"Growth & Developmental Milestones" — Practice

Question 1

At what age does a child typically develop a mature pincer grip?

Accepted Answer

C

Question 2

By what age should an infant have regained birth weight?

Accepted Answer

B

Question 3

A 10-year-old boy is short with a bone age of 8 years, and his father entered puberty late. What is the likely diagnosis?

Accepted Answer

A

Question 4

A 3-year-old is on the third centile for height and the fiftieth for weight. What does this suggest?

Accepted Answer

B

Question 5

Which finding in a 15-month-old is most concerning?

Accepted Answer

B

Question 6

Why does weight falter before length, and length before head circumference, in undernutrition?

Accepted Answer

Because the body allocates scarce energy according to a hierarchy of biological priority, and the sequence of faltering makes that hierarchy visible.

Adipose tissue and skeletal muscle are energy stores and functional reserves that can be mobilised without immediate threat to survival, so they are consumed first and weight falls earliest. This is wasting, and it can develop within weeks.

Linear growth is next to be sacrificed. Chondrocyte proliferation at the growth plate is energetically expensive and can be suspended without immediate harm, so persistent deficit produces stunting, which by definition takes months to years.

The brain is protected longest. It is metabolically privileged, receiving a disproportionate share of available substrate, so head circumference faltering means either the deficit has been prolonged and severe enough to exhaust that protection, or the problem was never nutritional and the brain itself is primarily abnormal.

Reading the three measurements in order therefore tells you both the nature and the duration of the problem before any test is sent.

Question 7

Why does periventricular leukomalacia in a preterm infant characteristically cause spastic diplegia?

Accepted Answer

B

Question 8

An 18-month-old girl who was walking and saying words has lost both over two months and now wrings her hands repetitively. What is the diagnosis and why does it matter that skills were lost?

Accepted Answer

Loss of previously acquired skills is regression, and it separates this immediately from developmental delay. Delay means milestones are reached late; regression means the nervous system is losing function it had already built, which implies an active destructive or degenerative process rather than a static one.

The specific picture here, a girl with normal early development who loses purposeful hand use and develops stereotypic hand-wringing, together with deceleration of head growth and loss of speech, is characteristic of Rett syndrome, caused by mutations in MECP2 and almost exclusively affecting girls.

The differential includes neurodegenerative and metabolic disorders, and some are treatable, which is why the response is urgent investigation rather than observation. Neuroimaging, metabolic screening and genetic testing are indicated.

The general rule is the point: regression is never normal at any age, and a child who is losing skills requires a different and more urgent pathway than a child who is simply behind.

Question 9

A 7-year-old is obese and on the third centile for height. Why does this combination warrant investigation when obesity alone would not?

Accepted Answer

Because the two findings normally move in opposite directions, and their coexistence is therefore informative.

Simple nutritional obesity involves a chronic energy surplus, and that surplus accelerates linear growth as well as increasing fat mass, partly through raised insulin and insulin-like growth factor activity. An overnourished child is therefore characteristically both heavy and tall for age, often with a modestly advanced bone age.

A child who is obese but short has grown poorly despite an evident energy surplus, which means something is actively suppressing linear growth. Hypothyroidism does this by removing the permissive effect of thyroid hormone at the growth plate. Cushing syndrome does it through glucocorticoid inhibition of growth while promoting central adiposity. Growth hormone deficiency reduces height while increasing fat mass. Prader-Willi syndrome combines short stature with hyperphagic obesity.

The practical rule is that obesity plus tall stature needs lifestyle intervention, whereas obesity plus short stature needs endocrine investigation.

Practice — "Growth & Developmental Milestones"

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