Failure to thrive evaluation US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Failure to thrive evaluation. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Failure to thrive evaluation US Medical PG Question 1: A 7-day-old male infant presents to the pediatrician for weight loss. There is no history of excessive crying, irritability, lethargy, or feeding difficulty. The parents deny any history of fast breathing, bluish discoloration of lips/nails, fever, vomiting, diarrhea, or seizures. He was born at full term by vaginal delivery without any perinatal complications and his birth weight was 3.6 kg (8 lb). Since birth he has been exclusively breastfed and passes urine six to eight times a day. His physical examination, including vital signs, is completely normal. His weight is 3.3 kg (7.3 lb); length and head circumference are normal for his age and sex. Which of the following is the next best step in the management of the infant?
- A. Reassurance of parents (Correct Answer)
- B. Evaluation of the mother for malnutrition
- C. Admission of the infant in the NICU to treat with empiric intravenous antibiotics
- D. Emphasize the need to clothe the infant warmly to prevent hypothermia
- E. Supplementation of breastfeeding with an appropriate infant formula
Failure to thrive evaluation Explanation: ***Reassurance of parents***
- A **weight loss of 8.3%** (300g from 3.6kg) is within the expected range for a 7-day-old exclusively breastfed infant, which can be up to 7-10% in the first week.
- The infant's normal physical exam, good urine output, and lack of other symptoms suggest **adequate feeding** and overall well-being.
*Evaluation of the mother for malnutrition*
- The mother's nutritional status is not directly indicative of the infant's weight loss within the normal physiological range in this scenario.
- There is no information to suggest the mother is malnourished or that it would directly impact the quality or quantity of breast milk to cause pathological weight loss.
*Admission of the infant in the NICU to treat with empiric intravenous antibiotics*
- This is an overly aggressive intervention as there are **no signs or symptoms of infection** (e.g., fever, lethargy, poor feeding) and the infant appears well.
- Empiric antibiotics are not warranted in an otherwise healthy, full-term infant with normal physiological weight loss.
*Emphasize the need to clothe the infant warmly to prevent hypothermia*
- The infant's **vital signs are normal**, indicating no hypothermia, and there is no clinical evidence to support this as a primary concern.
- While maintaining warmth is important, it is not the next best step for addressing this specific presentation of physiological weight loss.
*Supplementation of breastfeeding with an appropriate infant formula*
- Supplementation is typically not needed for physiological weight loss in an otherwise healthy, exclusively breastfed infant with **adequate urine output** and no signs of dehydration.
- Encouraging continued exclusive breastfeeding and providing support for proper latch and feeding techniques would be more appropriate if there were concerns about inadequate milk intake.
Failure to thrive evaluation US Medical PG Question 2: A two-year-old female presents to the pediatrician with her mother for a routine well-child visit. Her mother is concerned that the patient is a picky eater and refuses to eat vegetables. She drinks milk with meals and has juice sparingly. She goes to sleep easily at night and usually sleeps for 11-12 hours. The patient has trouble falling asleep for naps but does nap for 1-2 hours a few times per week. She is doing well in daycare and enjoys parallel play with the other children. Her mother reports that she can walk down stairs with both feet on each step. She has a vocabulary of 10-25 words that she uses in the form of one-word commands. She is in the 42nd percentile for height and 48th percentile for weight, which is consistent with her growth curves. On physical exam, she appears well nourished. She can copy a line and throw a ball. She can follow the command to “give me the ball and then close the door.”
This child is meeting her developmental milestones in all but which of the following categories?
- A. Social and receptive language skills
- B. Fine motor skills
- C. This child is developmentally normal
- D. Gross motor skills
- E. Expressive language skills (Correct Answer)
Failure to thrive evaluation Explanation: ***Expressive language skills***
- At two years old, a child should typically have an **expressive vocabulary of 50-200 words** and be putting **two-word sentences** together.
- This child's vocabulary of 10-25 words, used primarily as one-word commands, is significantly below the expected range for her age.
*Social and receptive language skills*
- The child is reported to be doing well in daycare and enjoys **parallel play**, which reflects appropriate **social development** for her age.
- Her ability to follow the two-step command "give me the ball and then close the door" demonstrates intact **receptive language skills**.
*This child is developmentally normal*
- While many areas of her development appear normal, her **expressive language skills** are clearly delayed, indicating that she is not entirely developmentally normal.
- Identifying specific areas of delay is crucial for early intervention.
*Gross motor skills*
- The child's ability to **walk down stairs with both feet on each step** is a normal gross motor milestone for a two-year-old.
- Other gross motor skills like running and kicking a ball are typically present, and there is no information to suggest a deficit.
*Fine motor skills*
- The ability to **copy a line** is an expected fine motor skill for a two-year-old.
- Throwing a ball also involves fine motor coordination and is within the expected range for this age.
Failure to thrive evaluation US Medical PG Question 3: A 4-year-old girl is brought to the physician by her parents because she is severely underweight. She is easily fatigued and has difficulty keeping up with other children at her daycare. She has a good appetite and eats 3 full meals a day. She has 4 to 5 bowel movements daily with bulky, foul-smelling stools that float. She has had recurrent episodes of sinusitis since infancy. Her parents report that she recently started to snore during her sleep. She is at the 15th percentile for height and 3rd percentile for weight. Her vital signs are within normal limits. Examination shows pale conjunctivae. A few scattered expiratory crackles are heard in the thorax. There is abdominal distention. Which of the following is the most likely underlying cause of this patient's failure to thrive?
- A. T. whippelii infiltration of intestinal villi
- B. Impaired intestinal amino acid transport
- C. Exocrine pancreatic insufficiency (Correct Answer)
- D. Small intestine bacterial overgrowth
- E. Intestinal inflammatory reaction to gluten
Failure to thrive evaluation Explanation: ***Exocrine pancreatic insufficiency***
- The constellation of **failure to thrive**, **bulky, foul-smelling, floating stools** (suggesting **steatorrhea**), recurrent **sinusitis**, and **recurrent respiratory symptoms** (snoring, expiratory crackles) is highly indicative of **cystic fibrosis**, whose primary cause of malabsorption is **exocrine pancreatic insufficiency**.
- **Cystic fibrosis** leads to thick, viscous secretions that obstruct pancreatic ducts, preventing digestive enzymes from reaching the small intestine and causing **malabsorption of fats and fat-soluble vitamins**.
*T. whippelii infiltration of intestinal villi*
- This describes **Whipple's disease**, which typically affects **middle-aged men** and presents with malabsorption, arthralgia, and neurological symptoms.
- It is rare in children and usually presents with symptoms like diarrhea and weight loss, but not commonly with the **recurrent respiratory infections** and **pancreatic insufficiency** seen here.
*Impaired intestinal amino acid transport*
- This typically refers to conditions like **Hartnup disease**, which involves defective transport of neutral amino acids and can lead to **pellagra-like symptoms** (dermatitis, diarrhea, dementia) due to niacin deficiency.
- This condition does not explain the **steatorrhea**, **recurrent sinusitis**, or **respiratory symptoms** found in the patient.
*Small intestine bacterial overgrowth*
- While **SIBO** can cause malabsorption, **abdominal distention**, and loose stools, it does not typically cause **recurrent sinusitis** or the classic **bulky, foul-smelling, floating stools associated with pancreatic insufficiency**.
- SIBO is also not a primary cause of **failure to thrive** in a global sense, but rather a secondary complication.
*Intestinal inflammatory reaction to gluten*
- This describes **celiac disease**, which presents with **malabsorption**, **abdominal distention**, **failure to thrive**, and **anemia** (pale conjunctivae).
- However, celiac disease does not typically cause **recurrent sinusitis** or the **respiratory symptoms** (snoring, crackles) that are prominent in this patient's presentation.
Failure to thrive evaluation US Medical PG Question 4: A 4-day-old male newborn is brought to the physician for a well-child examination. His mother is concerned that he is losing weight. He was born at 40 weeks' gestation and weighed 2980g (6-lb 9-oz); he currently weighs 2830g (6-lb 4-oz). Pregnancy was uncomplicated. He passed stool and urine 8 and 10 hours after delivery. He has been exclusively breast fed since birth and feeds 11–12 times daily. His mother says she changes 5–6 heavy diapers daily. Examination shows an open and firm anterior fontanelle. Mucous membranes are moist. Capillary refill time is less than 2 seconds. Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next best step in management?
- A. Continue breastfeeding (Correct Answer)
- B. Add rice based cereal
- C. Add cow milk based formula
- D. Serum creatinine and urea nitrogen
- E. Switch to soy-based formula
Failure to thrive evaluation Explanation: ***Continue breastfeeding***
- A 4-day-old newborn losing less than 7% of birth weight, with good feeding frequency, adequate wet diapers, and normal physical examination findings, is considered typical for **physiological weight loss** in breastfed infants.
- The infant's current weight of 2830g is within the expected range, as healthy full-term newborns may lose up to 7-10% of their birth weight in the first few days, and his weight loss is only about 5%.
*Add rice based cereal*
- **Solid foods**, including rice cereal, should not be introduced before 4-6 months of age due to the immaturity of the infant's digestive system and potential for choking.
- Introducing solids too early can interfere with nutrient absorption from breast milk and increase the risk of allergies.
*Add cow milk based formula*
- Supplementing with formula is unnecessary in a healthy, breastfed infant exhibiting normal physiological weight loss and adequate feeding cues.
- Early introduction of formula can interfere with **successful breastfeeding establishment** and alter the infant's gut microbiome.
*Serum creatinine and urea nitrogen*
- These tests are used to assess **renal function** and are not indicated here, as the infant shows no signs of renal impairment (e.g., adequate urine output, moist mucous membranes).
- The physical examination findings and feeding pattern suggest a healthy newborn, not one requiring investigation for kidney issues.
*Switch to soy-based formula*
- Switching to any formula is unwarranted given the normal weight loss and breastfeeding progress, and specifically, soy-based formula is not routinely recommended for healthy infants.
- Soy formula is often reserved for infants with **cow's milk protein allergy** or **galactosemia**, neither of which is suggested by this clinical picture.
Failure to thrive evaluation US Medical PG Question 5: A 13-year-old boy is being evaluated for failure to thrive and bad performance at school. He has a history of microcytic anemia and takes a multivitamin every morning with breakfast. An electrophoresis analysis shows no adult hemoglobin (HbA), elevated hemoglobin adult type 2 (HbA2), and normal fetal hemoglobin (HbF). A skull X-ray revealed a crewcut appearance. Which of the following is the most likely diagnosis?
- A. β-thal minor
- B. Hb Bart disease
- C. α-thal trait
- D. β-thal major (Correct Answer)
- E. HbH disease
Failure to thrive evaluation Explanation: ***β-thal major***
- The absence of **HbA**, elevated **HbA2**, and normal HbF (which is usually also elevated) in the presence of severe microcytic anemia, failure to thrive, and a **crewcut appearance** on skull X-ray are classic signs of **β-thalassemia major**, also known as **Cooley's anemia**.
- The "crewcut" appearance is due to **extramedullary hematopoiesis** to compensate for severe anemia, leading to widening of the diploic space and typical perpendicular **spicules of new bone formation** on the skull X-ray.
*β-thal minor*
- This condition is typically **asymptomatic** or only causes **mild microcytic anemia** and would not lead to failure to thrive or the severe skeletal changes seen here.
- While it features elevated **HbA2** and potentially slightly reduced HbA, it would still have significant HbA production.
*Hb Bart disease*
- This is the most severe form of **α-thalassemia**, characterized by the complete absence of alpha-globin chains.
- It results in **hydrops fetalis** and is usually lethal in utero or shortly after birth, so a 13-year-old would not present with this.
*α-thal trait*
- This refers to two forms: **silent carrier** (one gene deleted) or **α-thalassemia minor** (two genes deleted).
- Both are usually **asymptomatic** or cause **mild microcytic anemia**, and would not present with the severe clinical picture or bone changes described.
*HbH disease*
- This is an intermediate form of **α-thalassemia** where three out of four alpha-globin genes are deleted.
- It presents with **moderate to severe hemolytic anemia**, but the **hemoglobin electrophoresis** would show the presence of **HbH** (a tetramer of four beta-globin chains) and not the described pattern of HbA, HbA2, and HbF.
Failure to thrive evaluation US Medical PG Question 6: A 6-month-old girl is brought to the physician because of drooling and excessive crying for 3 days. She calms down when cuddled or with a pacifier in her mouth. She feeds well and has no vomiting or diarrhea. She was breastfed exclusively for 5 months. She is given no medications and was born at 39 weeks gestation via spontaneous vaginal delivery. She is up to date on all vaccines and is meeting all developmental milestones. At the clinic, her weight is 7.3 kg (16 lb 1 oz) and her height is 65.8 cm (25.9 in) in length. She appears irritable. Her pulse is 124/min, the respirations are 32/min, the blood pressure is 92/63 mm Hg, and the temperature is 36.8°C (98.2°F). On physical examination, she has no conjunctivitis, cervical lymphadenopathy, or pharyngeal erythema. Which element of the physical examination is most likely to be present in this patient?
- A. The rooting reflex
- B. Crying on frontal sinus palpation
- C. Eruption of mandibular incisors (Correct Answer)
- D. Closure of the anterior fontanel
- E. Erythema and fluctuance of the submandibular area
Failure to thrive evaluation Explanation: ***Eruption of mandibular incisors***
- The patient's age (6 months), **drooling**, and **irritability** strongly suggest **teething**, which commonly involves the eruption of the mandibular incisors.
- Teething pain and discomfort can be relieved by pacifiers or cuddling, consistent with the patient's presentation.
*The rooting reflex*
- The **rooting reflex** is a primitive reflex typically present at birth and usually disappears by **4 months of age**; this patient is 6 months old.
- Its presence would not explain the current symptoms of irritability and drooling.
*Crying on frontal sinus palpation*
- **Frontal sinuses** are typically underdeveloped or absent in infants and children until later ages (around 6-10 years old), so their palpation is not clinically relevant in a 6-month-old.
- Crying on palpation would only be significant if the sinuses were developed and inflamed, which is unlikely and not indicated by other symptoms.
*Closure of the anterior fontanel*
- The **anterior fontanel** typically remains open until **12-18 months of age**, allowing for brain growth; abnormal closure at 6 months would be a concerning finding but is not indicated by the drooling and irritability.
- Premature closure of the fontanel is usually associated with microcephaly or other cranial abnormalities, not teething symptoms.
*Erythema and fluctuance of the submandibular area*
- **Erythema** and **fluctuance** in the submandibular area suggest an **infection or abscess**, which would likely be accompanied by fever and other signs of systemic illness not present in this patient.
- While teething can cause local inflammation, it does not typically lead to a submandibular abscess without other contributing factors.
Failure to thrive evaluation US Medical PG Question 7: A laborer's younger child is brought to the OPD with a swollen belly and dull face. He has been fed rice water (rice milk) in his diet mostly. On investigations, the child is found to have low serum protein and low albumin. What is the probable diagnosis?
- A. Kwashiorkor (Correct Answer)
- B. Kawasaki disease
- C. Marasmus
- D. Indian childhood cirrhosis
- E. Nephrotic syndrome
Failure to thrive evaluation Explanation: ***Kwashiorkor***
- The symptoms of a **swollen belly** (due to **edema** from low albumin), **dull face**, and a diet primarily of **rice water** (low in protein) are classic signs of Kwashiorkor.
- Kwashiorkor is a form of severe protein-energy malnutrition characterized by **protein deficiency** that is greater than the calorie deficit, leading to **hypoalbuminemia** and fluid retention.
- The **dietary history** of rice water (carbohydrate-rich but protein-poor) is the key distinguishing feature.
*Kawasaki disease*
- This is an **acute vasculitis** primarily affecting young children, presenting with fever, rash, conjunctivitis, mouth changes, and lymphadenopathy.
- It does not involve a swollen belly or dull face as primary symptoms, nor is it linked to dietary protein deficiency.
*Marasmus*
- Marasmus is a form of severe malnutrition characterized by an **overall deficiency of calories** and nutrients, resulting in severe **wasting** of muscle and fat.
- While it involves low weight and energy deficit, the prominent **edema** (swollen belly) seen in this case points away from marasmus.
*Indian childhood cirrhosis*
- This is a rare, **fatal liver disease** in young children, often characterized by jaundice, hepatosplenomegaly, and liver failure.
- It is not primarily caused by protein deficiency and its symptoms are distinct from the presentation described.
*Nephrotic syndrome*
- While nephrotic syndrome also presents with **hypoalbuminemia and edema**, it would show **proteinuria** (>3.5 g/day), hyperlipidemia, and lipiduria on urinalysis.
- The **dietary history** and absence of urinary findings distinguish kwashiorkor from nephrotic syndrome.
Failure to thrive evaluation US Medical PG Question 8: A 10-year-old male presents with generalized edema. His cholesterol level is $238 \mathrm{mg} / \mathrm{dl}$, urine protein is $3+$, and stool microscopy shows fat in the stool. What is the most likely diagnosis?
- A. Nephritic syndrome
- B. Goodpasture syndrome
- C. Nephrotic syndrome (Correct Answer)
- D. Urine infection
- E. Minimal change disease
Failure to thrive evaluation Explanation: ***Nephrotic syndrome***
- **Nephrotic syndrome** is characterized by **generalized edema**, **massive proteinuria** (3+ in urine protein), and **hyperlipidemia** (elevated cholesterol).
- **Fat in the stool** (steatorrhea) can be an associated finding due to malabsorption or metabolic derangements, though not a primary diagnostic criterion for nephrotic syndrome.
- This is the **syndrome** that encompasses the entire clinical presentation.
*Minimal change disease*
- **Minimal change disease** is the **most common etiology** of nephrotic syndrome in children (accounting for ~80% of cases in this age group).
- While this child likely has minimal change disease as the underlying cause, the question asks for the **syndrome/diagnosis** based on the clinical presentation, which is **nephrotic syndrome**.
- Minimal change disease is the pathologic diagnosis that would be confirmed on **renal biopsy**.
*Nephritic syndrome*
- **Nephritic syndrome** typically presents with **hematuria**, **hypertension**, **azotemia**, and mild to moderate proteinuria, rather than massive proteinuria and generalized edema.
- It is characterized by inflammation of the glomeruli, often leading to a decrease in **glomerular filtration rate (GFR)**.
*Goodpasture syndrome*
- **Goodpasture syndrome** is an autoimmune disease characterized by **rapidly progressive glomerulonephritis** and **pulmonary hemorrhage**.
- While it causes renal involvement, its distinct feature is the presence of **anti-glomerular basement membrane (GBM) antibodies**, and the clinical picture does not align with the given symptoms.
*Urine infection*
- A **urine infection** (urinary tract infection) typically presents with dysuria, frequency, urgency, and sometimes fever, with positive urine cultures and pyuria.
- It does not explain the presence of **generalized edema**, **hyperlipidemia**, or **massive proteinuria**.
Failure to thrive evaluation US Medical PG Question 9: In a child with a height-for-age Z-score of less than -2 standard deviations (SD), what is the most likely cause?
- A. Chronic malnutrition (Correct Answer)
- B. No malnutrition
- C. Acute malnutrition
- D. Recent infection
- E. Genetic short stature
Failure to thrive evaluation Explanation: ***Chronic malnutrition***
- A **height-for-age Z-score of less than -2 SD** is a key indicator for **stunting**, which is primarily caused by prolonged periods of **inadequate nutrition** and/or recurrent infections.
- This reflects **long-term nutritional deprivation** impacting linear growth, rather than recent or acute issues.
*No malnutrition*
- A Z-score below -2 SD for height-for-age is a critical threshold indicating **significant growth faltering**, making the absence of malnutrition highly unlikely.
- This measurement directly reflects that the child's height is significantly below the expected range for their age, signifying a nutritional problem.
*Acute malnutrition*
- **Acute malnutrition** is typically assessed by **weight-for-height Z-score** (wasting) or Mid-Upper Arm Circumference (MUAC).
- While acute malnutrition impairs growth, a low height-for-age Z-score specifically points to a problem of **longer duration (chronic)** rather than immediate weight loss.
*Recent infection*
- While **recent infections** can lead to temporary weight loss and affect appetite, they typically do not cause a **pronounced and sustained reduction in height-for-age** (stunting) unless they are recurrent or chronic, contributing to overall chronic malnutrition.
- A single, recent infection is more likely to impact **weight-for-height** acutely.
*Genetic short stature*
- While **genetic factors** can influence height, a height-for-age Z-score of less than -2 SD in the context of population-based assessment typically indicates **pathological growth failure** due to chronic malnutrition.
- Genetic short stature typically maintains **proportional growth** with consistent growth velocity, whereas stunting shows **growth faltering** over time.
Failure to thrive evaluation US Medical PG Question 10: A child presents with rachitic changes in the limbs that are not responding to Vitamin D supplementation. Investigations reveal the following results:
- Calcium: $9.5 \mathrm{mg} / \mathrm{dl}$
- Phosphorus: $1.6 \mathrm{mg} / \mathrm{dl}$
- Alkaline phosphatase (ALP): 814 IU
- Serum PTH: $24.2 \mathrm{pg} / \mathrm{ml}$
- Serum electrolytes, creatinine, and blood gases: Normal.
What is the most likely diagnosis?
- A. Hypophosphatemic rickets (Correct Answer)
- B. Vitamin D-dependent rickets type 2
- C. Vitamin D-dependent rickets type 1
- D. Chronic renal failure
- E. Vitamin D deficiency rickets
Failure to thrive evaluation Explanation: ***Hypophosphatemic rickets***
- The combination of **rachitic changes** not responding to Vitamin D, **low serum phosphorus (1.6 mg/dl)**, and **normal calcium and PTH levels** strongly points to hypophosphatemic rickets, a condition characterized by impaired renal phosphate reabsorption.
- The **elevated alkaline phosphatase** indicates increased bone turnover as the body tries to mineralize bone despite phosphate deficiency.
*Vitamin D-dependent rickets type 2*
- This condition involves resistance to **1,25-dihydroxyvitamin D**, leading to **hypocalcemia** and elevated PTH, none of which are present here.
- It would also typically show an inadequate response to Vitamin D, but the primary biochemical derangement is different.
*Vitamin D-dependent rickets type 1*
- This type is caused by a defect in **1-alpha-hydroxylase**, leading to an inability to convert 25-hydroxyvitamin D to its active form, resulting in **hypocalcemia** and elevated PTH, which are not observed.
- It would also show a poor response to standard Vitamin D supplementation.
*Vitamin D deficiency rickets*
- This is the most common form of rickets caused by inadequate Vitamin D intake or synthesis, presenting with **hypocalcemia**, **elevated PTH**, and **low phosphorus**.
- However, it typically responds well to Vitamin D supplementation, unlike the presentation here, and would show elevated PTH levels.
*Chronic renal failure*
- Chronic renal failure would present with **elevated creatinine**, and typically leads to **secondary hyperparathyroidism** (elevated PTH), **hyperphosphatemia**, and metabolic acidosis, none of which are suggested by the provided lab results.
- The serum electrolytes, creatinine, and blood gases are explicitly stated as normal.
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