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The answer is a. This boy is most likely experiencing night terrors, which occur in 1% to 4% of children. Night terrors are more common in boys than in girls, and the incidence is highest in preschool-age children. The disturbance commonly occurs during non-rapid eye movement sleep; a history of fright, confusion, and disorientation, along with intense autonomic signs, is characteristic. Sleepwalking may accompany the episodes, which usually last a few minutes. Typically, the child does not become lucid before the end of the episode and has no recollection of the event the next morning. The episodes frequently are related to a specific precipitating stressful event, such as the birth of a sibling. The events are selflimited. Management involves an understanding of the precipitating factors, reassurance, and support.

Unlike night terrors, nightmares:

In addition, a person who has had a nightmare awakens, quickly becomes lucid, and often remembers the content of the dream.

Separation anxiety and depression can cause sleep disturbances but are not commonly associated with episodes of fright and confusion. Sibling rivalry is rarely manifested as a sleep disturbance.

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The answer is a. Thumb sucking, although normal in infancy, should never be considered normal after the age of 5 years or after the permanent teeth have begun to erupt. Potential complications in the older child include malocclusion and flaring of the incisors. The management of thumb sucking in the older child is controversial, although most experts recommend behavior modification with positive reinforcement as the most appropriate form
of therapy. Occlusive dental appliances are generally not recommended, and psychological testing is not warranted unless other abnormal behaviors are present.

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The answer is c. Enuresis (bed wetting) is a common problem encountered by pediatricians. Persistent (primary) enuresis, in which the child has never been dry at night, accounts for 75% of cases and is often the result of inappropriate or inadequate toilet training. In the regressive type of enuresis, the child has been dry for 1 year and then begins to wet the bed. This type is often the result of a stressful or traumatic event in the child’s life. In both types of enuresis, an organic cause is rarely found. A thorough physical examination and urinalysis are indicated to rule out conditions such as urinary tract infection and diabetes mellitus. Modifying behavior with positive reinforcement, avoiding liquids at bedtime, and making older children launder their own clothing and bed sheets have been suggested as methods of management. Punishment and negative reinforcement should be avoided. Conditioning devices such as alarms should be reserved for recurrent and refractory cases. Drug therapy with desmopressin acetate should be used with caution as side effects can include hyponatremia, seizures, and volume overload. FDA ALERT [12/4/2007]: “FDA has requested the manufacturers update the prescribing information for desmopressin to include important new information about severe hyponatremia and seizures. Certain patients taking desmopressin are at risk for developing severe hyponatremia that can result in seizures and death. Children treated with desmopressin intranasal formulations for primary nocturnal enuresis (PNE) are particularly susceptible to severe hyponatremia and seizures. As such, desmopressin intranasal formulations are no longer indicated for the treatment of primary nocturnal enuresis and should not be used in hyponatremic patients or patients with a history of hyponatremia. PNE treatment with desmopressin tablets should be interrupted during acute illnesses that may lead to fluid and/or electrolyte imbalance. All desmopressin formulations should be used cautiously in patients at risk for water intoxication with hyponatremia.”

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The answer is d. Fungal infection of the scalp (tinea capitis) can present in the form of:

In the United States, Trichophyton tonsurans is the most common etiologic agent. Fungal hyphae or spores can often be seen when scaly areas or hair is examined with a potassium hydroxide preparation, or when material from the affected area is plated onto appropriate fungal media and incubated for 2 to 3 weeks. Because T. tonsurans does not produce fluorescence, an examination under ultraviolet light (Wood lamp) is not a reliable diagnostic tool.

Systemic therapy with an oral antifungal agent is required for the effective treatment of tinea capitis. Topical agents cannot penetrate the hair and therefore are not effective. Griseofulvin remains the preferred agent based on its long history of success and proven safety record. The drug should be administered with a lipid-containing meal to enhance absorption, which may be erratic. Because the drug is fungistatic, a prolonged course of therapy (6-8 weeks or longer) is required, and therapy should be continued for at least 2 weeks after clinical resolution. Adverse side effects associated with griseofulvin include nausea, headaches, rash, and rarely leukopenia and elevated transaminases. Routine monitoring with liver function tests is not indicated in healthy children receiving griseofulvin for the treatment of tinea capitis. Selenium sulfide shampoos may be used with oral antifungal agents to reduce fungal shedding. Corticosteroids may be used as adjunctive therapy for the treatment of kerion. Antibiotics are not indicated for tinea capitis or kerion.

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The answer is b. The description of this eruption is most consistent with pityriasis rosea, a self-limited disorder commonly affecting healthy children and adolescents. The incidence of pityriasis rosea is highest in adolescents and is slightly higher in girls than in boys. The cause remains unknown, but a viral infection is suspected. Although atypical cases are not uncommon, the classic form begins with a herald patch, a solitary, oval, pink scaly lesion usually found on the trunk. Several days after the appearance of the herald patch, a secondary eruption develops in which small crops of macules with a scaly center appear in a fir tree pattern. The eruption usually spares the face, feet, and hands. Pruritus is not uncommon. The diagnosis can usually be made clinically, although atypical cases may be difficult to diagnose. The differential diagnosis of pityriasis should include:

Secondary syphilis more typically involves the palms and soles; erythema multiforme does not typically appear in a symmetric fir tree pattern; tinea corporis may be confused with the herald patch but rarely results in the eruption of crops of lesions. Drug eruptions most typically manifest as morbilliform rashes, urticaria, or as a “fixed” demarcated, erythematous lesions. None of these lesions are usually associated with any scaling as described in the question.

The herald patch is lacking in guttate psoriasis. The scale in psoriasis is usually thick and diffuse.

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The answer is c. This child presents with nonspecific vulvovaginitis, which in young girls is most often caused by poor perineal hygiene, which results in contamination of the vaginal area with stool flora. Irritation also may be caused by soaps, shampoos, bubble baths, detergents, and tight clothing. The clinical features include intermittent signs of vaginal irritation, including erythema and a fetid odor. The most important concepts in the management of this common problem include reassuring the child and her family and stressing the importance of proper perineal hygiene. This includes having the child take sitz baths and removing potential irritants. Close follow-up is prudent because recurrent or refractory symptomatology would warrant investigation for sexual abuse.

Children with group A streptococcal vulvovaginitis present with an acute, progressive, painful rash that often involves the perianal area. Purulent drainage is also common.

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The answer is c. The average age to attain the ability to walk alone is 12 to 13 months, and most children are walking by 15 months. This 14-month-old child is able to pull to stand and cruise. His language skills are slightly advanced for his age. Given the choices, it is most appropriate to reassure the parents and re-evaluate the child’s development in 2 months.

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The answer is d. Osgood-Schlatter disease, or tibial tubercle apophysitis, is the most likely cause of her pain. This condition
most commonly occurs between 10 and 15 years of age. The examination is usually positive for swelling, prominence, and tenderness of the tubercle. Symptoms may be present for 6 to 24 months. Treatment consists of attempting to identify training errors, to decrease the frequency and intensity of exercise; stretching of the hamstrings and quadriceps; and applying ice postactivity. “Shin splint” pain does not occur at the knee.

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The answer is b. By 4 to 6 months of age total sleep requirements are 14 to 16 hours per day. Seventy to eighty percent of infants sleep for a 6- to 8-hour period by 4 to 6 months of age.

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The answer is d. The skills mentioned in the question and the average age when they are attained are as follows:

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The answer is d. Children aged 3 to 4 years should be able to copy a circle, pedal a tricycle, and hop on one foot. A typical 5-year-old child should be able to skip.