III. Preventive Pediatrics2002

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2002 Self-Assessment Exercise —
III. Preventive pediatrics
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Questions
Question 32. Answer.

The parents of a 15-year-old boy report that their son, who has a history of depression, has
had increasing difficulties controlling his anger. He recently was expelled from school for
carrying a knife. The parents have always kept a handgun in their bedroom.
During the discussion about firearms, you are MOST likely to inform the parents that:
A. approximately 75% of homicides involving adolescents occur during criminal acts
B. fewer than one third of the adolescent homicides attributed to firearms involve
handguns
C. having a gun in the house is associated with a five-fold increase in adolescent suicide
risk
D. the risk of lethal assault with a knife is greater than with a gun
E. their handgun can be safely kept with a trigger lock installed
Answers
Critique 32. Preferred Response: C

[View Question]
The 15-year-old boy described in the vignette has a history of depression and aggressive
behavior and is at risk for suicide. His parents need to know that this risk is markedly
increased by the presence of a gun in their home.
There are guns in almost 50% of all United States households. Approximately 36% of
the guns owned by Americans are rifles, 34% are handguns, 25% are shot guns, and 5% are
other long guns. Many of these guns, including the majority of handguns, are kept loaded,
unlocked, and ready for use. Handguns account for the majority of firearm-related injuries
and deaths. Almost 75% of handgun owners have cited self-protection as the primary reason
for ownership, but ironically, the presence of a gun in the home increases the risk of a
domestic homicide threefold and the risk of suicide fivefold.
Firearm safety issues should be a routine part of injury and violence prevention
counseling. Pediatricians should provide information to parents about the dangers of guns,
especially handguns, in their homes, schools, and communities. Gun-free homes should be
encouraged, but where this is not acceptable, safety measures need to be discussed to attempt
III. Preventive pediatrics, Self-Assessment Exercise by Category
PREP® Archive on CD-ROM. Copyright © 2003, American Academy of Pediatrics.
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to reduce the risks associated with the presence of a gun. Guns should be stored unloaded and
locked, and ammunition should be kept locked in a different location. Safety mechanisms
such as trigger locks, although yet of unproven benefit, may reduce unintentional injuries and
deaths and domestic homicides.
Parents need to understand that the presence of a gun in the home increases the
possibility that an impulsive or well-thought out suicide attempt will involve a gun and be
lethal. More than 90% of suicide attempts with a gun are fatal, supporting a clear
recommendation of removing firearms from homes of at-risk children and adolescents,
especially those who have a history of aggressive or violent behavior, previous suicide
attempts, and/or depression. Two thirds of successful suicides have involved firearms, and
70% of the guns involved in adolescent suicides have been handguns. Firearms have become
the most frequently used method for both males and females who commit suicide. Reported
suicide rates for males are six times greater than for females among adolescents 15 to 19
years of age.
Most homicides occur on impulse during interpersonal conflict and involve guns.
More than 75% of adolescent homicides attributed to firearms involve handguns.
The case fatality of a gun shot injury is 10 times higher than the rate for a stabbing.
Many firearm-related deaths occur before arrival at a hospital.
References:
American Academy of Pediatrics Committee on Adolescents. Suicide and suicide attempts in
adolescents. Pediatrics. 2000;105:871-874
American Academy of Pediatrics Committee on Injury and Poison Prevention.
Firearm-related injuries affecting the pediatric population. Pediatrics. 2000;105:888-895
Rivara FP, Grossman D. Injury control. In: Behrman RE, Kliegman RM, Jenson HB, eds.
Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:236-237

Questions [Print Directions](1)

The Parent-Teacher Association at the local elementary school has asked you to speak about
bicycle safety at their next meeting.
Of the following, a TRUE statement regarding bicycle safety is that
A. bicycle helmets reduce the risk of head injury by 50%
B. bicycles produced after 1974 must have reflectors on the front and rear
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C. fewer than 25% of deaths from bicycle crashes are due to head injury
D. most bicycle injuries occur in adolescents and adults
E. most school-age children wear bicycle helmets routinely

The 23-valent pneumococcal polysaccharide vaccine is RECOMMENDED for the child who
A. attends a large child care center
B. has frequent ear infections
C. is older than 2 years of age and has nephrotic syndrome
D. is younger than 2 years of age and has sickle cell disease
E. lives in the same household as a patient who has asplenia

As part of the examination of a 3-year-old girl during a health supervision visit, you review
her medical history.
Of the following, the condition that is the STRONGEST indication for routine annual
influenza immunization is
A. all healthy children
B. asthma
C. asymptomatic heart disease
D. attendance at child care
E. frequent otitis media

At a prenatal health supervision visit, the prospective parents ask you for recommendations in
choosing an age-appropriate infant car safety seat.
Of the following, the MOST appropriate advice is that
A. infant carrier seats should not be used as infant car safety seats
B. integrated car safety seats provide good protection from infancy through 4 years of
age
C. the angle of an infant car safety seat must be at 45 degrees for adequate crash
protection
D. the car safety seat may be placed in the front seat if the vehicle has passenger-side air
bags
E. the car safety seat should face forward until the infant is 1 year old

You are examining a 12-month-old girl whose family recently moved to your town. Her
mother is concerned about lead poisoning because their home was built before 1950.
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Of the following, the MOST appropriate test(s) to screen this infant for lead poisoning is(are)
A. free erythrocyte protoporphyrin (FEP)
B. FEP and plasma lead level
C. FEP and wrist radiographs
D. plasma lead level
E. plasma lead level and wrist radiography

You have been asked by a pediatric surgeon to evaluate a 3-month-old infant who was born
at term and is scheduled to have an elective herniorrhaphy. Findings on preoperative
laboratory testing include: hemoglobin, 90 g/L (9.5 g/dL); mean corpuscular volume, 72 fL;
white blood cell count, 8.7 x 109/L (8,700/mm3); platelets, 313 x 109/L (313,000/mm3); and
normal peripheral blood smear.
Of the following, this child's hemoglobin level is MOST likely due to
A. Blackfan-Diamond anemia
B. hereditary spherocytosis
C. iron deficiency anemia
D. physiologic anemia
E. transient erythroblastopenia of childhood

Of the following, the child for whom further diagnostic evaluation is indicated MOST
strongly is a
A. 4-month-girl whose blood pressure is 90/50 mm Hg
B. 14-month-old boy whose blood pressure is 95/50 mm Hg
C. 4-year-old girl whose blood pressure is 100/60 mm Hg
D. 14-year-old boy whose blood pressure is 130/80 mm Hg
E. 14-year-old girl whose blood pressure is 120/75 mm Hg

A 1-year-old boy who acquired human immunodeficiency virus infection perinatally presents
for a routine health supervision visit. He receives highly active antiretroviral therapy with
three drugs, and he is currently asymptomatic. However, he has a history of treatment for
Pneumocystis carinii pneumonia.
Of the following, the vaccine that is CONTRAINDICATED for this boy is
A. conjugated Haemophilus influenzae type b
B. diphtheria-tetanus toxoids with acellular pertussis
C. injectable poliovirus
D. split-virus influenza
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E. varicella
Answers
Critique 34. Preferred Response: B

[View Question]
Bicycle riding is an extremely popular sport, even for young children. Approximately 80% to
90% of second graders in the United States own bicycles. Each year about 1,200 bicyclists
are killed, and more than 500,000 bicycle-related injuries are treated in emergency
departments. About 33% of deaths and 65% of the injuries involve school-age children
younger than age 15. Approximately 75% of the deaths are due to head injury, and about
30% of the total injuries seen are to the head and face.
It is estimated that bicycle helmets are worn by fewer than 10% of bicycle riders.
Bicycle helmets are known to be extremely effective in preventing serious head trauma, and
they have been demonstrated to reduce significant injuries by 85%. For a helmet to provide
protection during impact, it must have a chin strap and fit snugly. There are two nationally
recognized voluntary safety standards for bicycle helmets sold in the United States, and
parents should be instructed to purchase only helmets that meet these standards.
Since 1974, Consumer Product Safety Commission regulations have required
reflectors on the front and rear of the bicycle as well as on the pedals and reflective tire
sidewalls or wheel rims or spoke-mounted reflectors. Other safety precautions for higher
visibility and for riding at dusk include using front or rear lights and wearing clothing with
reflective tape or markings.
Community bicycle helmet campaigns have been shown to increase helmet use and
can help reduce head injuries. Helmet use among Seattle school children increased from 5%
to 40% during 5 years of the city’s Head Smart Campaign, and bicycle-related head injuries
that required medical attention decreased by two thirds during the same period.
References:
Council on Scientific Affairs, American Medical Association. Helmets and preventing
motorcycle- and bicycle-related injuries. JAMA. 1994;16:1535-1538
Mumper EA, Brennan TL. Hats off to helmets! Contemp Pediatr. 1997;14:123-134
Rivara FP, Thompson DC, Thompson RS, et al. The Seattle children's bicycle helmet
campaign: changes in helmet use and head injury admissions. Pediatrics. 1994;93:567-569
United States Department of Transportation, National Highway Traffic Administration. 10
Smart Routes to Bicycle Safety. 1998

[View Question]
The 23-valent polysaccharide pneumococcal vaccine is composed of purified capsular
polysaccharide antigens of 23 pneumococcal serotypes. Like other polysaccharide antigens,

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many of the pneumococcal serotypes in the vaccine have limited immunogenicity in children
younger than 2 years of age. Current recommendations for immunization with pneumococcal
polysaccharide vaccine include children 2 years of age or older:
who have diseases that increase the risk of acquiring pneumococcal infection or
serious disease if they become infected, such as sickle cell disease, functional or
anatomic asplenia, nephrotic syndrome or chronic renal failure, immunosuppression
due to organ transplantation or drug therapy, human immunodeficiency virus
infection, or cerebrospinal fluid leaks
who have chronic cardiovascular, pulmonary, or liver disease
who live in settings in which the risk of invasive pneumococcal disease or its
complications is high, such as Alaskan Natives and certain Native-American
populations
Immunization with pneumococcal polysaccharide vaccine is not recommended for
preventing otitis media during the first 2 years of life. Some experts suggest immunizing
older children who have recurrent otitis media, but this recommendation is not universal.
Vaccination of household contacts of patients who have asplenia and those who attend child
care is not currently recommended.
In February 2000, pneumococcal conjugate vaccine (PCV7) was licensed. This
vaccine, like the Haemophilus influenzae conjugate vaccine, is immunogenic in children
younger than 2 years of age. PCV7 is recommended for universal use in children 23 months
of age and younger at 2, 4, 6, and 12 months of age. The child older than age 2 who is at high
risk of invasive pneumococcal disease also should receive PCV7.
References:
American Academy of Pediatrics. Pneumococcal infections. In: Pickering LK, ed. 2000 Red
Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill:
American Academy of Pediatrics; 2000:452-460
Prevention of pneumococcal disease: recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997;46(RR-8):1-24
Critique 87. Preferred Response: B

[View Question]
Yearly influenza immunization, administered in the fall, is recommended for children 6
months of age or older who have one or more specific risk factors. Children at risk are those
who have needed regular medical follow-up, hospitalization, or both during the preceding
year because of one or more of the following:
Asthma and other chronic pulmonary diseases
Hemodynamically significant cardiac disease
Immunosuppressive disorders or therapy
Human immunodeficiency virus (HIV) infection
Sickle cell anemia and other hemoglobinopathies
Diseases requiring long-term aspirin therapy, such as rheumatoid arthritis or Kawasaki
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disease, which may increase the risk for development of Reye syndrome following influenza
Children and adolescents who are potentially at increased risk for complicated
influenza and may benefit from influenza immunization are those who have the following
conditions.
Diabetes mellitus
Chronic renal disease
Chronic metabolic disease
Pregnancy
Routine yearly vaccination is not recommended for children in child care, those who
have asymptomatic heart disease, and those who have frequent otitis media. Although its
administration is not necessary, influenza vaccine may be administered to any healthy child
or adolescent at the patient’s or parent’s request. More important is the need for children in
households with high-risk adults, such as those who have symptomatic HIV infection, to be
immunized with the influenza vaccine, as should adults in households with high-risk
children.
References:
American Academy of Pediatrics. Influenza. In: Pickering LK, ed. 2000 Red Book: Report of
the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill: American Academy of
Pediatrics; 2000:351-359
Prevention and control of influenza: recommendations of the Advisory Committee on

[View Question]
The American Academy of Pediatrics (AAP) recommends that all newborns be transported
home from the hospital in car safety seats that meet Federal Motor Vehicle Safety Standard
(FMVSS) 213. The AAP estimates that with 100% compliance, car safety seat use in children
4 years of age or younger could prevent approximately 53,000 injuries and 500 deaths each
year.
Children should face the rear of the vehicle until they weigh at least 9 kg (20 lb) and
are 1 year of age. This position provides increased protection to the spinal column in a frontal
crash. The safest placement for children of any age is the middle of the rear seat. Rear-facing
infant seats never should be used in the front passenger seat of any vehicle equipped with a
passenger-side front air bag; the infant can suffer serious injuries if the air bag inflates and
forcefully propels the car seat.
Lightweight infant carrier seats should not be used with a seat belt as a substitute for
an infant car safety seat. However, some FMVSS 213-compatible infant car seats have
detachable bases that remain secured to the vehicle’s passenger seat, allowing the infant seat
to be used as an infant carrier seat as well.
Some vehicles are now equipped with integrated car safety seats. These systems may
provide better protection and have the advantage of eliminating problems with installing and
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anchoring the car seat. However, these seats are forward-facing and never should be used in
children younger than 1 year of age.
Rear-facing infant car safety seats are maximally effective if they position the infant
at approximately a 45-degree angle. If the vehicle seat slopes so that the infant’s head flops
forward, a firm roll of cloth or newspaper should be wedged under the safety seat below the
infant’s feet to maintain the proper 45-degree angle.
The AAP provides up-to-date information for physicians and parents about car safety
seats on the AAP web page at: www.aap.org.family/mncrseat.htm.
References:
Agran P, Winn D, Anderson C. Child occupant protection in motor vehicles. Pediatr Rev.
1997;18:413-422
American Academy of Pediatrics. Committee on Injury and Poison Prevention. Selecting and
using the most appropriate car safety seats for growing children: guidelines for counseling
parents. Pediatrics. 1996;97:761-763
American Academy of Pediatrics. 1999 Family Shopping Guide to Car Seats. Available at:
http://www.aap.org/family/famshop.htm
Critique 143. Preferred Response: D

[View Question]
Obtaining a plasma lead level is the most appropriate method of screening for lead poisoning.
This readily available test is technically difficult to perform and has a wide margin of error
(±0.19 mcmol/L [4 mcg/dL]). This error is acceptable at higher lead levels, but when the
level is 0.72 mcmol/L (15 mcg/dL) or less, the test should be repeated for confirmation.
Interpretation of lead levels is more accurate when serial samples are followed over time. The
current definition of lead poisoning is a level of 0.48 mcmol/L (10 mcg/dL).
For mass lead screening programs, capillary samples are preferable to venous
samples. Contamination of a capillary sample by environmental lead is a risk, but it is less
than 10% in the hands of experienced technicians. If a child is asymptomatic, the results of a
single capillary sample never should be used to institute therapy without a confirmatory
venous sample. If the child is symptomatic, it is useful to obtain supportive evidence, such as
a measurement of free erythrocyte protoporphyrin (FEP), an abdominal radiograph to
examine for ingested lead, and radiography of long bones to look for lead lines. These studies
can provide supportive evidence to justify treatment when only a potentially contaminated
capillary sample is available for a child who is symptomatic.
Blood lead levels are the most accurate indicators of recent lead exposure; they are
less helpful in assessing the accumulation of lead over time. However, alternative measures
are problematic. Ethylenediamine-tetraacetic acid (EDTA) provocative testing is difficult to
perform, radiographic fluorescence is not widely available, and dental lead levels are
impractical to obtain.
FEP had been used as a routine screening test for lead poisoning because it can be
performed easily using fingerstick techniques. However, it is an inadequate screening tool for
several reasons. It is insensitive to lead levels of 0.48 to 1.21 mcmol/L (10 to 25 mcg/dL),
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which now are recognized as being associated with neurodevelopmental harm, and it fails to
identify more than 50% of children who have lead levels of 1.21 mcmol/L (25 mcg/dL) or
greater. It also fails to identify recent exposures to lead, particularly within the prior 2 weeks,
even if those exposures are substantial.
Wrist radiography is a very insensitive method of evaluating lead poisoning and has
no role as a screening test.
References:
Chisolm JJ Jr. Lead poisoning. In: McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB,
eds. Oski's Pediatrics: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott Williams
& Wilkins; 1999:629-634
Piomelli S. Lead poisoning. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson
Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:2156-2160
Weitzman M, Glotzer D. Lead poisoning. Pediatr Rev. 1992;13:461-468

[View Question]
The hemoglobin concentration in the infant described in the vignette reflects physiologic
anemia. Hemoglobin levels are at their highest in the fetus and neonate. These high levels
improve the relatively inefficient delivery of oxygen to the fetus. The rapid improvement in
the neonatal oxygen saturation that occurs upon delivery makes such high levels unnecessary
in the postnatal period. Thus, hemoglobin concentrations decrease until the point at which
oxygen delivery becomes impaired. This occurs at 8 to 12 weeks of age in term infants, when
normal hemoglobin levels can fall to as low as 90 g/L (9.0 g/dL). The levels subsequently
rise gradually, reaching a lower limit of normal of 110 g/L (11 g/dL) at 6 months of age and
continuing to increase to adult levels at approximately 18 years of age. Preterm infants
have even greater decreases in hemoglobin that occur at earlier ages than in term infants.
Although this process is in part physiologic, controversy surrounds how low to allow the
hemoglobin to decrease in ill preterm infants. Clinical criteria for transfusion and
recombinant erythropoietin therapy continue to be developed.
In physiologic anemia, the erythrocytes are normocytic, and white blood cell, absolute
neutrophil, and platelet counts are normal. One disorder to be considered when these levels
are abnormal is Blackfan-Diamond syndrome, which is a congenital red blood cell aplasia.
The inheritance of the disorder is not clear. Almost 25% of patients demonstrate a variety of
physical anomalies. It is a serious chronic disorder, although spontaneous remissions do
occur.
Another cause of erythroid aplasia is transient erythroblastopenia, which is much
more common than Blackfan-Diamond syndrome. Spontaneous recovery occurs, but when
the anemia becomes severe enough prior to recovery, red blood cell transfusion may be
necessary. Iron deficiency anemia is unusual in the first 3 to 4 months of life, but it may
occur when iron stores are depleted because of perinatal or postnatal blood loss. Hemolytic
anemias, such as spherocytosis, may be confused with red blood cell aplasia during aplastic
crises, but abnormalities on the peripheral blood smear and hyperbilirubinemia help

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distinguish these disorders from physiologic anemia.
References:
Alter BP, Young NS. The bone marrow failure syndromes. In: Nathan DG, Orkin SH, eds.
Nathan and Oski's Hematology of Infancy and Childhood. 5th ed. Philadelphia, Pa: WB
Saunders Co; 1998:237-335
Brugnara C, Platt OS. The neonatal erythrocyte and its disorders. In: Nathan DG, Orkin SH,
eds. Nathan and Oski's Hematology of Infancy and Childhood. 5th ed. Philadelphia, Pa: WB
Curtis JA. Physiologic anemia. Pediatr Rev. 1995;16:356-357

[View Question]
The Update on the Task Force Report on Hypertension in Children and Adolescents
recommends that children who have repeated systolic or diastolic blood pressure
measurements at or above the 95th percentile for age receive further diagnostic evaluation
and possibly intervention. The Task Force Report contains tables of gender-specific
normative blood pressure values for all ages, including young children. Tall individuals may
have somewhat higher normal blood pressures, and variations for height are considered in the
tables.
A systolic blood pressure of 135 mm Hg meets the criterion for further evaluation.
Accordingly, the 14-year-old boy whose blood pressure is 135/80 mm Hg on at least three
occasions should be evaluated further.
References:
Daniels SR. Consultation with the specialist: the diagnosis of hypertension in children: an
update. Pediatr Rev. 1997;18:131-135
Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood
Institute, Bethesda, Maryland. Report of the Second Task Force on Blood Pressure Control in
Children-1987. Pediatrics. 1987;79:1-25
Update on the Task Force Report (1987) on High Blood Pressure in Children and
Adolescents: A Working Group Report from the National High Blood Pressure Education
Program. NIH Publication No. 96-3790. September, 1996. Available at:
http://www.nhlbi.nih.gov/nhlbi/cardio/hbp/prof/hbp_ped.pdf
Critique 224. Preferred Response: E

[View Question]
Patients who have immunodeficiencies, such as the boy described in the vignette, generally
should not receive live viral or bacterial vaccines. Fatal infections with poliomyelitis and
measles have occurred in children who have congenital immunodeficiencies after
administration of live measles and oral poliovirus (OPV) vaccines. Patients who have
immunodeficiencies should receive inactivated vaccines (eg, diphtheria-tetanus toxoids with
acellular pertussis [DtaP], hepatitis B, inactivated poliovirus [IPV], Haemophilus influenzae
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type b [Hib] conjugate, pneumococcal, and influenza vaccine). However, the immune
responses of immunocompromised children to some of these inactivated vaccines can be
inadequate, and the vaccine’s efficacy may be substantially reduced. The ability to develop a
normal immunologic response is influenced by the type and degree of immunosuppression.
Use of live viral and bacterial vaccines such as bacillus Calmette-Guérin and measles
has been associated with complications in human immunodeficiency virus (HIV)-infected
children. Because of reports of severe and even fatal measles in symptomatic HIV-infected
children, measles vaccination now is recommended only for those who are symptomatic but
not severely immunocompromised as well as those who are asymptomatic. Varicella vaccine
is a live virus vaccine that usually is not administered to immunocompromised patients. An
additional exception is a special protocol for vaccinating children who have acute
lymphocytic leukemia in remission that is available through the manufacturer.
Children who have either asymptomatic or symptomatic HIV infection should receive
other routinely recommended killed vaccines, including DTaP, hepatitis B, and Hib conjugate
vaccines and IPV according to the recommended schedule. Annual influenza immunization
of HIV-infected children also is recommended. Pneumococcal vaccination is indicated for
children 2 years of age or older.
Vaccination is however, recommended for HIV-infected children who are
asymptomatic.
References:
American Academy of Pediatrics. Immunocompromised children. In: Pickering LK, ed. 2000
Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill:
American Academy of Pediatrics; 2000:56-67
Prevention of varicella. Update recommendations of the Advisory Committee on
Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of
vaccines and immune globulins for persons with altered immunocompetence. MMWR Morb
Mortal Wkly Rep. 1993;42(RR-4):1-18


During a prenatal visit a mother asks where the infant car seat should be placed for maximal
protection of her newborn.

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For a newborn, the BEST location for the car seat is
A. facing front in the back seat on the driver side
B. facing front in the front seat on the passenger side
C. facing rear in the back seat on the passenger side
D. facing rear in the middle of the back seat
E. facing rear in the front seat on the passenger side

During a health supervision visit, you note that a 4-year-old child is sunburned.
Of the following, the statement you are MOST likely to include in counseling the child's
mother regarding the risk of sun exposure is that
A. clothing offers little protection against ultraviolet radiation
B. 80% of a person's lifetime sun exposure occurs after the age of 21 years
C. rates of skin cancer in the United States are declining
D. the intensity of ultraviolet B radiation is constant throughout the day
E. use of appropriate sunscreen during the first two decades of life reduces skin cancer
risk by 80%
Answers
Critique 102 Preferred Response: D

[View Question]
The best location for an infant or child in a motor vehicle is the position where he or she is
protected most from injury in the event of a crash. In most cars, the safest place is in the
middle of the back seat, where the child is farthest from an impact at the front, rear, or sides
of the car. Infants who weigh less than 9.1 kg (20 lb) should be in a car seat that is facing rear
because this offers the most stability for the infant's head and neck. The cranial portion of an
infant's body is large in proportion to the rest of the body, and a severe neck injury can occur
following a sudden deceleration if the infant is facing forward. Accordingly, a newborn
should be in a rear-facing infant car seat that is placed in the middle of the back seat. A
newborn should not be in a front-facing seat, either in the front on the passenger side or in the
back on the driver side. Further, infants should not be placed in the front or back passenger
seats because these positions offer less protection than the middle of the back seat if the point
of impact occurs on the passenger side.
Children and infants who weigh more than 9 kg (20 lb) can ride in a convertible car
seat that faces forward. Most children weigh 9 kg by their first birthday at which time they
also have developed good neck control. The safest place in a car for a child of this age still is
in the middle of the back seat, but the car seat can be facing forward. Children can move to a
booster seat safely if they are 4 years old and weigh 18 kg (40 lb), but booster seats still
should be placed in the back seats of cars. As the child reaches 27 to 36 kg (60 to 80 lb),

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booster seats can be exchanged for standard seat belts, but the back seat remains the safest
location until a child reaches the age of 12 years.
References:
Agran P, Winn D, Anderson C. Child occupant protection in motor vehicles. Pediatr Rev.
1997;18:413-422
Rivara FP, Brownstein DR. Injury control. In: Behrman RE, Kliegman RM, Nelson WE, eds.
Critique 178 Preferred Response: E

[View Question]
An important part of anticipatory guidance is a discussion of the consequences of sun
exposure and the benefits of sun protection. Damage caused by the sun is mediated by
ultraviolet (UV) light. UVB is a major cause of skin aging, sunburn, and skin cancer. The
intensity of UVB varies throughout the day; it is greatest between the hours of 10:00 am and
5:00 pm. UVA radiation is responsible for most drug-induced photosensitivity reactions, and
it contributes to skin aging, sunburn, and skin cancer. UVA intensity is constant throughout
the day.
Rates of skin cancer continue to rise; more than 1 million new cases are diagnosed
annually in the United States. Although most of these are nonmelanoma skin cancers
(NMSC) that have a good prognosis if treated early, 38,000 are malignant melanomas. In
1995, malignant melanoma caused 7,200 deaths. Many studies confirm the relationship
between sun exposure and skin cancer. Cumulative exposure predisposes to the development
of NMSC, while cutaneous melanomas appear to be related to intermittent intense exposure.
Approximately 80% of a person's lifetime sun exposure occurs during the first two decades of
life. If sunscreens were used during this period, it is estimated that the risk of skin cancer
could be reduced by almost 80%.
In counseling parents and patients, the following issues deserve emphasis. The risk of
sunburn is related to an individual's ethnic background and underlying pigmentation.
Children who have very fair skin, always (skin type I) or often (skin type II) burn, and
develop minimal or no tan are at highest risk for sun damage and require the greatest
protection. In contrast, African-Americans (skin type VI) generally do not experience
sunburn and, therefore, do not need to use sunscreens. Parents should be advised to select a
sunscreen that has a sun protection factor (SPF) of at least 15 and is active against both UVA
and UVB radiation. Among chemical sunscreens, products containing benzophenones or
anthranilates provide some UVA protection, while those containing dibenzoyl-methanes (eg,
Parsol 1789) offer the best UVA coverage. Physical sunscreens contain agents that
effectively block both UVB and UVA radiation. In the past, however, these products were
thick and opaque and, therefore, cosmetically unacceptable. The development of formulations
containing microsized titanium dioxide particles has overcome this problem.
To obtain maximum benefit, sunscreen should be applied 20 minutes before
anticipated sun exposure. Furthermore, to achieve the labeled SPF, sunscreens must be used
liberally. It is recommended that 2 mg of sunscreen be applied for each square centimeter of
body surface. For adults, approximately 30 mL of sunscreen should be applied. Most persons
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apply only 25% to 50% of this amount. Decreasing the amount applied by 50% can reduce
the labeled SPF by as much as 40%. To combat the reduction in sunscreen efficacy that
results from sweating or swimming, products labeled water-resistant, very water-resistant, or
sweat-resistant can be used. Those that are water-resistant retain their SPF after two
20-minute immersions; very water-resistant or sweat-resistant sunscreens will retain their
SPF after four 20-minute immersions.
Parents should be aware that currently available sunscreens do not offer perfect
protection. Although most chemical sunscreens (those that absorb UV radiation) provide
good protection from UVB radiation, they offer less UVA protection. This is of particular
importance in view of recent information linking UVA radiation with malignant melanoma.
Therefore, sunscreens should be viewed as one part of a broader program that includes
wearing protective clothing, wearing sunglasses that block UVA and UVB, and avoiding sun
exposure during periods when UVB is most intense.
References:
Hebert AA. Photoprotection in children. Adv Dermatol. 1993;8:309-324
Kim HJ, Ghali FE, Tunnessen WW. Here comes the sun. Contemporary Pediatrics.
1997;14:41-69


A mother expresses concern about her 3-year-old son’s clumsiness; he seems to fall
frequently when climbing. Physical examination reveals an asymmetric corneal light reflex
and a black defect in the red reflex of the left eye; the right eye is normal. You decide to
perform a cover test on both eyes.
The result of the cover test that would be MOST consistent with your physical findings is
A. deviation of the left eye when it is uncovered
B. deviation of the right eye when the left is covered
C. deviation of the right eye when the left is uncovered
D. resistance to covering the left eye
E. resistance to covering the right eye

A 4½-year-old boy is being seen for a health supervision visit. His mother concerned about
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him receiving the measles, mumps, and rubella (MMR) vaccine because he is allergic to
eggs. You determine that he eats egg contained in cooked dishes without difficulty, but when
he was 3 years old, he ate scrambled eggs and broke out in hives.
Of the following, the BEST course of action is to
A. administer MMR without prior skin testing
B. perform skin testing with egg antigen
C. perform skin testing with egg antigen and MMR
D. perform skin testing with MMR
E. withhold administration of MMR

The blood pressure of a 13-year-old boy is normal, and his growth parameters are at the
75th percentile for age. His grandfather underwent coronary bypass surgery at age 49, and a
great-aunt had a “heart attack” at age 60, but both of his parents are healthy.
The NEXT step according to the National Cholesterol Education Program (NCEP) guidelines
is to
A. measure total blood cholesterol
B. obtain a fasting lipoprotein profile
C. provide cardiovascular risk factor education without any laboratory testing
D. recommend a diet that contains increased quantities of fish oils
E. recommend a diet that has a total cholesterol intake of less than 200 mg/dL

Of the following, the best drug for the INITIAL treatment of anaphylaxis is
A. inhaled albuterol
B. intravenous aminophylline
C. intravenous diphenhydramine
D. oral prednisone
E. subcutaneous epinephrine

At which health supervision visit is it MOST appropriate to discuss the storage of hazardous
substances where children cannot reach them?
A. 2 month
B. 4 month
C. 6 month
D. 9 month
E. 12 month

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At a recent health supervision visit, the parents of a 2-year-old and a 6-month-old report that
they soon will be moving to a new house with a pool. They ask how best to safeguard their
young children.
Of the following, the BEST way to prevent a drowning at a home pool is to
A. erect a fence with a locked gate
B. have life jackets near the pool
C. insist on adult supervision at all times
D. install a pool cover with a weight-sensitive alarm
E. teach the children to swim
Answers

[View Question]
Periodic ophthalmologic examinations can identify several conditions that, if detected early,
are amenable to therapy. Part of such an examination is the red reflex test and corneal light
reflex test, which indicate whether the eyes are aligned correctly.
The defect in the red reflex of the left eye in the child described in the vignette
probably represents a cataract in the lens of the eye, which is impeding the reflection of light
from the retina that results in a normal circular red reflex. As the cataract enlarges, vision is
impaired, and the brain often suppresses the images from the affected eye. If the images are
suppressed for an extended period of time, amblyopia (loss of visual acuity) results. With
prolonged suppression and poor acuity, the affected eye does not fix or align itself with the
normal eye, resulting in a shift of the corneal light reflex so that it is not symmetric when
compared with the other eye. Depth perception is impaired by the loss or decrease in visual
acuity in one eye, and these children are more likely to fall, spill liquids, and run into objects
than their unaffected peers.
An accurate method of confirming the presence of such malalignment or strabismus is
the cover test. The child is asked to look at the wall and focus on a particular spot, then one
eye is covered completely. If amblyopia is present in the uncovered eye, the child may fight
or become unruly when the good eye is covered. The ocular tropias are manifest deviations of
alignment. If the uncovered eye moves outward to fixate on the wall, then an esotropia (an
inward turning eye) is present. An exotropia is present when the uncovered eye moves
inward to fix upon the wall. Ocular phorias, or latent deviations, can occur as well and also
can be diagnosed by the cover test. If there is no movement when one eye is covered, but
there is movement of the covered eye when occlusion is removed, then a phoria is present.
Strabismus revealed by the cover test may be associated with cataracts.
The child described in the vignette has a cataract in the left eye, with symptoms
consistent with strabismus and amblyopia. The right eye appears normal. Based on these
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findings, when the right or functional eye is covered, the child should resist the maneuver and
try to avoid its occlusion. If the left eye deviates when uncovered, a phoria, which often is not
clinically symptomatic, is present. Phorias are not necessarily associated with cataracts; they
may occur independently. Deviation of the right eye when the left is covered indicates a
tropia and a problem with the right eye rather than the left. Deviation of the right eye when
the left eye is uncovered may indicate a dominant left eye that functions normally with a
tropia on the right. It is possible that the child exhibiting such test results could have
amblyopia (from cataract or strabismus), but the problem would be in the right eye, which
appears normal on examination. Resistance to covering the left eye would occur if this was
the normal or functional eye, which does not agree with findings on physical examination of
the boy described in the vignette.
References:
Apt L, Miller KM. The eyes. In: Rudolph AM, ed. Rudolph's Pediatrics. 20th ed. Stamford,
Conn: Appleton & Lange; 1996:2063-2066
Magramm I. Amblyopia: etiology, detection, and treatment. Pediatrics in Review.
1992;13:7-15
Nelson LB. Disorders of eye movement and alignment. In: Behrman RE, Kliegman RM,
Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co;
1996:1772-1776
Critique 55 Preferred Response: A

[View Question]
Current measles and mumps vaccines are derived from chick embryo fibroblast tissue
cultures and do not contain significant amounts of egg cross-reacting proteins. Recent studies
have shown that children who have egg allergy, including severe hypersensitivity, are at low
risk for anaphylactic reactions to these vaccines singly or in combination (ie, measles,
mumps, and rubella [MMR]). Further, skin testing with dilute vaccine is not predictive of an
allergic reaction following vaccination. Accordingly, administering the MMR vaccine
without prior skin testing will not place the child in the vignette at any increased risk for an
allergic reaction and would be recommended.
Withholding the MMR vaccine or skin testing with egg antigen or a combination of
egg antigen and MMR vaccine is not necessary in children who are allergic to eggs. Some
experts recommend that such children be observed for 90 minutes following administration
of MMR, measles, or mumps vaccine so that signs of anaphylaxis could be treated promptly,
if necessary.
Current yellow fever and influenza vaccines contain egg proteins and on rare
occasions have been associated with allergic reactions, including anaphylaxis. In contrast to
MMR vaccine, skin testing with yellow fever vaccines is recommended before administration
to persons who have a history of systemic anaphylactic symptoms (eg, generalized urticaria,
hypotension, manifestations of upper or lower airway obstruction) following egg ingestion.
Of note, children who have had severe anaphylactic reactions to eggs should not receive the
influenza vaccine because of the need for annual vaccination and the risk of reaction;
chemoprophylaxis against influenza A infection is available as an alternative preventive
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measure. However, less severe or localized reactions to eggs or feathers are not
contraindications to the administration of yellow fever or influenza vaccine and do not
warrant skin testing prior to vaccination.
References:
Committee on Infectious Diseases. Hypersensitivity reactions to vaccine constituents. In:
Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Ill: American
Academy of Pediatrics; 1997:32-35
James JM, Burks AW, Roberson PK, Sampson HA. Safe administration of the measles
vaccine to children allergic to eggs. N Engl J Med. 1995;332:1262-1266
Critique 104 Preferred Response: B

[View Question]
The pediatric guidelines of the National Cholesterol Education Program (NCEP) delineate an
approach to the child who may be at risk for coronary artery disease later in life because of
abnormal lipid metabolism. Specific recommendations to perform blood cholesterol
screening, lipid profile analysis, or no lipid screening are based on the family history or
presence of other risk factors for coronary heart disease.
The NCEP recommends against universal screening with blood tests, suggesting
instead a population approach to promote nutrition education, encourage healthier eating
patterns consistent with recommended nutritional guidelines, and promote fitness and
exercise.
A total blood cholesterol test is recommended for all children who have a parent who
has an elevated total cholesterol level (³240 mg/dL). Children who have other risk factors for
coronary disease, including cigarette smoking, high blood pressure, physical inactivity,
diabetes, or severe obesity (³30% above ideal weight), also should be screened, even in the
absence of a positive family history.
A fasting lipoprotein profile is recommended for all children who have parents or
grandparents who had evidence of coronary atherosclerosis on or before the age of 55,
including myocardial infarction, angina, coronary bypass surgery, angioplasty, or sudden
cardiac death. Accordingly, evaluation of a fasting lipid profile is warranted for the boy
described in the vignette. Children whose parents or grandparents had peripheral vascular
disease or cerebrovascular disease on or before the age of 55 also should have their
lipoprotein profiles obtained. This profile includes measurement of total cholesterol,
triglycerides, and high-density lipoprotein (HDL) cholesterol with a measured or calculated
low-density lipoprotein (LDL) cholesterol.
Some experts believe that the definition of premature coronary heart disease should
begin at an older age in females than males. They suggest that the age to begin screening
based on family history in females should be increased to a cutoff of 60 years (or even 65
years) rather than the 55-year level applied to males.
Although the family history of the boy described in the vignette was not suggestive of
extreme risk, subsequent laboratory testing documented probable heterozygous familial
hypercholesterolemia, with a total cholesterol level of 260 mg/dL, LDL cholesterol level of
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180 mg/dL, and a normal triglyceride level. Further testing showed that the father had similar
values of total cholesterol and LDL, establishing the inheritance pattern of this heterozygous
condition. If aggressive dietary therapy fails to lower the boy's LDL cholesterol level below
160 mg/dL, the positive family history of premature cardiovascular events may justify
offering drug therapy per NCEP guidelines.
Some experts have questioned the usefulness of any attempt to screen patients by
family history or the presence of risk factors in childhood. Arguments both in favor of
universal screening and against any screening during childhood have been made. There is
evidence that a screening approach that uses all the NCEP guidelines appropriately can
identify up to 75% of children who have lipid abnormalities.
References:
National Cholesterol Education Program. Blood cholesterol levels in children and
adolescents. Pediatrics. 1992;16(suppl):525-584
Sprecher DL, Daniels SR. Rational approach to pharmacologic reduction of cholesterol levels
in children. J Pediatr. 1996;129:4-7

[View Question]
Anaphylaxis usually begins within seconds or minutes after exposure to the inciting antigen.
The clinical manifestations of anaphylaxis vary little from event to event in the same patient,
but they will differ significantly among individuals. Cutaneous symptoms include pruritus,
flushing, urticaria, and angioedema. Laryngeal edema (with inspiratory stridor),
bronchospasm (with expiratory wheezing), dyspnea, and hypotension associated with either
sinus tachycardia or sinus bradycardia have been observed. Visceral symptoms include
intestinal cramping, diarrhea, and vomiting. Severe symptoms have been associated with a
feeling of impending doom. In some cases, shock and death may occur.
Epinephrine is the drug of choice for the initial treatment of patients who have
anaphylaxis. Subcutaneous administration of aqueous epinephrine at a dilution of 1:1,000 (1
mg/mL) usually terminates such a reaction if it is administered at an appropriate dose (0.01
mg/kg of body weight, up to a maximum dose of 0.3 mL). In the patient who is hypotensive
or unresponsive to subcutaneous administration of epinephrine, it also may be necessary to
administer intravenous fluids to correct hypovolemia. If the intravenous administration is
required, it should be diluted further to 1:10,000 (maximum concentration, 0.1 mg/mL). The
dose of intravenous epinephrine should be titrated according to its effect on blood pressure
and pulse. If respiratory failure is imminent, sedation followed by intubation and ventilation
may be needed. Oxygen should be provided to all patients who are experiencing any
symptoms of anaphylaxis.
Patients who have less severe allergic reactions that consist solely of mild urticaria
may be treated effectively with antihistamines (eg, diphenhydramine). However,
administration of antihistamines alone is inadequate therapy in patients who have
anaphylaxis because of the slower onset of action compared to epinephrine, the large amount
of histamine released after degranulation of the mast cells, and the presence of other
mediators in addition to histamine.
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Patients who develop bronchospasm during anaphylaxis and those whose symptoms
do not improve following administration of epinephrine may require a beta2-agonist by inhalation
(eg, albuterol), aminophylline intravenously, or other bronchodilators. Patients who have significant bronchospasm or
hypotension or those who reside at some distance from the medical facility should be observed for 8 to 12 hours following
improvement before being discharged.
Corticosteroids have an uncertain role in the initial treatment of anaphylaxis because

there is a 4 to 6 hour latency period before they become effective, even if given
intravenously. However, they may help prevent a late-phase reaction and should be
administered after the acute symptoms have responded to immediate therapy.
All patients who have a history of systemic reactions to allergens (eg, Hymenoptera
sting, latex, foods) must carry an epinephrine kit. However, self-administration of injectable
epinephrine at the time of a serious reaction is not intended to be a substitute for prompt
evaluation and treatment, if necessary, by a medical professional.
References:
Lieberman PL. Specific and idiopathic anaphylaxis: pathophysiology and treatment. In:
Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB
Pearlman DS, Greos LS, Vitanza JM. Allergic disorders. In: Hay WW Jr, Groothuis JR,
Hayward AR, Levin MJ, eds. Current Pediatric Diagnosis & Treatment. 13th ed. Stamford,
Conn: Appleton & Lange; 1997:922-943
Yunginger JW. Anaphylaxis. Ann Allergy. 1992;69:87-96
Critique 206 Preferred Response: C

[View Question]
The most appropriate time to discuss the storage of hazardous or poisonous substances is
before a child becomes mobile and can pursue his or her curiosity independently. At 2
months and 4 months of age, an infant is rolling or scooting and, therefore, is not likely to
discover hazardous materials (eg, cleaning solutions or rat poison) stored in low cabinets.
Thus, the 6-month health supervision visit is the ideal time to discuss storage of potentially
harmful substances because at 9 months and 12 months of age, an infant will be crawling or
walking and long since has learned how to open cabinet doors and drawers. It always is
important to discuss safety issues before the child's development progresses to a level where
he or she can explore independently of the parents. Anticipatory guidance should promote
health and safety for children by educating parents about the changing abilities of their
children before age-appropriate activities put the children in danger.
It also is important to discuss how such potentially harmful substances should be
stored. If children find chemicals stored in familiar containers, such as those used to hold
milk or juice, they mistakenly will assume that the substance is the familiar item and ingest it.
Hazardous materials should be stored in their original containers, marked clearly as
poisonous, and placed in a location that children cannot reach, preferably with a lock.
References:

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Committee on Psychosocial Aspects of Child and Family Health. In: Guidelines for Health
Supervision III. Elk Grove Village, Ill: American Academy of Pediatrics; 1997:47-52
Overby KJ. Counseling and anticipatory guidance. In: Rudolph AM, ed. Rudolph's
Pediatrics. 20th ed. Stamford, Conn: Appleton & Lange; 1996:19-29

[View Question]
Preschool children are notorious for eluding parental supervision and escaping into areas that
might not be safe. This is particularly true concerning a home pool. The best method to
prevent a drowning at a home pool is to erect a surrounding fence with a locked gate. It
should be impossible for a child to climb under or over the fence to enter the pool area. The
lock should have a key that is kept only where adults can reach it or it should be a
combination lock that can be opened only by adults.
Other safety methods used around a pool, including use of life jackets, rescue buoys,
and other lifeguard gear, are not adequate in and of themselves to insure the safety of
children. Infants and toddlers can escape the line of sight of supervising adults quickly and
end up in the pool. Most drownings occur when a child wanders into a pool area that is not
secure and then slips or falls into the pool when no adults are present. In such a situation, no
one would be available to throw a buoy to a child or put on life jackets to perform a rescue.
Weight-sensitive alarms that are attached to pool covers have been developed in recent years.
However, if the child falls into the pool and slips under the cover, the weight-sensitive alarm
may not be triggered. Also, alarms must be heard by a nearby adult to be effective.
Swimming lessons for children in the age range described in the vignette may not be
effective in preventing drowning. In fact, such lessons may generate a false sense of security
concerning the safety of a child in the water. Thus, exposure to swimming lessons does not
replace the need for a fence with a locked gate and close adult supervision. Even children
who know how to swim may panic when they accidentally placed themselves in deeper than
usual water or can injure themselves falling into the pool and drown while unconscious.
References:
Aoki B. Drowning and near-drowning in childhood. In: Rudolph AM, ed. Rudolph's
Pediatrics. 20th ed. Stamford, Conn: Appleton & Lange; 1996:857-861
Committee on Injury and Poison Prevention. Drowning in infants, children, and adolescents.
Pediatrics. 1993;92:292-294
Fiser DH. Near-drowning. Pediatrics in Review. 1993;14:148-151
Rivara FP, Grossman DC, Cummings P. Injury prevention. N Engl J Med. 1997;337:613-618


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A 2-year-old child has a venous blood lead level of 45 mcg/dL. He lives in a 50-year-old
house. There is no history of pica.
The MOST likely source of this child's lead poisoning is
A. folk remedies
B. garden soil
C. household dust
D. lead-glazed pottery
E. lead plumbing

Hearing loss is suspected in a 4-year-old boy who had recent otitis media and meningitis. The
decision to assess this child's hearing by brainstem evoked audiometry should take into
account the fact that this test
A. correlates best with behavioral hearing thresholds in the lower frequencies (<500 Hz)
B. is a poor indicator of brainstem impairment
C. is a poor indicator of eighth cranial nerve dysfunction
D. is affected by general anesthesia
E. is affected by otologic conditions that impair conductive hearing

Of the following, the statement that BEST characterizes the timing of immunization in the
preterm infant is that immunizations should be
A. administered at the same postconceptual age as for term infants
B. administered at the same chronologic age as for term infants
C. delayed until the infant reaches 40 weeks postconceptual age
D. withheld until the infant has been discharged from the hospital
E. withheld until the infant has no apneic episodes for 2 months

Studies have shown that even low levels of lead in the serum can have adverse effects in
children.
In children who have serum levels of 10 to 20 mcg/dL, which of the following findings would
be MOST likely?

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A. Anemia
B. Cognitive delay
C. Encephalopathy
D. Headaches
E. Lead lines on the gingiva

Which of the following otologic conditions causes the MOST severe degree of conductive
hearing loss?
A. Atresia of the ear canal
B. Congenital cholesteatoma
C. Otitis media with effusion
D. Tympanic membrane perforation
E. Tympanosclerosis

The father of a 16-year-old boy recently had a myocardial infarction at age 55 years. The
adolescent is concerned about his own risk for heart problems.
Of the following, the MOST important aspect of your counseling regarding this boy's risk of
cardiac disease is to recommend that he
A. avoid smoking
B. exercise regularly
C. have his serum cholesterol level measured
D. limit his intake of saturated fat
E. maintain a desirable weight for his height

You are seeing a previously healthy 12-year-old boy for a health supervision visit. All
findings on physical examination are normal except for a blood pressure of 148/90 mm Hg.
Of the following, the most appropriate INITIAL management step is to obtain
A. a 24-hour blood pressure recording
B. a urinalysis and urine culture
C. renal sonography
D. serum concentrations of electrolytes, blood urea nitrogen, and creatinine
E. three blood pressure measurements at monthly intervals
Answers

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Critique 32 Preferred Response: C
[View Question]
Lead is a naturally occurring element that has been used almost since the beginning of
civilization. It can be absorbed into the human body through the respiratory and
gastrointestinal tracts as well as transplacentally by the fetus. Because lead is a toxic
substance, substantial efforts have been undertaken to reduce its content in food, water, and
air. However, household dust continues to be a major source of lead exposure for children in
the United States. In old housing that has not undergone lead decontamination, levels of up to
3,000 mcg of lead per gram of dust have been found in heavily contaminated areas. In 1984,
it was estimated that 12 million children were living in houses with lead paint that could
contaminate household dust and enter the body through normal hand-to-mouth activity.
A careful history can elicit clues suggestive of other, less frequent causes of lead
poisoning. For example, certain Mexican remedies used to treat colic (eg, amarcon, greta)
contain lead and can cause poisoning. Soil near roads, especially highways, can contain high
levels of lead from exhaust fumes, and if eaten by a child, can cause lead poisoning. The lead
found in lead-glazed pottery can leach into foods or drinks, especially acidic items, stored in
such containers. Lead plumbing nearly has been eliminated, but use of lead-containing solder
in plumbing joints may transfer small amounts of the metal into water.
Lead poisoning continues to be a major public health concern. There is evidence that
blood lead levels as low as 10 mcg/dL can cause impairment of cognitive function. A child
who has a blood lead level of 45 mcg/dL, such as in the vignette, is at increased risk of
central nervous system damage. Appropriate management includes chelation therapy as well
as removal of the child from the contaminated house until lead decontamination is achieved.
References:
Agency for Toxic Substances and Disease Registry. Case Studies in Environmental
Medicine: Lead Toxicity. 1990
Charney E. Lead poisoning. In: Roberts KB, ed. Manual of Clinical Problems in Pediatrics.
4th ed. Boston, Mass: Little, Brown and Company; 1995:62-65
Mahaffey KR. Exposure to lead in childhood. The importance of prevention. N Engl J Med.
1992;327:1308-1309
Piomelli S. Lead poisoning. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds.
Weitzman M, Glotzer D. Lead poisoning. Pediatrics in Review. 1992;13:461-468

[View Question]
A brief auditory stimulus (ie, click) delivered to one ear produces sequential activation of the
peripheral auditory apparatus (ie, eighth nerve), followed by activity of related brainstem
structures (ie, the cochlear nucleus, tracts and nuclei of the lateral lemniscus, and inferior
colliculus). The sequential waves produced are known as brainstem auditory evoked response

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(BAER) potentials. These potentials can be used to assess both conductive and sensorineural
hearing loss as well as to investigate the brainstem auditory tracts in disorders of the central
nervous system. Therefore, brainstem evoked response audiometry has two broad
applications: testing of hearing threshold and diagnostic interpretation of the integrity of the
auditory pathway.
Excessive muscle activity can affect the accuracy of BAER recordings. For this
reason, a child must be completely relaxed (preferably asleep) during the procedure. Natural
sleep often can be facilitated in babies up to approximately 6 months of age by feeding them
immediately before the test. Children 6 years or older frequently can lie quietly for the
procedure. Because BAER testing is not affected by sedation or general anesthesia, these
may be administered for evaluating hearing in children too young or too uncooperative for
behavior testing.
To test hearing threshold, the minimum stimulus intensity that will yield an
observable BAER is sought. BAER thresholds using click stimuli are correlated best with
behavioral hearing thresholds in the middle- to high-frequency range (1,000 to 4,000 Hz).
Conventional BAER testing cannot assess adequately the responsivity to stimulus frequencies
lower than 500 Hz.
As an otoneurologic technique, the BAER may be used to infer the level of the
auditory system at which an impairment exists (ie, middle ear, cochlea, eighth cranial nerve,
or brainstem) based on the comparative latency or delay of the BAER waves. In patients who
have middle ear impairment such as that due to otitis media, the entire series of BAER waves
is delayed in time by an amount commensurate with the degree of conductive hearing loss. In
eighth cranial nerve and brainstem impairments, there is an increased latency difference
between specific wave forms that reflects altered wave conduction.
References:
Haslam RHA. The nervous system. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM,
eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co;
1996:1667-1677
Morriss MC, Hyder DJ, Zimmerman RA. Neurodiagnostic techniques. Pediatrics in Review.
1997;18:192-203
Nozza RJ. The auditory brain stem response. In: Bluestone CD, Stool SE, Kenna MA, eds.
Pediatric Otolaryngology. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:190-193
Rapin I. The ear, hearing, and hearing loss. In: Swaiman KF, ed. Pediatric Neurology:
Principles and Practice. 2nd ed. St Louis, Mo: Mosby-Year Book, Inc; 1994:285-295

[View Question]
The American Academy of Pediatrics (AAP) has recommended that the preterm infant be
immunized at the same chronologic or postnatal age as the term infant. Using the
postconceptual age or waiting until the infant reaches term or is discharged from the hospital
will delay unnecessarily the protection accorded by the vaccines. Similarly, the presence of
apneic episodes should not delay the immunization schedule.
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Many preterm infants receive their initial immunizations in the nursery. If the infant
reaches 2 months of age in the nursery, diphtheria and tetanus toxoids combined with
acellular pertussis (DTaP) or whole-cell pertussis absorbed (DTP), Haemophilus influenzae
type b conjugate, and inactivated poliovirus vaccines should be administered. Oral (live)
polio vaccine, a live virus vaccine, should not be administered to avoid nosocomial
transmission of poliovirus vaccine strains in the nursery.
If the mother is seropositive for hepatitis B surface antigen, the preterm infant should
receive hepatitis B immune globulin (HBIG) within 12 hours of birth and hepatitis B vaccine
on the same schedule as the term infant. The optimal time to initiate hepatitis B immunization
in preterm infants who weigh less than 2 kg at birth has not been determined. If the mother is
seronegative, the first dose of hepatitis vaccine can be delayed until discharge or until the
infant reaches 2 kg in weight or 2 months of age.
At 6 months of age, any infant who has chronic heart or lung disease should receive
two doses of influenza vaccine administered 1 month apart. To protect such infants before
they reach 6 months of age, other family members, household contacts, and caretakers,
including hospital personnel, also should be immunized against the influenza virus.
References:
Ballard RA, Bernbaum JC. Post-hospital care and long-term outcome of the intensive care
nursery graduate. In: Rudolph AM, Hoffman JIE, Rudolph CD, eds. Rudolph's Pediatrics.
20th ed. Stamford, Conn: Appleton & Lange; 1996:260-263
Bart KJ. Immunization practices. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM,
eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co;
1996:1013-1021
Cole FS. Infant immunization. In: Taeusch HW, Ballard RA, Avery ME, eds. Schaffer &
Avery's Diseases of the Newborn. 6th ed. Philadelphia, Pa: WB Saunders Co; 1991:316-317
Committee on Infectious Diseases. Immunization in special clinical circumstances. In: Report
of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Ill: American Academy
of Pediatrics; 1997:48
Scanlon JW. The very-low-birthweight infant. In: Avery GB, Fletcher MA, MacDonald MG,
eds. Neonatology: Pathophysiology and Management of the Newborn. Philadelphia, Pa: JB
Lippincott Co; 1994:399-416
Scott DT, Tyson JE. Follow-up of infants discharged from newborn intensive care. In: Oski
FA, DeAngelis CD, Feigin RD, McMillan JA, Warshaw JB, eds. Principles and Practice of
Pediatrics. 2nd ed. Philadelphia, Pa: JB Lippincott Co; 1994:335-339

[View Question]
The impact of lead on the overall health of the population has been debated vigorously. It is
very clear that there are no normal values for levels of lead in the blood, but questions remain
about the type of clinical response warranted by various measured levels in children.
The effect of lead varies with the degree and length of exposure, and manifestations

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range across a broad clinical spectrum. Headaches, encephalopathy, lead lines on the gingiva,
and anemia rarely are seen with lead levels below 60 mcg/dL; such findings represent chronic
exposure and severe toxicity.
The Centers for Disease Control and Prevention (CDC) published their most recent
guidelines in 1992, which proposed that a measured and confirmed lead level of 10 to 20
mcg/dL represents a Class II level. Lead concentrations in this range have been reported to
result in mild cognitive delays, with a deficit of 2 to 5 intelligence quotient points on most
standardized intelligence tests when all other factors are controlled. Accordingly, levels of
blood lead greater than 10 mcg/dL require a clinical response. The current treatment for such
individuals involves, at a minimum, education concerning lead exposure, environmental
control measures, and ongoing monitoring of lead levels.
References:
Centers for Disease Control. Preventing Lead Poisoning in Young Children. Atlanta, Ga: US
Department of Health and Human Services, Public Health Service; 1991
Prikle JL, Brody DJ, Gunter EW, et al. The decline in blood lead levels in the United States.
The National Health and Nutrition Examination Surveys (NHANES). JAMA.
1994;272:284-291

[View Question]
The patient who has a conductive hearing loss has two primary advantages over the patient
who has sensorineural hearing loss. First, the cause of conductive hearing loss often can be
detected on otologic assessment, which alerts the physician to evaluate the situation further
by hearing testing. Second, the sources of conductive hearing loss frequently can be corrected
surgically or the hearing can be amplified satisfactorily with a hearing aid.
Congenital malformation of the auricle (microtia) and external ear canal (aural
atresia) is a rare but easily recognized reason for compromised conductive hearing. In this
condition, the auricle is malformed, and usually no meatus or ear canal is present. The
incidence of this disorder is approximately 1 in 10,000 children. Unilateral microtia is more
common than bilateral. Not surprisingly, the conductive hearing loss in such children
typically approximates a 60 dB hearing level.
A common cause of conductive hearing loss is perforation of the tympanic membrane.
The severity of the associated conductive hearing loss is a reflection of both the size and
position of the perforation; the larger the perforation, the greater the loss. Damage to the
ossicles also may be associated with traumatic perforations, particularly trauma to the
posterosuperior aspect of the tympanic membrane.
Tympanosclerosis results from trauma to the tympanic membrane that has either an
inflammatory or iatrogenic (surgical) etiology. Fortunately, the degree of conductive hearing
compromise associated with tympanosclerosis typically is quite minimal, even in situations
of extensive tympanic membrane involvement.
The most common cause of conductive hearing compromise is otitis media with
effusion (OME), but the hearing loss generally is mild. Children aged 2 to 12 years who have
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OME demonstrate average pure tone and speech reception thresholds in the 22 to 24 dB
range. Importantly, the hearing loss associated with OME fluctuates. Composite data from
several studies indicate that within the speech frequency range, approximately 90% of
children who have OME exhibit a conductive hearing loss of 16 to 40 dB. However, at any
one point in time, 49% of patients who have OME would pass a hearing evaluation that uses
a 20 dB hearing threshold.
Cholesteatoma is a destructive middle ear process in which keratinizing stratified
squamous epithelium accumulates within the middle ear or other pneumatized portions of the
temporal bone. Aural cholesteatoma can be congenital or acquired. Congenital cholesteatoma
is a congenital collection of epithelial tissue that appears as a white, cyst-like structure within
the middle ear; the tympanic membrane is intact. Acquired cholesteatoma is the sequela of
otitis media or eustachian tube dysfunction and occurs in a setting of associated tympanic
membrane abnormalities. Although cholesteatoma has a definite potential for ossicular
destruction, many children who have congenital disease have no hearing compromise at the
time of diagnosis. In one review of 41 children who had congenital cholesteatoma, 22 (54%)
had normal hearing, 13 (32%) had a mild conductive hearing deficit with pure tone averages
of 25 to 40 dB, and 6 (15%) had moderate conductive hearing loss with pure tone averages of
40 to 55 dB.
References:
Bluestone CD, Klein JO, Paradise JL, et al. Workshop on effects of otitis media on the child.
Pediatrics. 1983;71:639-652
Eavey RD. Structural reasons for conductive hearing loss. In: Eavey RD, Klein JO, eds.
Hearing Loss in Childhood: A Primer. Columbus, Ohio: Ross Laboratories; 1992:45-52
Fria TJ, Catekin EI, Eichler JA. Hearing acuity of children with otitis media with effusion.
Arch Otolaryngol. 1985;111:10-16
McGill TJ, Merchant S, Healy GB, Friedman EM. Congenital cholesteatoma of the middle
ear in children: a clinical and histopathological report. Laryngoscope. 1991;101:606-613

[View Question]
The risk factors for early onset of coronary artery disease include family history of premature
coronary heart disease and onset of cerebrovascular or peripheral vascular disease in a sibling
or parent before 55 years of age for men and 65 years for women. In addition, cigarette
smoking, hypertension, elevated serum total cholesterol, elevated levels of low-density
lipoprotein (LDL) cholesterol, low levels of high-density lipoprotein (HDL) cholesterol,
diabetes mellitus, physical inactivity, and probably obesity are risk factors for early onset of
coronary disease. Of these risk factors, smoking is the most important and deserves the most
emphasis in preventive health care. Accordingly, the importance of avoiding smoking should
be emphasized to the adolescent in the vignette.
Risk factors for increased serum cholesterol levels include high intake of total
saturated fat, total fat, and dietary cholesterol. In addition, secondary hypercholesterolemia
can be caused by drugs such as corticosteroids, contraceptives, anabolic steroids, certain

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anticonvulsants, beta-blockers, and alcohol. Relatively common diseases that can be
associated with elevated cholesterol levels include hypothyroidism, glycogen storage disease,
obstructive liver disease, chronic renal disease, certain collagen diseases, and anorexia
nervosa.
References:
Schieken RM. Atherosclerosis. In: Emmanouilides GC, Riemenschneider TA, Allen HD,
Gutgesell HP, eds. Moss and Adams Heart Disease in Infants, Children, and Adolescents:
Including the Fetus and Young Adult. 5th ed. Baltimore, Md: Williams & Wilkins;
1995:1627-1641
Troxler RG, Park MK. Hyperlipidemia in childhood. In: Park MK, ed. Pediatric Cardiology
for Practitioners. 3rd ed. St Louis, Mo: Mosby-Year Book, Inc; 1996:430-442

[View Question]
It has been recommended that blood pressure be measured at least annually after the age of 3
years. Because the signs and symptoms of elevated blood pressure may be relatively
nonspecific, many clinicians also include blood measurements when evaluating neonates and
infants.
Hypertension is defined as average systolic and diastolic pressures greater than the
95th percentile for age and gender measured on at least three occasions, preferably a month
apart. A single blood pressure reading that is mildly elevated in an asymptomatic 12-year-old
whose physical examination otherwise is normal is not diagnostic of hypertension.
Accordingly, the most appropriate initial management step for the boy in the vignette is to
obtain three measurements at monthly intervals. The 95th percentiles for blood pressure have
been published, which indicates that the values vary not only by age and gender, but also by
height percentiles.
It is neither necessary nor desirable to begin evaluation for hypertension when
borderline values are obtained on only one occasion. Although 24-hour blood pressure
recordings are available, this added expense usually is not necessary when confirming an
initial diagnosis of hypertension.
References:
Jung FF, Ingelfinger JR. Hypertension in childhood and adolescence. Pediatrics in Review.
1993;14:169-179
National High Blood Pressure Education Program Working Group on Hypertension Control
in Children and Adolescents. Update on the 1987 Task Force Report on High Blood Pressure
in Children and Adolescents: a working group report from the National High Blood Pressure
Education Program. Pediatrics. 1996;98:649-658
Shalma A, Sinaiko AR. Systemic hypertension. In: Emmanouilides GC, Riemenschneider
TA, Allen HD, Gutgesell HP, eds. Moss and Adams Heart Disease in Infants, Children, and
Adolescents: Including the Fetus and Young Adult. 5th ed. Baltimore, Md: Williams &
Wilkins; 1995:1641-1659

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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 32. Answer.

Critique 32. Preferred Response: C

2001 Self-Assessment Exercise —

Questions [Print Directions](1)

Question 34. Answer.

Question 58. Answer.

Question 87. Answer.

Question 115. Answer.

Question 143. Answer.

Question 170. Answer.

Question 199. Answer.

Question 224. Answer.

Critique 34. Preferred Response: B

Critique 58. Preferred Response: C

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 87. Preferred Response: B

Critique 115. Preferred Response: C

Critique 143. Preferred Response: D

Critique 170. Preferred Response: D

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 199. Preferred Response: D

Critique 224. Preferred Response: E

2000 Self-Assessment Exercise —

Questions [Print Directions](2)

Question 102. Answer.

III. Preventive pediatrics, Self-Assessment Exercise by Category

Question 178. Answer.

Critique 102 Preferred Response: D

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 178 Preferred Response: E

1999 Self-Assessment Exercise —

Questions [Print Directions](3)

Question 13. Answer.

Question 55. Answer.

Question 104. Answer.

Question 156. Answer.

Question 206. Answer.

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 13 Preferred Response: E

Critique 55 Preferred Response: A

Critique 104 Preferred Response: B

Critique 156 Preferred Response: E

Corticosteroids have an uncertain role in the initial treatment of anaphylaxis because

Critique 206 Preferred Response: C

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 250 Preferred Response: A

1998 Self-Assessment Exercise —

III. Preventive pediatrics, Self-Assessment Exercise by Category

Question 32. Answer.

Question 62. Answer.

Question 92. Answer.

Question 122. Answer.

III. Preventive pediatrics, Self-Assessment Exercise by Category

Question 153. Answer.

Question 184. Answer.

Question 268. Answer.

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 62 Preferred Response: E

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 92 Preferred Response: B

Critique 122 Preferred Response: B

III. Preventive pediatrics, Self-Assessment Exercise by Category

Critique 153 Preferred Response: A