A boy is brought for evaluation; he has stunting with excessive weight gain. His height is below -2 SD for age, and his weight is above +2 SD. Developmental milestones are normal. He has a history of recurrent respiratory infections for which he frequently receives oral medications. What is the next best step to do?

1. A

   Promote physical activity as Child is overweight

2. B

   Screen child for Growth hormone deficiency

3. C

   Check TFT, as the child has congenital hypothyroidism

4. D

   Test for Cushing Syndrome secondary to steroid use

Appeared in: INI-CET EXAM -2025

Explanation

• The combination of growth failure (stunting) and significant central obesity is the hallmark presentation of Cushing syndrome (hypercortisolism) in children.
• Excess cortisol, whether from an internal source or external medication, directly inhibits linear bone growth while simultaneously promoting appetite and fat deposition.
• The patient's history of recurrent respiratory infections treated with frequent 'oral medications' is highly suggestive of repeated courses of corticosteroids, leading to iatrogenic Cushing syndrome.
• Testing for Cushing syndrome is the most direct and logical next step to confirm the underlying cause of the child's growth and weight abnormalities before initiating any management.

Why Other Options Were Wrong

• Option A: This is a management strategy for simple obesity, not a diagnostic step. The priority is to identify the underlying pathological cause of the child's condition, which is clearly more than just a lifestyle issue.
• Option B: Children with Growth Hormone (GH) deficiency typically have short stature with proportional weight or only mild chubbiness. They do not usually present with weight above the +2 SD for age.
• Option C: While congenital hypothyroidism causes stunting and some weight gain, it is almost always accompanied by developmental delay. The prompt explicitly states that the child's developmental milestones are normal, making this diagnosis highly unlikely.

Related Visual

• Visual 1: Chart - A comparative table showing the clinical features of Cushing syndrome, Growth Hormone Deficiency, and Hypothyroidism in children, focusing on height, weight, and development.
• Visual 2: Illustration - An image depicting the classic physical signs of Cushing syndrome in a child, such as moon facies, central obesity, and thin extremities.

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Differential diagnosis of short stature and obesity in children as background academic context rather than a clinical decision trigger.
• This case highlights the critical importance of taking a thorough medication history, including over-the-counter or alternatively prescribed drugs, as they can be the source of significant pathology.
• Nurses must be vigilant for the signs of iatrogenic Cushing syndrome in children who are on long-term or frequent steroid therapy for conditions like asthma or nephrotic syndrome. Key signs include slowing growth, rapid weight gain, and facial changes.
• What if the child's developmental milestones were delayed? If development was also delayed, congenital hypothyroidism would become the leading diagnosis, and checking Thyroid Function Tests (TFT) would be the most appropriate next step.

How to Approach the Question

• First, identify the two core clinical findings in the stem: 1) stunting (height < -2 SD) and 2) excessive weight gain (weight > +2 SD).
• Next, consider the differential diagnoses for this specific combination. Think about the main endocrine causes of growth failure: hypothyroidism, GH deficiency, and Cushing syndrome.
• Use the additional information provided to narrow down the possibilities. The statement 'Developmental milestones are normal' effectively rules out congenital hypothyroidism.
• Compare the features of the remaining options. GH deficiency typically causes mild, not severe, obesity. Cushing syndrome classically causes growth arrest with significant central obesity.
• Finally, look for a unifying cause in the history. The 'frequent oral medications' for 'recurrent respiratory infections' is a strong clue pointing to exogenous steroid use, which directly causes Cushing syndrome. This makes testing for it the most logical next step.

Concept Tested & Keywords

• Concept Tested: Differential diagnosis of short stature and obesity in children.
• Stem keywords: stunting, excessive weight gain, height below -2 SD, weight above +2 SD, recurrent respiratory infections, oral medications
• Lead-in keywords: next best step
• Clinical cues: The combination of stunting and obesity is a key clinical pointer towards an endocrine cause, specifically hypercortisolism.
• Clinical cues: The history of frequent oral medication use is a major clue for an iatrogenic (medication-induced) condition.

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