilibrium
responses. In most cases, infants learn to maintain new positions long before they can achieve
them voluntarily.
Head lag begins to disappear by 4 months of age, but sitting in an armed-propped
position, as described for the infant in the vignette, is more typical of a 6-month-old child.
This is replaced at 7 to 8 months with upright sitting and an ability to achieve a sitting
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position independently. A 6-month-old also should be able to roll over in both directions,
demonstrate an immature raking grasp, reach for objects, and transfer them from hand to
hand.
References:
1996;26:238-257
1996;26:279-306
Critique 107 Preferred Response: C

[View Question]
Assessment of language development includes observation as well as consideration of history
provided by the parents. Receptive language progresses more quickly than expressive
language and is characterized by an increasing ability to localize sounds by 5 months of age.
This skill is followed by the ability to attach meaning to specific sounds (eg, turning when
name is called) by 9 months of age. Expressive language advances from musical-like vowel
sounds (3 months) into repetitive consonant sounds (6 to 7 months). The use of these “words”
by the infant does not take on specific meaning or symbolic use until approximately 12
months of age. The production of meaningful speech is the result of cognitive, oral-motor,
and social processes. It is the most sensitive to caretaking practices of any sensorimotor skill.
Social cognition is part of language development. The infant must learn to distinguish
familiar faces from strangers. When fully developed, facial images take on emotional
meaning, as demonstrated by anxiety with strangers or protests over separation (stranger
anxiety). A young infant (eg, 5 to 7 months old) will not seem anxious when held by the
examiner or protest separation from the parent. By 9 months, an infant will seek reassurance
from a parent or caretaker by making eye contact when frightened.
References:
1996;26:238-257
1996;26:279-306
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[View Question]
The child described in the vignette is demonstrating a spectrum of abilities that are typical for
a 24-month-old child. Referring to himself by name (John) is consistent with a developmental
age of 24 months. The ability to use language to describe an immediate experience is typical
for this age and precedes the exponential explosion in expressive language that occurs
between 24 and 36 months.
The neat use of a spoon requires the development of purposeful wrist supination and
is characteristic of the fine motor skills that develop late in the second year of life. This skill
precedes the neat use of a fork to eat, which generally occurs between 30 and 36 months.
By 24 months, most children will remain dry overnight and may begin to
communicate an urge to urinate. This dryness is more a function of an awareness of bladder
fullness than volitional toilet training. The ability to void or inhibit voiding voluntarily
develops later in the second and third years of life.
References:
1996;26:238-257
1996;26:279-306
Needleman RD. Developmental assessment and biologic variation. In: Behrman RE,
Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa:
WB Saunders Co; 1996:67-72
Needleman RD. The second year. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson

[View Question]
The actions of children in play situations reflect their social, cognitive, fine motor,
visual-perceptual, and gross motor skills. Observing children during pencil and paper tasks
also reveals much about their attention span and temperament, their experience with such
activities, and their progression though the range of normal skill acquisition.
Asking children to copy the Gesell figures has been used by pediatricians for many
years because of the well-described normative values of this test. For a child to complete
more mature drawings, he or she must have developed a mature pencil grasp that allows him
or her to close objects (circle), add isolated branches (cross, square), and change directions
while drawing (triangle, diamond). This progression forms the motor basis for the evolving
“people drawings” produced by children. Most 2-year-olds will be able to copy a vertical
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line, and most 3-year-olds can copy a circle. A 4-year-old can reproduce a cross reasonably
well, whereas 5-year-olds can copy a square, and a 6-year-old can copy a diamond.
References:
Shonkoff JP. Preschool. In: Levine MD, Carey WB, Crocker AC, eds.
Developmental-Behavioral Pediatrics. 2nd ed. Philadelphia, Pa: WB Saunders Co;
1992:39-47
Pediatr Rev. 1997;18: 291-301
development. Pediatr Rev. 1997; 18:327-336
Critique 266 Preferred Response: A

[View Question]
The infant described in the vignette is receiving approximately 36 oz of formula daily.
Appropriate weight gain should occur if the formula contains at least the standard
concentration of 20 kcal/oz. Accordingly, the first step in management is to ascertain how the
formula is being mixed. This should be done before any diagnostic studies are obtained. The
only change in the infant's routine has been the mother's return to work. It is possible that the
grandmother, who is doing most of the feedings, is mixing the formula incorrectly. A
common mistake is to mix two cans of water with one can of the formula concentrate,
resulting in a decreased caloric content. Although a 6-month-old child should be eating some
solid food, failure to provide solid foods would not completely account for this infant's
failure to thrive. Sometimes caretakers who are facing financial difficulties are forced to
knowingly dilute the formula to make it last longer. Parental neglect or inexperience also can
lead to undernutrition from low caloric intake despite an apparently adequate volume of
formula.
Chronic renal insufficiency can lead to poor growth, and it is possible for hereditary
and acquired renal diseases to present at the age of 6 months. If a thorough history and
physical examination does not yield any clue to the diagnosis in an infant who is failing to
thrive, a serum creatinine concentration should be considered. A sweat test will confirm the
diagnosis of cystic fibrosis and would be an appropriate investigation if loose stools and
recurrent pulmonary infections have been present. Evaluation of thyroid function also should
be considered in any child who has no obvious cause of growth failure based on the history
or physical examination. A growth pattern such as the one described for the infant in the
vignette never should be considered normal.
References:
Bauchner H. Failure to thrive. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson
Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev.
1992;13:453-460
Overby KJ. Common growth concerns. In: Rudolph AM, ed. Rudolph's Pediatrics. 20th ed.
Stamford, Conn: Appleton & Lange; 1996:5-7
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Zenel JA Jr. Failure to thrive: a general pediatrician's perspective. Pediatr Rev.
1997;18:371-378

Question 1. Answer.
Three stimulant medications (methylphenidate, dextroamphetamine, pemoline) are used
frequently to treat patients who have attention deficit hyperactivity disorder.
Of the following, the statement you are MOST likely to include in a discussion with residents
concerning the use of these medications is that
A. common side effects include insomnia and decreased appetite
B. lack of response to one stimulant predicts lack of response to all stimulants
C. long-term use of stimulants results in decreased adult height
D. only 25% of children will respond to medication
E. the most serious side effect is weight loss

Of the following fine motor milestones, the one that is MOST characteristic of a
12-month-old child is the ability to
A. build a tower of four blocks
B. release a raisin into a bottle
C. scribble spontaneously
D. transfer objects between hands
E. use a neat pincer grasp to attain a raisin or pellet

A mother brings her 5-year-old son to your office before he starts kindergarten. She asks that
you check his development to be sure he is ready to attend school.
Of the following, the BEST use of a preschool developmental screening test is to
A. determine school readiness
B. diagnose learning disabilities
C. diagnose mental retardation
D. identify children who require a more formal evaluation

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E. predict school success
Answers

[View Question]
Approximately 80% of children diagnosed with attention deficit hyperactivity disorder
(ADHD) will derive benefit from one of the frequently used stimulant medications. Recently
it has become clear that a child who does not respond favorably to one stimulant may respond
to another. When all stimulants are tried sequentially, the rate of positive benefit approaches
95%.
Commonly reported side effects of the stimulants include insomnia, decreased
appetite, irritability or other mood changes, headache, and abdominal pain. Of note, many of
these effects also are reported by patients receiving placebo. The most serious side effect of
stimulant use is the appearance of motor tics. Fewer than 1% of children who have ADHD
develop a tic disorder; in 13% of cases, stimulants appear to exacerbate a pre-existing
disorder. Long-term studies of children who received stimulants for ADHD have shown no
appreciable difference in eventual adult height or weight compared with those who have not
received stimulants.
The management of a child who exhibits attention deficits must be multimodal.
Although other drugs have proved beneficial in certain children who have ADHD, only
stimulants have demonstrated a consistent improvement in sustained attention. Effective
medical management requires the clinician to allow an adequate amount of time to discuss
and evaluate the issue of medication side effects and its impact on current social and adaptive
behaviors, academic performance, and attention span. Stimulant medications alone are not
curative, and successful management requires close involvement of the clinician, school
personnel, family, and child.
References:
Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and
Treatment. New York, NY: The Guilford Press; 1990
Cantwell DP. Attention deficit disorder: a review of the past 10 years. J Am Acad Child
Adolesc Psychiatry. 1996;35:978-987
Faigel HC, Sznajderman S, Tishby O, Turel M, Pinus U. Attention deficit disorder during
adolescence: a review. J Adolesc Health. 1995;16:174-184
Critique 88 Preferred Response: E

[View Question]
The development of fine motor skills in the 12-month-old infant demonstrates several general
concepts about neurodevelopment. Over time, children progress from having obligatory
symmetric reactions to developing voluntary, asymmetric, and precise movements.
Development proceeds in a cephalic to caudal as well as a proximal to distal direction. The
final goal of every step of developmental progression is a move from dependence to
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independence.
The highlight of fine motor development in the first year of life is the development of
the pincer grasp. By the age of 12 months, most children should be able to use this pincer
grasp to attain a raisin or pellet. Achieving this milestone requires the use of the upper
extremities to make the transition from primarily assisting with balance and positioning to
using the pincer grasp as manipulative instruments that can help explore the nearby
environment.
At the same time, the typical 12-month-old child will begin to take a few independent
steps, will attempt to build a tower of two blocks, will follow a single step command with an
accompanying gesture, will cooperate with dressing, and will drink from a cup with
assistance.
The ability to transfer an object between hands appears initially at 6 months of age,
and building a tower of four blocks and accurately releasing a raisin into a bottle are fine
motor skills that are seen at 16 to 19 months. Spontaneous scribbling is a skill achieved by
the typical 18-month-old child.
References:
Blasco PA. Normal and abnormal motor development. Pediatric Rounds. 1992;1:1-6
Johnson CP, Blasco PA. Infant growth and development. Pediatrics in Review.
1997;18:224-242

[View Question]
"School readiness" implies that a child is prepared to participate successfully in formal
schooling. This requires that the child demonstrate the physical, developmental, and
behavioral skills necessary for formal schooling. School readiness tests were designed to
measure an individual child's preparedness for academic achievement and to identify children
who need early preventive intervention and further testing. However, school readiness tests
never should be used as the only determinant of a child's readiness for school. Unfortunately,
they are used for a wide variety of purposes, some of which are inappropriate and vary from
the original intent of the test designers.
Many of these school readiness tests are limited significantly in their reliability,
validity, sensitivity, specificity, and standardization sample. This is especially true of some
"homegrown" screening instruments. Despite these limitations, up to 50% of children who
are eligible to enter kindergarten are not enrolled because of their scores on readiness tests.
The limited number of standard academic skills apparent at the age of the screening
forces the use of preacademic and perceptual-motor skills that correlate only moderately with
later school success or achievement. It is also difficult to define "academic difficulties" in a
preschool child. Preschool developmental screening instruments are not designed to diagnose
mental retardation or learning disabilities or to predict school success. Further, when
concerns are raised about the results of a preschool developmental screening test, referral for
a more formal assessment should be made.
References:

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Balck R. Temperament and school performance. Pediatrics in Review. 1998;19:177
Casey PH, Evans LD. School readiness: an overview for pediatricians. Pediatrics in Review.
1993;14:4-10
Gilbride KE. Developmental testing. Pediatrics in Review. 1995;16:338-345
Pianta RC, McCoy SJ. The first day of school: the predictive validity of early school
screening. J Appl Devel Psychol. 1997;18:1-22


In deciding if a child's growth is normal, important information can be obtained by plotting
the rate of growth (growth velocity) on a growth curve chart.
In the prepubertal boy, the average growth rate (in cm/y) is CLOSEST to
A. 2
B. 5
C. 8
D. 11
E. 14

During the health maintenance examination of a 3-year-old girl, her mother expresses
concern about the child's "talking."
Of the following, the information from the mother that is MOST reassuring to you that the
girl's language development is normal is that she
A. combines two words into one sentence
B. knows 200 words
C. points to one body part
D. points to three named pictures in a book
E. understands two prepositions

The BEST method to assess age-appropriate visual development in an 8-week-old infant is to
observe for
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A. blinking as an object approaches the infant
B. circular tracking of a suspended object through 360 degrees
C. horizontal tracking of a suspended object through 180 degrees
D. smiling recognition of a familiar face
E. visual fixation while the child is held 8 to 12 in from the examiner's face

Of the following socioemotional behaviors, the one that would be MOST characteristic of a
28-week-old infant is to
A. bring feet to mouth while supine
B. play peek-a-boo
C. point to desired object
D. recognize strangers
E. smile spontaneously

Which of the following behaviors is MOST likely to appear at 8 weeks of age?
A. Following a visual stimulus just to midline
B. Regarding a face
C. Regarding own hand
D. Turning head toward a rattling sound
E. Turning toward a familiar voice

A mother is concerned that her 5-year-old son is excessively clumsy.
Among the following, the skill MOST likely to emerge in a 5-year- old child is
A. hopping on one foot
B. riding a tricycle
C. skipping
D. walking on his toes
E. walking up stairs

Among the following, the skill that is MOST likely to emerge at 18 months of age is
A. building a tower of four cubes
B. cutting paper with scissors
C. imitating the drawing of a vertical line
D. scribbling spontaneously with a crayon
E. turning the pages of a book one at a time
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The head size of a 6-month-old boy is at the 95th percentile. At birth, his head size was at the
50th percentile. His overall development has been normal.
Of the following, the MOST helpful method for distinguishing between benign macrocephaly
and hydrocephaly is to
A. examine the fundi
B. measure fontanelle size
C. measure the parents' head size
D. obtain plain radiography of the skull
E. plot the head circumference on a growth chart
Answers
Critique 36 Preferred Response: B

[View Question]
Measuring growth velocity or rate of growth (cm/y) is an extremely important part of every
health supervision visit. A child may present with what is considered a normal height and
weight but have an abnormal growth rate that indicates a need for evaluation. Evidence of an
abnormal growth pattern in children who have congenital growth hormone deficiency may
become apparent by 3 to 6 months of age. From the age of 1 year through the preadolescent
age, the lower limit of normal growth is approximately 5 cm/y. Most children will double
their birth length by the age of 4 years and triple it by 13 years, with an annual growth
velocity after the age of 2 years that usually will be at least 5 cm (2 in)/y. Children growing
less than 5 cm/y may require further evaluation for conditions such as growth hormone
deficiency or hypothyroidism.
References:
Kappy MS, Ganong CA. Short stature. In: Berman S, ed. Pediatric Decision Making. 3rd ed.
St Louis, Mo: Mosby-Year Book, Inc; 1996:178-181
Overby KJ. Physical growth. In: Rudolph AM, Hoffman JIE, Rudolph CD, eds. Rudolph's
Pediatrics. 20th ed. Stamford, Conn: Appleton & Lange; 1996:3-9
Plotnick LP. Growth, growth hormone, and pituitary disorders. In: Oski FA, DeAngelis CD,
Feigin RD, McMillan JA, Warshaw JB, eds. Principles and Practice of Pediatrics. 2nd ed.
Philadelphia, Pa: JB Lippincott Co; 1994:1973-1981
Rosenfeld RG. Growth hormone. Pediatrics in Review. 1996;17:143-144
Critique 71 Preferred Response: E

[View Question]
The acquisition of language skills is thought of as an orderly sequence of milestones, but
there is some variability in this fluid process. Language development correlates with later
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cognitive development. However, language development can be affected by environment,
temperament, and innate cognitive abilities of the child. Identifying children whose
individual language differences still fall within the range of normal can be problematic
between 20 and 26 months of age. However, it is important to make this distinction because
language delay is the most common presentation of a developmental disorder in children
aged 2 to 4 years. A hearing test is warranted for every child in whom there is a concern
about language.
The best assessment of language reviews not only what is being said, but the ability of
such communication efforts to express the child's needs and the child's understanding of
language directed toward him or her. Accordingly, both receptive and expressive language
skills should be evaluated to assess age-appropriate development.
Comprehension of prepositions, use of grammatically correct sentences, and an
800-word vocabulary is the best description of the expected language abilities for a
3-year-old child. Pointing to more than one body part is a skill attained by 90% of children
by 22 months. Most will combine two words in a sentence by 24 months and can point to
three named pictures in a book by 28 months. By 3 years of age, the number of words in a
child's vocabulary often is difficult to assess, but if the vocabulary of a 30-month-old is small
enough for the parents to count (eg, 150 to 200 words), it is probably too small.
References:
Coplan J. Normal speech and language development: an overview. Pediatrics in Review.
1995;16:91-100
Klein SK. Evaluation for suspected language disorders in preschool children. Pediatr Clin
North Am. 1991;38:1455-1467

[View Question]
The assessment of vision in young children requires not only an intact visual system in the
child, but use of a developmentally appropriate method of assessment by the examiner. The
majority of anatomic and physiologic changes in the visual system occur in the first few
months of life. Visual development progresses through a predictable series of milestones that
involve integration of certain nonvisual abilities, such as head control and use of upper
extremities. Additionally, many developmental tasks either are motivated by vision or their
performance is enhanced by visual abilities. Studies have demonstrated a relationship
between a child's visual abilities and upper extremity movements as prereaching skills (eg,
purposeful movement) and hand-to-mouth coordination develop.
The initial development components of visual function involve involuntary reflexive
patterns. Pupillary reactions are rapid to strong light in the newborn period, however,
response to weak light is not present until about 6 months of age. The consensual reflex
means that stimulation of one pupil results in an equal response in both pupils. When a bright
light is directed into the infants eyes, eyelid reflexes cause flinching, frowning, blinking and
tight eyelid closure. The newborn also responds to visual threats by blinking.
Subsequent visual behaviors are voluntary eye movements which are cognitively
directed including localization (or visual approach), fixation (or visual grasp), and ocular
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pursuit (or visual tracking). The process of localization is associated with the development of
head control. Indifference to faces, which incorporates both movement and sound, is typical
of the newborn. A reciprocal social smile generally appears at 6 weeks of age. In contrast, a
spontaneous social smile in response to a familiar face usually appears by 4 months of age.
Visual fixation and pursuit skills develop rapidly in an infant. Horizontal visual
tracking progresses from 30 degrees at birth through 120 degrees at 4 weeks of age and
reaches 180 degrees in the 8- to 10-week-old infant. Circular tracking of an object suspended
through 360 degrees requires smooth pursuit movements (no saccades) and appears by 16
weeks. Visual tracking with a focal length (the distance at which objects are most clear) of 8
to 12 in is present in the newborn. The newborn also responds to visual threats by blinking.
This visual ability progresses to a reciprocal social smile at 6 weeks of age. In contrast, a
spontaneous social smile in response to a familiar face usually appears by 16 weeks.
References:
Friendly DS. Development of vision in infants and young children. Pediatr Clin North Am.
1993;40:693-703
van der Meer AL, van der Weel FR, Lee DN. The functional significance of arm movements
in neonates. Science. 1995;267:693-695

[View Question]
In general, the 28-week-old infant can sit independently and upright on the table and babble
with vowel-dominated sounds, often in imitation. Additionally, the infant can change position
with good body control and, while supine, bring feet to mouth. Having achieved this
reasonably stable position with good hand control to feed himself or herself and purposefully
hold two items, the child is prepared to interact with the environment in every way possible.
A spontaneous smile appears soon after birth and develops further for use in social
situations by 2 months of age. Most infants can differentiate strangers by 3 to 4 months of
age, but will not demonstrate true stranger anxiety until 8 to 9 months. By 8 to 9 months of
age, the child typically has perfected reciprocal games like peek-a-boo. However, it is not
until 12 months, when the child successfully combines age-appropriate social, language, and
fine motor abilities, that he or she can point to a desired object.
References:
manual for CAT-CLAMS in the first two years of life, part 1. Curr Probl Pediatr.
1996;26:238-257
Frankenburg WK, Dodds J, Archer P, et al. Fine motor-adaptive. In: Denver II Screening
Manual. Denver, Colo: Denver Developmental Materials, Inc; 1990:20-25
Frankenburg WK, Dodds J, Archer P, et al. Personal-social. In: Denver II Screening Manual.
Denver, Colo: Denver Developmental Materials, Inc; 1990:17-20
Needlman RD. The first year. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds.

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[View Question]
Eight-week-old infants are adapting rapidly to the surrounding world. At the same time that
they are developing improved coordination of the eyes, head, and upper extremities, they also
must overcome primitive reflexes, replacing them with more functional and useful purposeful
movements.
Infant traits observed early in life, such as visual alertness, tracking, and
attentiveness, lay the groundwork for more advanced skills. The simple skill of regarding a
face appears shortly after birth and progresses to following a visual stimulus to the midline
by 2 to 4 weeks and past the midline by 8 weeks of age. At the same time, use of the upper
extremity improves as the grasp and fisting reflexes disappear. Most infants will begin to
regard their own hands for at least several seconds at 8 weeks. The ability to grasp and retain
an object briefly, such as a rattle placed in the hand, emerges at 8 to 12 weeks of age. The
ability to reach purposefully for an object at 4 months of age combines all of these previously
learned abilities.
Similarly, auditory behaviors of simple alerting are replaced with searching and
localization skills as the child matures. Recognition of a familiar voice becomes apparent by
4 months of age. Localization of sound by directly turning the head emerges by 5 months.
References:
1996;26:238-257
Frankenburg WK, Dodds J, Archer P, et al. Personal-social. In: Denver II Screening Manual.
Denver, Colo: Denver Developmental Materials, Inc; 1990:17-20
Needlman RD. The first year. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds.

[View Question]
Gross motor milestones are the abilities best known, remembered, and reported by parents
and medical professionals. These milestones may be achieved within the expected time range
in many children despite significant delays in other areas. Therefore, screening that
concentrates only on gross motor milestones is inadequate. However, abnormalities in
attaining these motor skills signal the need to search for delays in other developmental areas,
including a careful neuromuscular examination.
The typical 5-year-old child can tandem walk backwards, skip with alternating feet,
and hop in place up to 10 times. These abilities are built on the skills, balance, coordination,
and practice that are demonstrated in earlier milestones, such as walking up stairs (average
age, 17 months), purposefully walking on toes and riding a tricycle (average age, 36 months),
and hopping on one foot (average age, 43 months).
References:
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1996;26:238-257
1996;26:279-306
Needlman RD. Developmental assessment and biologic variation. In: Nelson WE, Behrman
RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa:
Needlman RD. The second year. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM,
eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:44-56

[View Question]
Any sequence of developmental milestones describes an average or typical child; there is a
range of variability among individuals of the same age. The accepted normal or typical range
also may be affected by the intended purpose of the task, whether it is for screening or
diagnosis. Accordingly, a child's failure to perform a single item within a number of expected
developmental milestones should not be considered sufficient to make a diagnosis or label a
child.
Gesell assessed development along five streams: gross motor, fine motor,
visuomotor-problem solving, expressive and receptive language, and social adaptive. As one
of the five streams of development, visuomotor milestones encompass fine motor and
problem solving skills. At 18 months of age, nearly 50% of normal children can stack four
blocks to create a tower, an activity that requires visuomotor maturity, upper extremity
coordination, and judgment concerning balance. On average, children typically demonstrate a
spontaneous scribble by 15 months, the ability to turn single pages in a book by 24 months,
the imitation of drawing vertical and horizontal lines by 24 months, and the effective use of
scissors by 36 months of age.
References:
1996;26:238-257
Frankenburg WK, Dodds J, Archer P, et al. Fine motor-adaptive. In: Denver II Screening
Manual. Denver, Colo: Denver Developmental Materials, Inc; 1990:20-25
Needlman RD. Developmental assessment and biologic variation. In: Nelson WE, Behrman
RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa:

[View Question]
Macrocephaly. If a parent has a large head, the other areas of the child's development are
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normal, and there are no signs of increased intracranial pressure, the infant's large head
usually is a result of benign familial macrocephaly.
Signs of increased intracranial pressure suggesting hydrocephalus or an intracranial
mass include irritability or somnolence, loss of appetite, vomiting, a bulging fontanelle,
strabismus, impairment of upward gaze, and increased tendon reflexes and hypertonicity.
Progressive hydrocephalus with increased intracranial pressure is the most common
pathologic cause of a rapidly enlarging head. Other causes include subdural effusions and
intracranial cysts.
Fontanelle size is too variable to be helpful in distinguishing between benign
macrocephaly and hydrocephaly. A large fontanelle is worrisome only if it is bulging or
enlarging serially, features of increased intracranial pressure. However, it is worthwhile to
measure and record the fontanelle size (eg, 4 x 5 cm) serially to assure that it is getting
smaller over a period of time.
Infants who have chronic increased intracranial pressure due to hydrocephalus rarely
develop papilledema because the soft brain tissue and loose sutures allow venting of the
increased pressure. In contrast, an acute increase in intracranial pressure, as seen following
nonaccidental trauma, may cause papilledema and retinal hemorrhages in infancy.
Plotting the serial measurements of head size on a growth chart occasionally may
reveal worrisome changes from low to high percentiles in a normal situation. For example, in
a preterm infant who is recovering from a difficult newborn course, catch-up brain growth
rather than a pathologic situation may explain such changes.
If there is concern about progressive hydrocephalus, ultrasonography performed
through the fontanelle is an excellent method of determining the ventricular size. However,
this evaluation should be performed in a laboratory experienced in obtaining and interpreting
ultrasonography. If ultrasonography is not available or the infant has a closed fontanelle,
computed tomography may be necessary. Serial imaging over a period of months may be
necessary to determine whether mild ventriculomegaly is static or progressively enlarging.
Changes on radiography (eg, separated sutures) are late, rather than early, findings in patients
who have increased intracranial pressure.
References:
Bosnjak V, Besenski N, Marusic-Della Marina B, Kogler A. Cranial ultrasonography in the
evaluation of macrocrania in infancy. Dev Med Child Neurol. 1989;31:66-75
Moe PG, Seay AR. Hydrocephalus. In: Hay WW Jr, Groothuis JR, Hayward AR, Levin MJ,
eds. Current Pediatric Diagnosis & Treatment. 12th ed. Norwalk, Conn: Appleton & Lange;
1995:749-750
Moe PG, Seay AR. Macrocephaly. In: Hay WW Jr, Groothuis Jr, Hayward AR, Levin MJ,
eds. Current Pediatric Diagnosis & Treatment. 12th ed. Norwalk, Conn: Appleton & Lange;
1995:751-752
Nellhaus G. Head circumference from birth to eighteen years. Practical composite
international and interracial graphs. Pediatrics. 1968;41:106-114
Nickel RE, Gallenstein JS. Developmental prognosis for infants with benign enlargement of
the subarachnoid spaces. Dev Med Child Neurol. 1987;29:181-186
Sondheimer FK, Grossman H, Winchester P. Suture diastasis following rapid weight gain.
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Pseudopseudotumor cerebri. Arch Neurol. 1970;24:314-318
Wilms G, Vanderschueren G, Demaerel PH, et al. CT and MR in infants with pericerebral
collections and macrocephaly: benign enlargement of the subarachnoid spaces versus
subdural collections. AJNR Am J Neuroradiol. 1993;14:855-860

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Endnotes
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To Print all questions and answers in this file, from the File Menu in the upper left-hand
corner of the screen, select Print, then select All, and click the OK button.
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Question 50. Answer.

Question 78. Answer.

Question 118. Answer.

Question 148. Answer.

Question 186. Answer.

Question 218. Answer.

Critique 50. Preferred Response: B

Critique 78. Preferred Response: B

Critique 118. Preferred Response: A

Critique 148. Preferred Response: B

I. Growth and development, Self-Assessment Exercise by Category

Critique 218. Preferred Response: D

I. Growth and development, Self-Assessment Exercise by Category

2001 Self-Assessment Exercise —

Questions [Print Directions](1)

Question 27. Answer.

Question 47. Answer.

I. Growth and development, Self-Assessment Exercise by Category

Question 67. Answer.

Question 88. Answer.

Question 107. Answer.

Question 150. Answer.

Question 168. Answer.

Question 190. Answer.

I. Growth and development, Self-Assessment Exercise by Category

Question 210. Answer.

Question 230. Answer.

Question 252. Answer.

Critique 5. Preferred Response: D

Critique 27. Preferred Response: E

Critique 47. Preferred Response: C

Critique 67. Preferred Response: C

Critique 88. Preferred Response: B

Critique 107. Preferred Response: E

Critique 127. Preferred Response: B

Critique 150. Preferred Response: A

Critique 168. Preferred Response: D

Critique 190. Preferred Response: A

Critique 210. Preferred Response: B

Critique 230. Preferred Response: B

Critique 252. Preferred Response: C

2000 Self-Assessment Exercise —

Questions [Print Directions](2)

Question 53. Answer.

Question 107. Answer.

Question 160. Answer.

Question 213. Answer.

Question 266. Answer.

I. Growth and development, Self-Assessment Exercise by Category

Critique 53 Preferred Response: B

Critique 107 Preferred Response: C

Critique 160 Preferred Response: C

Critique 213 Preferred Response: D

Critique 266 Preferred Response: A

1999 Self-Assessment Exercise —

Questions [Print Directions](3)

Question 88. Answer.

Question 186. Answer.

I. Growth and development, Self-Assessment Exercise by Category

Critique 1 Preferred Response: A

Critique 88 Preferred Response: E

Critique 186 Preferred Response: D

I. Growth and development, Self-Assessment Exercise by Category