Pediatrics
Certification Exam Review Online

If no other signs of sexual maturation are present, then the most appropriate next step is to reassure the mother and monitor the child every 6 months. It is important for the health care professional to be cautious and not consider breast development in a 3-year-old to mean that she is in central precocious puberty. In fact, most of these girls have premature thelarche, which is a normal and benign condition. Younger age and central precocious puberty is correlated with a higher likelihood of an underlying serious disorder.

Imaging studies may be indicated if the onset of puberty occurs between 7 and 8 years of age and pubic hair is not present on examination; however, this is not the case here. Only 10% of patients with typical, benign, idiopathic thelarche go on to develop central precocious puberty requiring treatment.

Reference:

Kaplowitz PB. Precocious puberty. Accessed January 19, 2015.

Educational Objective:

Review antibiotics most likely to result in Clostridia Difficile infection

Key Point:

C Difficile infection should be considered when a patient currently receiving antibiotics develops diarrhea.

Explanation: 

Clostridium difficile–associated diarrhea, is a major cause of antibiotic-associated diarrhea. It may occur in hospitalized patients or in any patient who has received prolonged antibiotic therapy. The bacterium produces toxins that may result in diarrhea; classically a foul-smelling watery diarrhea. Ampicillin, clindamycin, and second- and third-generation cephalosporins are commonly associated with C.difficile infection.

The infection attacks the colon and may result in sloughing of the intestinal lining (pseudomembranous colitis), a serious complication. Another serious complication is toxic megacolon characterized by pronounced abdominal distention. Refractory cases of C. difficile infections may require colectomy. These serious complications are observed, more often, in the elderly.

A diagnosis of pseudomembranous colitis is confirmed by the presence of the C difficile toxins in the stool of patients with symptoms. In many children, symptoms will resolve and no further treatment will be necessary. Treatment with vancomycin or metronidazole may be necessary for more severe cases.

Furadantoin is not a frequent cause of C difficile infection. Metronidazole and Vancomycin are drugs used to treat C difficile infection.  Metronidazole (Flagyl) and Vancomycin, as noted above) are drugs used to eliminate C. difficile infection.

Reference:

.Ahmad OZ, Cohen MB, Clostridium difficile infection.  NelsonTextbook of Pediatrics.., 2020; 239: 1552-1555.e1

Educational Objective:

Recognize the importance of child-restraint systems to increase car safety based on a child's weight, age, and gestational status.

Explanation:

Belt-positioning booster seats are recommended for children who have outgrown their forward-facing child safety seats by weight or height. Belt-positioning booster seats reduce injuries by positioning the child so that the seat belt of the motor vehicle, which is designed for adults, correctly fits the child, low over the hips and thighs and across the middle of the chest and shoulder, not over the face or neck. The use of belt-positioning booster seats can reduce the risk of seat-belt syndrome, which is the combination of cervical and lumbar spine and abdominal injuries that can occur as a result of restraining a child in an ill-fitting seat belt. Belt-positioning booster seats come in 2 varieties, high- and low-backs, and should only be used in seating positions with both a lap and shoulder seat belt. In general, low-back, belt-positioning booster seats are appropriate for use in vehicle-seating positions in which there is a head rest or vehicle seat back that extends above the child’s ears. High-back, belt-positioning booster seats are important for seating positions that have low seat backs or lack head rests to protect the child from whiplash injuries to the neck.

At the time of publication, 48 states in the United States (excluding Florida and South Dakota) have booster-seat laws in place for older children, although the laws vary in their requirements for belt-positioning booster seat use. It is important to remind parents that the law in your state may not be in alignment with best-practice recommendations and that most children are not able to properly fit in a motor vehicle seat belt without a booster seat until they are at least 4 feet 9 inches tall and 8 to 12 years of age.

References:

Hodges NL, Smith GA. Car safety. Pediatr Rev. 2014;35(4):155-160.

Educational Objective:

Identify the bacterial etiology of neonatal meningitis.

Explanation:

Meningitis in neonates is most commonly caused by Listeria monocytogenes, GBS, and Escherichia coli infection. GBS causes 50% to 60% of bacterial meningitis in neonates. The source of the meningitis is usually the maternal genitourinary tract. Prenatal care involves GBS screening and intrapartum treatment of disease. Other less-likely bacterial etiologies include H influenzae, staphylococci, and S pneumoniae.

References:

Prober CG, et al. Central nervous system infections. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2015:2936-2948.

Swanson D. Meningitis. Pediatr Rev. 2015;36(12):514-524.

Educational Objective:

Calculate scores from level of consciousness scales.

Explanation:

The AVPU pediatric response scale is used to assess a child's level of consciousness and cerebral function. The system measures the response to stimuli, so the child does not have to be awake or aware while the assessment is taking place.

A score of "A" signifies that the child is awake and alert. "V" signifies that the child responds only if his or her name is called. For "P," the child responds to painful stimuli, such as pinching the nail bed. A score of "U" suggests that the child is unresponsive to all stimuli.

Reference:

Hartman ME, Cheifetz IM. Pediatric emergencies and resuscitation. In: Kliegman RM, et al. Nelson Textbook of Pediatrics. 20th ed., 2015:489-506.