At what age does an infant reach the milestone of sitting up with support quizlet?

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B
32 weeks
Explanation
The patient has physical findings that are most consistent with a gestational age of 32 weeks. Several tests used to assess neuromuscular maturity are helpful in determining gestational age. The "square window test" is performed by flexing the hand on the wrist and measuring the resultant angle. The wrists of a term infant may be fully flexed while, at approximately 32 weeks of gestation, they can flex only from 45° to 90°. In contrast, flexion of the knees decreases with increasing gestational age. The popliteal angle, measured after bringing the foot as close to the ipsilateral ear as possible, measures from 180° at 24-26 weeks of gestation to ≤ 90° at term.

At 32 weeks of gestation, the popliteal angle measures ∼ 130°. While the foot can touch the ear ("heel-to-toe maneuver") at ≤ 30 weeks of gestation, this becomes more difficult, and is sometimes impossible, between 30 and 34 weeks of gestation. After 34 weeks, it is not possible to touch the foot to the ear. The resting tone of the upper extremities may be assessed by the scarf sign, i.e., traction of the upper extremity across the chest in a rostral direction reveals a decreasing displacement of the elbow with increasing gestational age. A marked extensor posture, typical of a preterm infant, is gradually replaced by a progressively more prominent flexor posture as gestational age increases.

Other indications for gestational age are: Vernix covers the entire body between 24-38 week of gestation, there is no breast tissue < 36 week, there is scant ear cartilage with slow return from folding between 32-35 weeks, and there are 1-2 anterior sole creases between 32 and 33 weeks of gestation.

Internal tibial torsion

No intervention—the problem will resolve itself with time

Internal tibial torsion is the most common cause of intoeing in children 2 years of age and younger. It may be associated with metatarsus adductus. This condition usually resolves without intervention, often is unilateral, and involves the left leg. Rarely, the torsion persists in the child older than 8 years of age and requires surgical intervention.

Other causes of intoeing include internal femoral torsion, metatarsus adductus, and clubfoot. Metatarsus adductus occurs when the forefoot is adducted. This adduction can be flexible or rigid. This disorder can be identified by following a line that bisects the base of the hindfoot forward to the toes. In the normal foot, this line should pass between the 2nd and 3rd toes. If it passes lateral to this, there is metatarsus adductus. Clubfoot occurs as the result of dislocation of the talonavicular joint. Examination of the clubfoot reveals hindfoot equinus, hindfoot and midfoot varus, and forefoot adduction. Internal femoral rotation is demonstrated by the entire lower leg being inwardly rotated while walking and is noticeable in children 3-5 years of age; this also resolves in most cases by 7 years of age. If present in the late childhood age group or if unilateral, orthopedic referral is recommended.

4 ¼ years of age

A child's fine motor control and cognitive development are often evaluated by asking the child to draw a person during a well-child examination. The age equivalent (age level) of a drawing is determined by assigning points to certain features. Each point converts to a value of 1/4 added to a base of 3. One point is credited for each of the following features: 2 eyes, 2 ears, a nose, a mouth, hair, 2 arms, 2 legs, 2 hands, 2 feet, a neck, and a trunk. The patient in this scenario is described as having drawn a figure that, when analyzed, has 5 points; therefore, 1¼ is added to 3, yielding a calculated age equivalent of 4¼ years of age.

Children who struggle with this task may also have associated visual and/or motor deficiencies (e.g., cerebral palsy) requiring further evaluation. The draw a person task is a valuable and nonthreatening tool that is useful in the ongoing assessment of a child's developmental and cognitive progress.

3¾ years of age is an incorrect answer because it involves adding 3 points to a base of 3 instead of 5 points.

3½ years of age is an incorrect answer because it involves adding 2 points to a base of 3 instead of 5 points.

5 and 6 years of age are incorrect answers based on developmental milestones.

An 8-week-old should be able to do all those developmental tasks outlined in the physical examination including: lifting her head 45 degrees off the exam table, smiling socially, and tracking objects 180 degrees. A head lag remains until 4 months of age and the palmar (involuntary) grasp persists until 3-4 months.

A newborn has a complete head lag, grasps reflexively, and startles and roots instinctively.

A 4-week-old can only momentarily raise her head to the plane of the body on ventral suspension. She is only beginning to smile and startles to sound.

A head lag is still expected at 2 months of age. There should be no head lag on pull-to-sit by 4 months of age; infants are typically able to sit with support by 6 months of age.

A newborn cannot support her head, has a predominance of primitive reflexes present (e.g., Moro, palmar, and plantar grasps), and has a visual preference for the human face. The Moro reflex disappears by 3-4 months of age, and palmar grasp disappears by 3-4 months of age as well. Therefore, a Moro reflex at 2 months of age is expected.

Consider bariatric surgery only in a mature adolescent dedicated to losing weight and able to give informed consent, with a family that is both supportive and equally committed. Additional criteria include failure to lose weight after ≥ 6 months of organized attempts at weight loss, physiologic maturity (late SMR 4, SMR 5), BMI ≥ 120% of the 95th percentile of BMI for age with a severe comorbidity (e.g., poorly controlled Type 2 diabetes, hypertension, obstructive sleep apnea, hypoventilation syndrome, nonalcoholic fatty liver disease, pseudotumor cerebri), and BMI ≥ 140% of the 95th percentile for age with less severe comorbidities.

Surgical weight loss procedures in adolescents include adjustable gastric banding (approved in patients ≥ 18 years of age), gastric bypass, and gastric sleeve.

The free fall technique describes the "parachute response," which is one of several balance and equilibrium reactions that emerge in the 1st year of life and persist throughout life. This response usually develops at 8-9 months of age. It is characterized by symmetrical extension of the extremities when the examiner allows the child to free fall while held in a ventral position. The parachute response allows the child to distribute weight over a broader and more stable base upon landing. The parachute reflex is the last of the postural reflexes to develop.

"Head righting," a balance and equilibrium reaction that usually develops at 4 months of age, allows the child to keep the head vertical despite a tilt in the body. By 6 months of age, infants are able to reach out an arm and hand to protect against falling from a sitting position, still another equilibrium reaction sometimes referred to as "lateral propping." Balance and equilibrium reactions develop in a cephalocaudal sequence and demonstrate appropriate central nervous system development.

The degree of mobility while on the hands and knees describes "creeping" or "crawling," a gross motor milestone that develops between 9 and 10 months of age. Most, but not all children crawl.

The "commando crawl," a gross motor milestone that develops around 8 months of age, is characterized by pulling with the upper arms while passively dragging the legs. Most, but not all children "commando crawl".

The ability to anticipate the direction of movement during the pull-to-sit maneuver, demonstrated by flexion of the neck before the shoulders begin to lift, develops at 5-6 months of age.

The presence of spontaneous extension of the arm and leg on the same side that the head is directed to while the patient is lying on the back describes the asymmetric tonic neck reflex, which usually appears at 2-4 weeks of age and disappears by 6 months of age.

In normal infants, the extensor plantar response (Babinski reflex) usually disappears between 9 and 12 months of age, but can be seen as late as 24 months of age. In this reflex, all the toes fan out with the exception of the hallus (big toe), which will dorsiflex slowly as the lateral side of the plantar surface of the foot is rubbed with a blunt instrument from the heel forward to the toes. Persistence of developmental (primitive) reflexes beyond the expected age of disappearance (> 24 months of age) is often the result of neurologic dysfunction associated with developmental delay and abnormal clinical findings, especially in infants with a history of perinatal hypoxia, birth trauma, and/or congenital malformations.

The rooting reflex occurs after an infant's cheek is stroked. The infant turns his head towards the side being stroked with his mouth open. This reflex generally disappears between 3 and 4 months of age.

The stepping reflex, in which the feet move in an alternating stepping motion as the infant is held in an upright vertical position while touching the feet to the exam table, can disappear as early as 1-2 months of age and is extinguished by 3-4 months of age.

The Moro reflex, elicited by allowing the infant's head and torso to move downward suddenly from an upright position, is characterized by symmetric extension and abduction of the arms and flexion of the thumbs with the hands open, followed quickly by flexion and adduction of the upper extremities. The Moro reflex disappears by 3-6 months of age.

The palmar grasp reflex, in which the infant grasps the examiner's finger after it is placed in the open palm and tries to resist attempts to remove the finger, generally disappears by 3-4 months of age

Several syndromes involve craniosynostosis, including Crouzon, Apert, Carpenter, and Pfeiffer syndromes. Any infant suspected of having craniosynostosis should have an early referral to a craniofacial or neurosurgeon. CT scans in axial, coronal, and three-dimensional constructs should be obtained prior to surgical reshaping of the calvarium. The optimal timing for surgery is less than 1 year of age.

Crouzon syndrome is the most common of these syndromes. It results from bilateral, premature closure of the coronal sutures (brachycephaly). Patients have midface hypoplasia, proptosis, normal intelligence, and normal hands and feet. One third of patients have associated hydrocephalus.

Apert syndrome involves the premature closure of multiple sutures (though often bicoronal synostosis is seen, as in Crouzon syndrome). These patients have syndactyly of the hands and feet with the characteristic mitten hand, as well as an intellectual disability.

Carpenter syndrome includes the fusion of multiple sutures (commonly lambdoid and sagittal sutures), syndactyly, intellectual disability, and less frequently CHD, orthopedic abnormalities, and corneal opacities.

Pfeiffer syndrome consists of brachycephaly (in Type 1) and a cloverleaf skull (in Type 2), midface hypoplasia, and finger/toe abnormalities. Type 1 is generally mild, but Types 2 and 3 are associated with severe neurologic deficits.

Soto syndrome (or cerebral gigantism) is characterized by macrocephaly, excessive physical growth in early childhood, and intellectual disability. Craniosynostosis is not a feature of Soto syndrome.

Proper sequence is: Mandibular central incisors, maxillary central incisors, mandibular lateral incisors

Primary tooth eruption is usually symmetrical—lower (mandibular) teeth before upper (maxillary) teeth in the following pattern: central incisors, lateral incisors, 1st molars, canines, 2nd molars.
Exfoliation usually follows a similar pattern. Primary teeth begin to erupt around 6 months of age (range 5-10 months of age). Eruption is complete by 24-36 months of age. It is reasonable to refer a child who has not erupted a tooth by 18 months of age to a dentist. By 3 years of age, there are usually 20 primary teeth.

Use the "7 + 4" rule to remember the timing of eruption of primary teeth. At 7 months of age, children should have their first teeth; at 11 months (7 months + 4), they should have 4 teeth. At 15 months of age (11 months + 4), they should have 8 teeth; at 19 months, 12 teeth; at 23 months, 16 teeth; and at 27 months, they should have 20 teeth.

The patient is exhibiting a normal primitive reflex called the asymmetric tonic neck reflex (ATNR). Reassurance is all that is necessary.

This early reflex pattern is usually first noted at 2-4 weeks of age following resolution of the normal newborn's high flexor tone. Considered as one of the first steps in the coordination of reaching and visual input, the reflex typically disappears by 6 months of age. The reflex is best seen following passive turning of the head to one side, which is quickly followed by an increase in extensor tone in both the arm and leg on that side and in the flexor muscles of the arm and leg on the other side. Flexion of the arm and leg on the occipital side of the head and extension of the upper and lower extremities on the other side of the head creates a "fencer-like" position characteristic of the ATNR. Persistence of primitive reflexes (including the ATNR, Moro, hand grasp, crossed adductor, and toe grasp reflexes) beyond the expected age of disappearance often indicates serious neurological dysfunction/damage.

An MRI might be needed if there is concern of neurological problems in the infant. If ATNR is still present after 6 months of age, this might be necessary. Other reasons to order an MRI include an abnormal head size or shape, seizures, loss of milestones, and neurocutaneous or craniofacial abnormalities.

Indications for physical therapy include torticollis and increased muscle tone. In this case, the infant's increased tone in the extremities on the side to which the head is turned is a normal reflex, not an abnormality. If the ATNR persists greater than 6 months, further evaluation is necessary.

An ultrasound of the spinal cord would be warranted if this infant had a large, deep sacral dimple or tufted hair along the spine and/or abnormal lower extremity movements or bladder/bowel dysfunction. The ultrasound is used as a screen for spinal bifida occulta, diastematomyelia, tethered cords, and lipomas. If an open or partially open neural tube defect is found or an irregularity is noted on the ultrasound, an MRI would be the modality of choice.

A cranial ultrasound should be considered if prematurity or seizures are present as well as for the evaluation of intraventricular hemorrhage and periventricular leukomalacia.

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