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2011 PREP SA on CD-ROM

Question: 43
The parents of an 18-month-old boy contact you after he has two episodes of holding his breath and
fainting. Most recently, he was upset when he had to leave the playground and began to scream and
cry. He turned blue while holding his breath prior to losing consciousness. He had a similar event 1
month ago when he cut his finger and saw that it was bleeding. The anxious parents ask what they
should do.
Of the following, the MOST appropriate intervention is to

A. obtain a complete blood count
B. pick up the child quickly and comfort him when he starts to cry
C. reassure the parents that this is a benign event
D. refer the child for behavioral therapy
E. refer the child for electroencephalography

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2011 PREP SA on CD-ROM

Critique: 43

Preferred Response: C

The child described in the vignette is having a breath-holding spell (BHS), which is the involuntary
stopping of breathing due to a painful or frustrating event. They occur in almost 5% of children, typically
between the ages of 6 and 18 months. A BHS of sufficient duration may lead to loss of consciousness
or a seizure. There are two major types of BHSs. The cyanotic spell occurs when the child is upset. The
child may give a cry, followed by forced expiration, apnea, cyanosis, and loss of consciousness. Pallid
spells are less common and occur following a painful experience or when the child is startled. The child
stops breathing, becomes pale and hypotonic, and may have a tonic seizure. These seizures do not
imply a diagnosis of epilepsy because they are provoked by the BHS. Electroencephalography may
show slowing but not epileptiform activity and, therefore, is not indicated.
The parents should be advised that while frightening to witness, a BHS is benign and will not lead to
epilepsy, brain damage, or death. Picking up or comforting a child who has become angry or frustrated
in an attempt to avert a BHS should be discouraged because it may reinforce an unwanted behavior.
Similarly, parents should be consistent and not reinforce the behavior after the child recovers.
Because BHSs are involuntary, behavioral therapy for the child is not indicated. Parents and
caregivers, however, do need to be instructed in appropriate behavioral modification approaches.
Hematologic conditions such as iron deficiency and transient erythroblastopenia have been reported
in conjunction with a BHS. Because anemia can exacerbate BHS, obtaining a complete blood count is
indicated in severe cases.
References:
Johnston MV. Conditions that mimic seizures. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2476-2477
Rubenstein JE, Vining EPG, Kossoff EHW. Epilepsy and developmental disabilities. In: Accardo PJ, ed.
Capute & Accardo’s Neurodevelopmental Disabilities in Infancy and Childhood. 3rd ed. Baltimore, Md:
Paul H. Brookes Publishing Co; 2008:399-412
Zuckerman B. Breath holding. In: Parker S, Zuckerman B, Augustyn M, eds. Developmental and
Behavioral Pediatrics: A Handbook for Primary Care. 2nd ed. Philadelphia, Pa: Lippincott Williams &
Wilkins; 2005:139-140

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2011 PREP SA on CD-ROM

Question: 55
You are seeing a 3-year-old boy for a health supervision visit. His mother is pregnant, and when you ask
how she is feeling, she bursts into tears. She tells you that recent prenatal ultrasonography has revealed
multiple physical anomalies in their unborn child. She has days when she is hopeful and days when she
is terrified; her husband has buried himself in his work.
Of the following, the approach that is MOST likely to address this couple’s concerns is

A. encouraging their extended family to be supportive
B. providing specific medical knowledge pertaining to fetal anomalies/outcomes
C. recommending they see a religious leader for spiritual guidance
D. recounting success stories relating to special needs children in your practice
E. suggesting they meet with another couple who has faced similar issues

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2011 PREP SA on CD-ROM

Critique: 55

Preferred Response: B

Learning that there are serious problems in their fetus or newborn creates a crisis for the parents that is
likened to experiencing the death of a loved one. In fact, such news brings about the death of the dream
of a healthy child. Parents experience shock, followed by the grieving stages that are associated with a
death in the family: denial, bargaining, confusion, anger, and depression. This journey is complex and
unique to each individual and family. Parents typically work through this process differently from each
other, which may cause further pain and suffering. In addition, they may be faced with extraordinarily
difficult decisions such as whether to terminate the pregnancy or whether to withdraw life support. In
situations when fetal or neonatal outcome is uncertain, there is the added strain of balancing hope with
the potential for loss.
In a scenario such as the one described in the vignette, it is important for the pediatrician to be a
good listener and to offer support. It also has been shown repeatedly that providing information about
the fetal/newborn diagnosis and potential outcomes allows parents to regain some control of the
situation. They may choose to pursue further research, seek another opinion, or simply put the
information to use in considering options and forming opinions.
Although it is wise to ask parents about their sources of support, clinicians must be careful not to
recommend a course of action that may not be appropriate for the couple. They may not have told their
extended family about their situation, or there may be conflicts among family members, in which cases
recommending discussion with family is not helpful. Even if parents consider themselves to be religious,
they might prefer not to discuss this particular topic with a religious leader. Recounting anecdotes about
families in similar situations may feel cold and impersonal to the parents. Finally, making an offer to
meet with another couple who has had a similar experience may be helpful, but this is a personal
preference and may not be desired or acceptable.
References:
Allen JS, Mulhauser LC. Genetic counseling after abnormal prenatal diagnosis: facilitating coping in
families who continue their pregnancies. J Genet Couns. 1995;4:251-265
Mayes LC. Child mental health consultation with families of medically compromised infants. Child
Adolesc Psychiatr Clin North Am. 2003;12:401-421
Starke M, Albertson Wikland K, Möller A. Parents’ experiences of receiving the diagnosis of Turner
syndrome: an explorative and retrospective study. Patient Educ Couns. 2002;47:347-354. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/12135826
Walker AP. Genetic counseling. In: Rimoin DL, Connor JM, Pyeritz RE, Korf BR, eds. Emery and
Rimoin’s Principles and Practice of Medical Genetics. 4th ed. London, United Kingdom: Churchill
Livingstone; 2002:842-874

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2011 PREP SA on CD-ROM

Question: 200
You are the preceptor in a pediatric clinic and a resident has just finished seeing an adolescent male for
a routine physical examination. This is the young man’s first visit in the clinic, and as part of the routine
screening, the resident takes a comprehensive psychosocial history. The patient reveals that he is more
attracted to males than females. You guide the resident on the range of issues she should address.
Of the following, the MOST immediate attention is required for

A. contraception
B. depression
C. harassment
D. social isolation
E. substance use

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2011 PREP SA on CD-ROM

Critique: 200

Preferred Response: B

Two thirds of physicians reportedly never ask their patients about sexual orientation. The importance of
exploring this area lies in knowing that gay, lesbian, bisexual, and transgendered (GLBT) youth are at
significantly increased risk for engaging in self-destructive behaviors, primarily as a response to feeling
marginalized and discriminated against.
Suicide is the third leading cause of death among adolescents, but it is the leading cause of death
among GLTB youth. Therefore, although these youth are at risk for harassment, social isolation, and
substance use, it is most important to screen them carefully for depression and suicidal ideation
because they are at higher risk for more frequent and serious suicide attempts. Fear of discrimination at
home, school, or work often leads to social isolation among these youth, and verbal harassment and
threats of physical violence are common. In addition, these youth are at risk for homelessness,
prostitution, sexual abuse, and substance use and misuse. Their risk for pregnancy or acquisition of
sexually transmitted infections depends on the behaviors in which they engage. The need for
contraception should be discussed with all youth, regardless of their sexual orientation.
References:
Cavanaugh RM Jr. Screening adolescent gynecology in the pediatrician's office: have a listen, take a
look. Pediatr Rev. 2007;28:332-342. DOI: 10.1542/10.1542/pir.28-9-332. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/9/332
Garofalo R, Katz E. Health care issues of gay and lesbian youth Curr Opin Pediatr. 2001;13:298-302.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/11717552
Gay, lesbian and transgender health. Medline Plus. 2010. Available at:
http://www.nlm.nih.gov/medlineplus/gaylesbianandtransgenderhealth.html
Perrin EC, Cohen KM, Gold M, Ryan C, Savin-Williams RC, Schorzman CM. Gay and lesbian issues in
pediatric health care. Curr Probl Pediatr Adolesc Health Care. 2004;34:355-398
US Preventive Services Task Force. Screening and treatment for major depressive disorder in children
and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics.
2009;123:1223-1228. DOI: 10.1542/peds.2008-2381. Available at:
http://pediatrics.aappublications.org/cgi/content/full/123/4/1223
Williams SB, O'Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in
primary care settings: a systematic evidence review for the US Preventive Services Task Force.
Pediatrics. 2009;;123:e716-e735. DOI: 10.1542/peds.2008-2415. Available at:
http://pediatrics.aappublications.org/cgi/content/full/123/4/e716

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2011 PREP SA on CD-ROM

Question: 250
A new mother is concerned that her 6-week-old infant is always crying. The infant has gained weight
appropriately and is happy and alert in your office. You reassure her that infants communicate by crying
to have their needs met, but the mother would like more information about infant crying.
Of the following, the information that you are MOST likely to provide is that

A. changing to a hypoallergenic formula can decrease the crying
B. constantly picking up a crying baby increases the frequency of crying
C. crying often is greater in the morning hours
D. crying tends to peak at 6 weeks of age
E. healthy newborns may cry 6 hours a day

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2011 PREP SA on CD-ROM

Critique: 250

Preferred Response: D

The infant described in the vignette is 6 weeks old, the age at which crying tends to peak. As noted in a
1962 study by Brazelton, infants may cry up to 3 hours daily at 6 weeks of age; crying decreases to 1
hour by 12 weeks. Crying is most common between the hours of 3 pm and 11 pm.
Crying is a normal aspect of psychomotor development in early infancy. It occurs in response to
stresses such as hunger, discomfort, too much or too little stimulation, and temperature change.
Constantly picking up a crying 6-week-old infant will not increase the frequency of crying. It is not normal
for a baby to cry for 6 hours, and this may be a nonspecific symptom of a medical problem such as an
infectious disease or nutritional or metabolic condition. Crying alone is not an indication to change the
infant’s formula to a hypoallergenic variety. Children who have allergies to proteins in cow’s milk
generally have small-volume intestinal bleeding and possibly diarrhea.
References:
Bolte R. The crying child: what are they trying to tell you? Part I. Contemp Pediatr. 2007;24(5)74-81
Carey WB “Colic”: prolonged or excessive crying in young infants. In: Levine MD, Carey WB, Crocker
AC, eds. Developmental-Behavioral Pediatrics. 3rd ed. Philadelphia, Pa: WB Saunders Company;
1999:365-369

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