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Pediatrics_Nelson. Other type (e.g., fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters) In the management of anxiety disorders, likely medical conditions, including hyperthyroidism, medication side effects, substance abuse, or other medical conditions, should be ruled out. The patient should be screened for comorbid psychiatric disorders, such as mood disorders, psychosis, eating disorders, tic disorders, and disruptive behavior disorders. A history from multiple sources is important because the child may be unable to effectively communicate symptoms. A detailed history that includes the nature of the anxiety triggers; psychosocial history; and family history of tics, anxiety disorders, depression, and other mood disorders should be taken. The younger child may better communicate his or her anxieties through drawings or play.


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Pediatrics_Nelson. Treatment consists of psychotherapy and psychopharmacology. For mild to moderate anxiety, evidence-basedpsychotherapies and psychoeducation should be used first.Combined therapy usually has better efficacy than psychotherapy and psychopharmacology alone. Cognitive andbehavioral therapy (including systematic desensitization,exposure, operant conditioning, modeling, and cognitiverestructuring ) can be beneficial in a variety of anxiety disorders. Patients with anxiety disorders are often less tolerant ofmedication side effects, and supportive therapy helps themmaintain treatment regimens.


Pediatrics_Nelson

Pediatrics_Nelson. A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people, and the anxiety must occur in peer settings, not just in interactions with adults. B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations or unfamiliar people. C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.


Pediatrics_Nelson

Pediatrics_Nelson. C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent. D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress. E. The avoidance, anxious anticipation, or distress in the feared social or performance situation interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. F. In children <18 years, the duration is at least 6 months. G. The fear or avoidance is not due to the direct physiologic effects of a drug of abuse, a medication, or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, pervasive developmental disorder, or schizoid personality disorder).


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Pediatrics_Nelson. H. If a general medical condition or another mental disorder is present, the fear in criterion A is unrelated to it (e.g., the fear is not of stuttering or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa). Specify the following: Generalized: if the fears include most social situations (e.g., initiating or maintaining conversations, participating in small groups, dating, speaking to authority figures, attending parties). Note: Also consider the additional diagnosis of avoidant personality disorder.


Pediatrics_Nelson

Pediatrics_Nelson. Family and individual psychotherapy and care coordination with a patient’s school is helpful. Reassurance that the patient does not have a life-threatening illness is important. Other psychosocial treatments include stress management, supportive therapies, and biofeedback. Emphasis is placed on decreasing morbidity through proper treatment. Panic disorder tends to be chronic but usually is responsive to treatment. In PTSD trauma-focused cognitive behavioral therapy has shown efficacy. Critical-incident stress debriefing and “psychological first aid,” soon after the event, greatly reduce distress and involve discussing the nature and impact of the trauma event in a group format.


Pediatrics_Nelson

Pediatrics_Nelson. Selective serotonin reuptake inhibitors (SSRIs) are the medication of choice. The SSRIs approved for children by the U.S. Food and Drug Administration (FDA) are fluoxetine, sertraline, and fluvoxamine. They can initially exacerbate anxiety or even panic symptoms. Clomipramine requires electrocardiographic and blood level monitoring but may be effective and is approved by the FDA for obsessive-compulsive disorder. Tricyclic antidepressants have also shown efficacy. Benzodiazepines (alprazolam and clonazepam) include a risk of causing disinhibition in children. Alpha-2a-agonists (guanfacine and clonidine) may be useful if autonomic symptoms are present. Anticonvulsant agents (gabapentin, topiramate, and oxcarbazepine) are used when other agents are ineffective. β-Blockers help with performance anxiety.


Pediatrics_Nelson

Pediatrics_Nelson. Co-occurrence of the inattentive type of attention-deficit/hyperactivity disorder (ADHD) and an anxiety disorder is common. When using a stimulant, it is advisable to start at a low dose, increasing slowly to minimize the risk of increasing anxiety. For PTSD, antidepressants may be augmented by clonidine (also useful in hyperarousal and impulsivity) in the presence of severe affective dyscontrol. Atypical antipsychotics are used if self-injurious behavior, dissociation, psychosis, and aggression are present. Atomoxetine is useful in PTSD with concurrent ADHD.


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Pediatrics_Nelson. Major depressive disorder (MDD) requires a minimum of 2 weeks of symptoms, including either depressed mood or loss of interest or pleasure in nearly all activities. Four additional symptoms must also be present (Table 18-1). In children and adolescents, a new onset of irritability, restlessness, or boredom may be seen instead of depressed mood. A sudden drop in grades is often present. A change in appetite (usually decreased but can be increased) with carbohydrate craving with or without accompanying weight changes and sleep disturbance along with somatic complaints (fatigue, vague aches and pains) may also be present. Psychotic symptoms, seen in severe cases of major depression, are generally mood-congruent (e.g., derogatory auditory hallucinations, guilt associated delusional thinking). Suicidal thoughts and attempts are common and should be evaluated.


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Pediatrics_Nelson. The prevalence of MDD in prepubertal children is 2% with 1:1 female-to-male ratio; in adolescents the prevalence is 6% to 8%, with a female-to-male ratio of 2:1 (similar to adults). If untreated, major depression can become chronic in 10% of patients. Depression has a clear genetic predisposition, with familyhistory as the strongest single factor for developing MDD.Twin studies show 40% to 65% heritability for depression.Family studies show a twofold to fourfold increased risk fordepression in offspring of depressed parents. Other potential responsible factors for depression include dysregulation of central serotonergic and/or noradrenergic systems,hypothalamic-pituitary-adrenal axis dysfunction, and theinfluence of pubertal sex hormones. The stress-diathesismodel relates to the interaction of genes and environment;for example, a less functional genetic variant of the serotonin receptor in presence of stressful life events could contribute to depression.


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Pediatrics_Nelson. Criteria for Diagnosis of a Major Depressive Episode A. Five or more of the following symptoms present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, mood can be irritable. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation by others) 3.


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Pediatrics_Nelson. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation by others) 3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains 4. 5. 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not self-reproach or guilt about being sick) 8. Diminished ability to think, concentrate, or be decisive nearly every day (subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a mixed manic episode.


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Pediatrics_Nelson. B. The symptoms do not meet criteria for a mixed manic episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiologic effects of a drug or abuse, a medication, or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by bereavement, and the symptoms persist >2 mo or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.


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Pediatrics_Nelson. Dysthymic disorder and anxiety disorders (prevalence 30% and 80%, respectively), substance abuse (20% to 30%), and disruptive behavior disorders (10% to 20%) are frequent comorbid disorders in depressed children and adolescents. Twenty percent of patients diagnosed with depression develop bipolar disorder (BD); this is more common in cases with a family history of mania or concurrent psychotic features. The differential diagnoses for MDD are diverse and many. It is always prudent to rule out mood disorder due to a general medical condition or substance-induced mood disorders before considering MDD. Schizophrenia in its initial stages and the dysphoria related to untreated attention-deficit/hyperactivity disorder (ADHD) may also be mistakenly diagnosed as depression. Hypothyroidism, anemia, diabetes, and folate and B12 vitamin deficiencies need to be ruled out.


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Pediatrics_Nelson. Dysthymic disorder (prevalence rate 0.6% to 1.7%) is a chronic, milder form of depression characterized by a depressed or irritable mood (subjectively or described by others) present for at least 1 year. Two of the following symptoms are also required: changes in appetite; sleep difficulty, fatigue; low self-esteem; poor concentration or difficulty with making decisions; and feelings of hopelessness. About 70% of children and adolescents with dysthymic disorder eventually develop major depression. The development of MDD after dysthymia is often referred to as double depression. Atypical depression is MDD characterized by hypersomnia, increased appetite with carbohydrate craving, weight gain, interpersonal rejection sensitivity, and mood reactivity.


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Pediatrics_Nelson. Atypical depression is MDD characterized by hypersomnia, increased appetite with carbohydrate craving, weight gain, interpersonal rejection sensitivity, and mood reactivity. Adjustment disorder with depressed mood is the most common depressive disorder in children and adolescents. Symptoms start within 3 months of an identifiable stressor (e.g., loss of a relationship), with distress in excess of what would be expected and interference with social, occupational, or school functioning. Symptoms should not meet criteria for another psychiatric disorder, should not be caused by bereavement, and should not last longer than 6 months after the stressor has stopped. Seasonal affective disorder is a condition common in northern or extreme southern latitudes, in which depressive symptoms occur in the late fall and early winter when the hours of daylight are shortening.


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Pediatrics_Nelson. Depressive disorder not otherwise specified is a diagnosis used when patients have functionally impairing depressive symptoms that do not meet criteria for another condition.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment of depression involves psychopharmacy and psychotherapy. First line antidepressant selective serotonin reuptake inhibitors (SSRIs) have response rates of 50% to 70% despite high-placebo response rate. Fluoxetine is the only agent approved by the U.S. Food and Drug Administration (FDA) for treatment of youth. Citalopram, escitalopram, paroxetine, and venlafaxine have positive clinical trial results as well. An antidepressant should be given an adequate trial (6 weeks at therapeutic doses) before switching or discontinuing unless there are serious side effects. For a first episode of depression in children and adolescents, treatment for 6 to 9 months after remission of symptoms is recommended. Patients with recurrent or chronic depression may need to take antidepressants for extended periods (years or even a lifetime). If a patient does not respond to adequate trials of two or more antidepressants, a child psychiatrist should be consulted. The psychiatrist’s evaluation should


Pediatrics_Nelson

Pediatrics_Nelson. periods (years or even a lifetime). If a patient does not respond to adequate trials of two or more antidepressants, a child psychiatrist should be consulted. The psychiatrist’s evaluation should focus on diagnostic clarity and psychosocial issues that might be preventing a full response. The psychiatrist may use augmentation strategies that may include lithium, thyroid hormone, lamotrigine, or bupropion.


Pediatrics_Nelson

Pediatrics_Nelson. For acute depression, more frequent visits are indicated, and the risks of medication (including suicidal and self-destructive behavior) should be discussed with parents, guardians, and patients. Higher frequency of monitoring can include phone calls or collaborative care with a psychotherapist. Parents and patients should also be educated about warning signs and to call immediately if these new symptoms occur. Notable side effects are thoughts of suicide, increased agitation, or restlessness. Other side effects include headache, dizziness, gastrointestinal symptoms, sleep cycle disturbance, sexual dysfunction, akathisia, serotonin syndrome, and risk of increased bruising (due to platelet inhibition.) There is also a risk of SSRI-induced mania.


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Pediatrics_Nelson. In 2004 the FDA issued warnings for all antidepressants regarding suicidal thinking or behavior. The data suggest that antidepressants pose a 4% risk, versus a 2% risk in placebo. An increase in suicides in children and adolescents since that year has many experts believing that it might be related to low prescription of antidepressants and resultant untreated depression. Substance use, concomitant conduct problems, and impulsivity increase the risk of suicide.


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Pediatrics_Nelson. Psychotherapy appears to have good efficacy in mild to moderate depression. In moderate to severe depression, combinedtreatment with psychotherapy and medication has the greatestrate of response, although in severe cases the efficacy was equivalent to medication alone. Cognitive-behavioral therapy andinterpersonal therapies are the empirically supported psychotherapies. Cognitive behavioral therapy and its derivative, dialectic behavioral therapy (for borderline personality disorder),involve techniques and skills-building to mitigate cognitivedistortions and maladaptive processing; whereas interpersonaltherapy focuses on collaborative decisions between the therapist and patient and is based on the exploration and recognition of precipitants of depression. Family therapy is often usedas an adjunct to other treatments for depression.


Pediatrics_Nelson

Pediatrics_Nelson. Light therapy has been shown to be beneficial for seasonal affective disorder and in MDD with a seasonal component. Electroconvulsive therapy is used in refractory and life-threatening depression. Depression is a chronic and debilitating illness that often starts in childhood or adolescence. It increases risk for future suicide, substance use, and other psychiatric sequelae. Adolescent depressive disorders are more likely to be recurrent into adulthood than childhood onset depression. Suicide is a fatal complication of MDD and surpasses motor vehicle accidents as a cause of death in adolescents. It has high prevalence among high school students with 20% having contemplated suicide and 8% having attempted each year. While the risk of suicide during an MDD episode is high, it can be paradoxically higher during start of treatment as energy and motivation improve with cognitive recovery from depression.


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Pediatrics_Nelson. Treatment is targeted toward decreasing morbidity and suicide. Along with treatments mentioned previously, modalities such as hospitalization, partial hospital, therapeutic after-school programs, or psychoeducation may be needed. Bipolar disorder consists of distinct periods of mania (elevated, expansive, or irritable moods and distractibility) that may alternate with periods of severe depression (Table 18-2).


Pediatrics_Nelson

Pediatrics_Nelson. Bipolar disorder consists of distinct periods of mania (elevated, expansive, or irritable moods and distractibility) that may alternate with periods of severe depression (Table 18-2). To diagnose mania associated with BD, euphoria (elevated or expansive mood) and three additional symptoms; or irritability and four additional manic symptoms are required. Children and adolescents with euphoric mood are bubbly, giggly, and “over-the-top” happy, to a degree that is socially unacceptable to others. Grandiosity in children is often dramatic. Children act as if they are superior even when it is obvious that it is not true, and they behave as if the laws of nature do not apply to them. Racing thoughts are common in BD. Periods of extreme rage also are common. Children with BD often present with rapid or ultra-rapid cycling with multiple shifts between euthymia, mania, and depression.


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Pediatrics_Nelson. A decreased need for sleep is a hallmark of mania. There areno other diagnoses where a child has a greatly decreased amountof total sleep (compared with age-appropriate norms) and is notfatigued. Sleep deprivation, substance abuse, and antidepressants may trigger mania. BD onset often begins with an episodeof depression. It is estimated that 33% of youth will develop BD A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) B. During the period of mood disturbance, three or more of the following symptoms have persisted (four if the mood is only irritability) and are present to a significant degree: 1. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5.


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Pediatrics_Nelson. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., easily drawn to unimportant or irrelevant external stimuli) 6. Increased goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation C. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., unrestrained buying sprees, sexual indiscretions, or foolish investments) D. The symptoms do not meet criteria for a mixed episode. E. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning, usual social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or with psychotic features.


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Pediatrics_Nelson. F. The symptoms are not due to the direct physiologic effects of a substance or a general medical condition. Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy) should not count toward a diagnosis of bipolar I disorder.


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Pediatrics_Nelson. within 5 years of a depressive episode. Features associated withswitching include early-onset depression, psychomotor retardation, psychosis, mood lability, seasonal pattern, family history ofBD or mood disorders, and antidepressant-induced hypomania.A mixed episode requires 1 week of symptoms of both a manicand major depressive episode. Dysphoric mania is another term used to describe periods of mania that are accompanied by “badfeelings.” Hypomania is used to describe a period of more than 4but fewer than 7 days of manic symptoms. It also is used less specifically to describe less intense mania. The prevalence of psychosis in adolescence (often auditory hallucinations) is 16% to60%. Although high, it is still less than its prevalence in adult BD.


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Pediatrics_Nelson. Bipolar II disorder includes at least one full major depressive episode and at least one period of hypomania. Bipolar disorder not otherwise specified is used to describe prominent symptoms of BD that do not meet full diagnostic criteria or when historical information is unclear. Cyclothymic disorder is characterized by 2 years or more (1 year in children) of numerous periods of hypomania and depression that do not meet full criteria for either a manic or a major depressive episode. BD occurs in up to 4% of the general population. It is estimated that 1% of children and adolescents meet diagnostic criteria for BD. According to retrospective studies, 60% of BD onset occurs before 20 years of age. Although BD in adults tends to be gender neutral, it is estimated that prepubertal BD is almost four times more frequently diagnosed in boys. This may be because aggression is the main reason for referral for psychiatric services.


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Pediatrics_Nelson. The etiology of BD is multifactorial. Studies in BD point to a highly familial etiology with family history of mental illness, including major depression, BD, schizophrenia, or ADHD. A first-degree relative with BD leads to a 10-fold increase in a child’s chance of developing BD. An earlier onset of BD in a parent increases the risk of early onset BD in offspring with a more chronic and debilitating course that may be less responsive to treatment. The differential diagnosis for BD includes ADHD, major depression, conduct disorder (CD), mood disorder due to a general medical condition, substance-induced mood disorder, pervasive developmental disorder, and schizophrenia.


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Pediatrics_Nelson. Patients with BD often have concurrent conditions that warrant treatment. ADHD occurs in approximately 60% to 90% ofchildren with BD. Anxiety disorders also commonly occur withBD and do not respond to antimanic agents. Substance abusecan precipitate and perpetuate mania and depression. The alteration between highs and lows related to some types of substanceabuse often mimics BD. Patients with BD may also self-medicate in attempts to alleviate symptoms. Many patients with BDmay commit crimes and meet criteria for CD due to aggressionand impulsivity. Prominent symptoms of mania assist in differentiating between CD and BD. Patients with BD generallyexhibit reactive aggression, whereas those with CD are morelikely to preplan and develop a typical pattern of crimes.


Pediatrics_Nelson

Pediatrics_Nelson. No laboratory or imaging studies can diagnose BD. Physical examination, careful history, review of systems, and laboratory testing are done to rule out suspected medical etiologies, including neurologic and substance-induced disorders.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment of BD includes decreasing acute symptoms. The FDA has approved lithium, divalproex sodium, carbamazepine, olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole for adults with BD. Lithium is the oldest proven treatment for mania in adults and has been used effectively in children and adolescents for years. Common side effects of lithium include hypothyroidism, polyuria, and acne. Divalproex is also a first-line agent (preferable for mixed or rapid cycling cases) for adults. It has been used effectively for decades in youth, but it is not FDA-approved. Periodic monitoring of blood levels for select medications (lithium and divalproex sodium) can help ensure both treatment safety and the receipt of therapeutic amounts of the medication. Anti-psychotics (risperidone, olanzapine, quetiapine, aripiprazole, and ziprasidone) have had positive results in youth with BD. It is likely that newer antipsychotics will also be effective in BD.


Pediatrics_Nelson

Pediatrics_Nelson. Treating comorbid psychiatric disorders must be done carefully. Stimulants may be used to treat ADHD once the patienthas been stabilized on a mood stabilizer. Antidepressants shouldbe avoided; if the youth is depressed or has significant anxietyand is not responsive to other pharmacotherapy, cautious useof antidepressants may be necessary. Careful monitoring formanic reactivation, cycling, and suicidality is needed. Cognitive and behavioral therapies are aimed at improving adherence to medication treatments and ameliorating anxiety and depressive symptoms. Psychoeducation and family therapy are needed to stabilize the patient’s environment and improve prognosis. There should be continuous ongoing safety assessment. Because developmental delays are also common in young children with BD due to poor learning while symptomatic, collaboration with school regarding behavioral management, special educational needs, and an appropriate individualized educational plan is also needed.


Pediatrics_Nelson

Pediatrics_Nelson. BD is an even higher risk factor for suicide than depression. Forty percent of children and 50% of adolescents with BD attempt suicide. High levels of irritability, impulsivity, and poor ability to consider consequences (substance abuse, and so on) increase the risk of completed suicide. Attempters are usually older, more likely to have mixed episodes and psychotic features, comorbid substance use, panic disorder, nonsuicidal self-injurious behaviors, a family history of suicide attempts, history of hospitalizations, and history of physical or sexual abuse. Ensuring safety is the first consideration. Hospitalization, partial hospitalization, intensive outpatient treatment, and intensive in-home services are used as needed for stabilization and safety.


Pediatrics_Nelson

Pediatrics_Nelson. Obsessive-compulsive disorder (OCD) is characterized by obsessions, compulsions, or both in the absence of another psychiatric disorder that better explains the symptoms (Table 19-1). Obsessions are persistent intrusive thoughts, images, or impulses. Compulsions are non-gratifying repeated behaviors aimed at reducing or preventing distress or anxiety. Usually the compulsions are performed to offset anxiety created by the obsessions. In children, due to low level of insight, rituals or compulsive symptoms may predominate over worries or obsessions. Symptoms are usually recognized as being excessive or unreasonable. Common examples of obsessions in children are fears of contamination, repeated doubts, need for orderliness, and aggressive or horrific impulses. Common compulsions are hand washing, ordering, checking, requesting or demanding reassurance, praying, counting, repeating words silently, and hoarding.


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Pediatrics_Nelson. Prevalence of OCD in children and adolescents ranges from 1% to 4%, increasing with age. It is more common in boys at a younger age and in girls during adolescence. At least 50% of youth with OCD have at least one other psychiatric illness. Psychiatric comorbidities include tics (20% to 30%), mood and anxiety disorders (up to 75%), disruptive behavior disorders (attention-deficit/hyperactivity disorder [ADHD] and oppositional defiant disorder), developmental disorders, body dysmorphic disorder, hypochondriasis, and obsessive-compulsive personality disorder. Twin studies suggest that obsessive-compulsive symptoms are moderately heritable, with genetic factors accounting for 45% to 65% of variance.


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Pediatrics_Nelson. Twin studies suggest that obsessive-compulsive symptoms are moderately heritable, with genetic factors accounting for 45% to 65% of variance. Streptococcal infection causing inflammation in the basal ganglia may account for 10% of childhood-onset OCD and is a part of a condition referred to as pediatric autoimmune neuropsychiatric disorders associated with streptococcal (also known as PANDAS) infection. Antistreptolysin O, antistreptococcal DNAase B titers, and a throat culture assist in diagnosing a A. Either obsessions or compulsions Obsessions are defined by (1), (2), (3), and (4). 1. Recurrent and persistent thoughts, impulses, or images experienced at some time during the disturbance as intrusive and inappropriate and causing marked anxiety or distress 2. Thoughts, impulses, or images are not simply excessive worries about real-life problems. 3.


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Pediatrics_Nelson. Thoughts, impulses, or images are not simply excessive worries about real-life problems. 3. The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other thought or action. 4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion). Compulsions are defined by (1) and (2). 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rigidly applied rules. 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not realistically connected with what they are designed to neutralize/prevent or are clearly excessive.


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Pediatrics_Nelson. B. At some point, the person recognizes that the obsessions or compulsions are excessive or unreasonable. Note: This is not required for children. C. The obsessions or compulsions cause marked distress; are time-consuming (taking >1 hour a day); or significantly interfere with a normal routine, occupational (or academic) functioning, or usual social activities or relationships. D.If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder). E. The disturbance is not due to thedirect physiologic effects of a drug of abuse, a medication, or a general medical condition. Specify the following: With poor insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable group A beta-hemolytic streptococcal infection. Early antibiotic therapy may help treat these cases.


Pediatrics_Nelson

Pediatrics_Nelson. OCD has been linked to a disruption in the brain’s serotonin,glutamate, and dopamine systems. Overactivity in neural pathways involving orbital frontal cortex and the caudate nucleushas been implicated in OCD. Physical examination may reveal rough, cracked skin as evidence of excessive hand washing. The Yale-Brown Obsessive-Compulsive Scale (also known as Y-BOCS) is regarded as the gold standard measure of obsessive-compulsive symptom severity. Although somewhat lengthy, it can be helpful in the clinical setting. Cognitive-behavioral therapy (CBT) involving exposure and response prevention is considered the treatment of choice in milder cases. CBT provides durability of symptom relief and avoidance of potential pharmacotherapy-associated side effects. As with other anxiety disorders, CBT is at least as good, if not better, than medications. The combination of medications and CBT has shown the best response.


Pediatrics_Nelson

Pediatrics_Nelson. Selective serotonin reuptake inhibitors (SSRI) are useful for higher severity of symptoms and complications with comorbidities or when cognitive or emotional ability are insufficient to cooperate in CBT. If quality CBT is not available, treatment with medications alone while psychotherapy referral is pursued is a reasonable choice. SSRI (paroxetine, fluoxetine, fluvoxamine, sertraline, citalopram and escitalopram) treatment is generally thought to show a favorable risk-to-benefit ratio in OCD. Side effects such as activation, akathisia, disinhibition, impulsivity, and hyperactivity may be seen. Monitoring of height may be advisable due to possible growth suppression associated with the SSRIs.


Pediatrics_Nelson

Pediatrics_Nelson. If an SSRI trial is unsuccessful, clomipramine can be tried next. Combination therapy using an SSRI with an antipsychotic medication (risperidone or another atypical antipsychotic) is also considered especially with specific comorbidities, for example, in tic disorders. Antipsychotics are also useful when the intrusive thoughts associated with OCD become nearly delusional in nature. Psychostimulants are used with comorbid ADHD, even though there is a risk that stimulants may increase obsessional symptoms and tics. Most responders exhibit partial response only, and as many as one third of young people with OCD are refractory to treatment. Poor prognostic factors include comorbid psychiatric illness and a poor initial treatment response.


Pediatrics_Nelson

Pediatrics_Nelson. Deep brain stimulation of the basal ganglia, through surgically implanted electrodes and surgical interventions (anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy), are reserved for very severe cases or highly refractory cases. The differential diagnosis for OCD includes psychotic disorders, complex tics, other anxiety disorders, and obsessive-compulsive personality disorder. Often a patient with OCD recognizesthat the intrusive thoughts are created by their own brain, whereaspsychotic patients feel they are not created by them. This may beless clear in youth. A delusional fixation on appearance in body dysmorphic disorder and impulsive hair pulling to relieve anxiety or tension in trichotillomania can be confused with OCD. Obsessive-compulsive personality disorder is a character styleinvolving preoccupation with orderliness, perfectionism, andcontrol. No true obsessions or compulsions are present.


Pediatrics_Nelson

Pediatrics_Nelson. Pervasive developmental disorders, also known as autism spectrum disorders (ASDs), consist of five disorders: autism, Asperger syndrome, childhood disintegrative disorder, Rett syndrome, and pervasive developmental disorder not otherwise specified. Onset of these disorders is in infancy and preschool years. Hallmarks of these disorders include impaired communication and impaired social interaction as well as stereotypic behaviors, interests, and activities. Mental retardation is common, with a few children showing remarkable isolated abilities (savant or splinter skills). ASDs are seen in less than 1% of the population with equal prevalence among all racial and ethnic groups. The prevalence is greater in boys (except for Rett syndrome), but girls with the disorders tend to be more severely affected. Differentiating features of the pervasive developmental disorders are listed in Table 20-1.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment of ASD is symptomatic and multimodal. Atpresent there are no treatments for the core symptoms ofASDs. Antipsychotics (risperidone, olanzapine, quetiapine,aripiprazole, ziprasidone, paliperidone, haloperidol, thioridazine) are used for aggression, agitation, irritability, hyperactivity, and self-injurious behavior. Anticonvulsants and lithium can be used for aggression. Naltrexone has been usedto decrease self-injurious behavior, presumably by blockingendogenous opioids. Selective serotonin reuptake inhibitors are given for anxiety, perseveration, compulsions, depression,and social isolation. Stimulants are useful for hyperactivityand inattention (better response with Asperger syndrome).There are reports of significant worsening of irritability andaggression in some patients treated with stimulants. Alpha-2agonists (guanfacine, clonidine) are used for hyperactivity,aggression, and sleep dysregulation, although melatonin isfirst-line medication for sleep dysregulation.


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Pediatrics_Nelson. treated with stimulants. Alpha-2agonists (guanfacine, clonidine) are used for hyperactivity,aggression, and sleep dysregulation, although melatonin isfirst-line medication for sleep dysregulation. Behavioralmanagement training for parents is useful in teaching protocols to help their child learn appropriate behavior. Special educational services should be individualized for the child. Occupational, speech, and physical therapy are oftenrequired. Referral for disability services and support is oftenwarranted. Potentially useful therapies tailored to the individual include applied behavioral analysis, discrete trialtraining, and structured teaching. There is a need for family support groups and individual supportive counseling for parents. The prognosis for autism is guarded. There are no known methods of primary prevention. Treatment and educational interventions are aimed at decreasing morbidity andmaximizing function.


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Pediatrics_Nelson. Autism, the prototypic pervasive developmental disorder, ischaracterized by lifelong marked impairment in reciprocal socialinteraction, communication, and a restricted range of activitiesand interests (Table 20-2). Approximately 20% of parents reportrelatively normal development until 1 or 2 years of age, followedby a steady or sudden decline. If no clinical manifestations ofthe disorder are present by 3 years of age, Rett syndrome orchildhood disintegrative disorder need to be considered. As aninfant, there is delayed or absent social smiling. The young childmay spend hours in solitary play and be socially withdrawnwith indifference to attempts at communication. Patients withautism often are not able to understand nonverbal communication (eye contact, facial expressions) and do not interact withpeople as significantly different from objects. Speech often isdelayed and, when present, it is frequently dominated by echolalia (sometimes mistaken as a sign of obsessive-compulsivedisorder


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Pediatrics_Nelson. withpeople as significantly different from objects. Speech often isdelayed and, when present, it is frequently dominated by echolalia (sometimes mistaken as a sign of obsessive-compulsivedisorder [OCD]), perseveration (confused with psychosis or


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Pediatrics_Nelson. Table 20-1 Pervasive Developmental Disorder: Characteristics FEATURE AUTISM ASPERGER RETT CDD PDD-NOS Epidemiology 10 cases per 10,000; 5:1 male-to-female ratio 2.5 per 10,000; 5:1 male-to-female ratio 0.44 to 2.1 per 10,000; diagnosed only in girls; associated with MECP2 gene mutation 0.11 per 10,000 2 to 16 per 10,000 CDD, Childhood disintegrative disorder; PDD-NOS, pervasive developmental disorder-not otherwise specified. OCD), pronoun reversal, nonsense rhyming, and other abnormalities. Intense absorbing interests, ritualistic behavior, andcompulsive routines are characteristic, and their disruptionoften invokes tantrum or rage reactions. Head banging, teethgrinding, rocking, diminished responsiveness to pain and external stimuli, and self-mutilation may be noted.


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Pediatrics_Nelson. Although the etiology of autistic disorder is unknown, there is an increased risk of autistic disorder in siblings compared to the general population. Twin studies have revealed high levels of concordance for monozygotic twins. Family studies reveal prevalence rates of between 2% and 10% in siblings, and, when absent, there may be increased risk for language, learning, and social development problems. It is proposed that the brain connectivity is adversely affected. Abnormalities in the limbic system, temporal, and frontal lobes have been suggested. Some postmortem studies reveal abnormalities in the brain microarchitecture, size, and neuronal packing. Functional magnetic resonance imaging (MRI) studies show hypoactivity of the fusiform gyrus of the amygdala, a location involved in face processing tasks and facial expression recognition involved in social and affective judgments.


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Pediatrics_Nelson. The American Academy of Pediatrics recommends screening for autism at 18 and 24 months of age. Comprehensive testing should be done if there is an affected sibling or parental, other caregiver, or pediatric concern.


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Pediatrics_Nelson. There are no definitive laboratory studies for autistic disorder, but they can help rule out other diagnoses. A hearing test (may account for the language deficits), chromosomal testing (to identify fragile X syndrome, tubular sclerosis, and genetic polymorphisms), congenital viral infections, and metabolic disorders (phenylketonuria) should be performed. Electroencephalography abnormalities may be seen in 20% to 25% of children with autism but are not diagnostic. Psychological tests in children with autism often show strengths in nonverbal tasks (e.g., puzzles) and marked deficiency in verbal cognitive abilities. IQ is usually low, though savant skills and hyperlexia (a precocious interest in letters and numbers) are sometimes observed. Speech pathology consultation can be helpful in evaluating the communication difficulties.


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Pediatrics_Nelson. Common comorbidities are mental retardation (in up to 80%), seizure disorder (in 25%), anxiety disorders, OCD, and attention-deficit/hyperactivity disorder. Seizures often start around the onset of puberty. Higher IQ and better language skills are related to improved prognosis. Good communication by the age of 6 years and average nonverbal cognitive skills predict the likelihood of living independently or in a less structured group living situation. The earliest studies of autism suggested a relatively poor prognosis, with only a small number of individuals (1% to 2%) being able to function independently as adults. Recent research reveals major gains, but not a cure, with early diagnosis and treatment. Schizophrenia generally presents in adolescence or early adulthood. The same diagnostic criteria are applied as in adults but must be interpreted in terms of the developmental stage of the child (Table 20-3).


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Pediatrics_Nelson. Childhood-onset schizophrenia is a rare disorder (<1 in 10,000 children) and usually indicates a more severe form of schizophrenia. The frequency increases between 13 and 18 years of age. Boys tend to be affected about twice as often as girls, regardless of ethnic or other cultural factors. The etiology of schizophrenia is unknown. Numerous studies have shown genetic predisposition and linkages for the disorder. In addition, family studies consistently show a higher risk in monozygotic twins compared with dizygotic twins and siblings. First-degree relatives of patients with schizophrenia have a 10-fold higher risk. The symptoms of schizophrenia typically fall into four broad categories: • Positive symptoms include hallucinations and delusions. Hallucinations are auditory or visual misperceptions that occur without external stimuli. Delusions are fixed false


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Pediatrics_Nelson. A. Six or more items from (1), (2), and (3), with at least two from (1) and one each from (2) and (3) 1. Qualitative impairment in social interaction, as manifested by at least two of the following: a. Marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction b. Failure to develop peer relationships appropriate to developmental level c. A lack of spontaneously seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) d. Lack of social or emotional reciprocity 2. Qualitative impairments in communication as manifested by at least one of the following: a. Delay in, or total lack of, the development of spoken language (not accompanied by attempts to compensate through alternative modes of communication, such as gesture or mime) b.


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Pediatrics_Nelson. Delay in, or total lack of, the development of spoken language (not accompanied by attempts to compensate through alternative modes of communication, such as gesture or mime) b. In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others c. Stereotyped and repetitive use of language or idiosyncratic language d. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level 3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: a. Encompassing preoccupation with stereotyped and restricted patterns of interest that is abnormal either in intensity or focus b. Apparently inflexible adherence to specific, nonfunctional routines or rituals c. Stereotyped and repetitive motor mannerisms (e.g., handor finger-flapping or twisting or complex whole body movements) d.


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Pediatrics_Nelson. Stereotyped and repetitive motor mannerisms (e.g., handor finger-flapping or twisting or complex whole body movements) d. Persistent preoccupation with parts of objects B. Delays or abnormal functioning in at least one of the following areas, with onset before age 3 yr 1. 2. Language as used in social communication 3. C. The disturbance is not better accounted for by Rett syndrome or childhood disintegrative disorder. beliefs and can be bizarre or non-bizarre, depending on cultural norms. • Negative symptoms include a lack of motivation and social interactions and flat effect. Negative symptoms are most frequent in early childhood and later adolescence. Children with high IQs often show more positive and fewer negative symptoms than children with low IQs. • Disorganization of thoughts and behavior can cause significant impairment. • Cognitive impairment is common and is perhaps the most disabling feature of schizophrenia, causing marked social and functional impairment.


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Pediatrics_Nelson. • Cognitive impairment is common and is perhaps the most disabling feature of schizophrenia, causing marked social and functional impairment. A. Characteristic symptoms: two of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated) 1. 2. 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. 5. Negative symptoms (i.e., affective flattening, alogia, or avolition) Note: Only one criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts or two or more voices conversing with each other.


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Pediatrics_Nelson. B. Social/occupational dysfunction: for a significant portion of the time since the onset of the disturbance, major areas of functioning, such as work, interpersonal relations, or self-care, are markedly below the level achieved before the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). C. Duration: continuous signs of the disturbance persist for at least 6 months with at least 1 month of symptoms (or less if successfully treated) that meet criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During prodromal or residual periods, signs of disturbance may be manifested by only negative symptoms or symptoms listed in criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).


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Pediatrics_Nelson. D. Schizoaffective and mood disorder exclusion: schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. The disturbance is not due to the direct physiologic effects of a drug abuse, a medication, or a general medical condition. F. If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations also are present for at least 1 month (or less if successfully treated). Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):


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Pediatrics_Nelson. Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms): Episodic with inter-episode residual symptoms (episodes are defined by the reemergence of prominent psychotic symptoms); also specify if: with prominent negative symptoms. Episodic with no inter-episode residual symptoms Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: with prominent negative symptoms. There are five subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. Paranoid type: prominent hallucinations and delusions with relatively normal cognition. The delusions are often persecutory, but other types of delusions also may occur. Disorganized type: disorganized speech, disorganized behavior, and flat or inappropriate affect.


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Pediatrics_Nelson. Disorganized type: disorganized speech, disorganized behavior, and flat or inappropriate affect. Catatonic type: prominent psychomotor abnormalities that may include extreme inactivity or excessive motor activity. Cataplexy (waxy flexibility) is rare in children and adolescents. Undifferentiated type: case in which a patient meets the diagnostic criteria for schizophrenia but not paranoid, disorganized, or catatonic type. Residual type: clinical situation in which full diagnostic criteria have been met previously but no current, prominent, positive symptoms.


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Pediatrics_Nelson. Residual type: clinical situation in which full diagnostic criteria have been met previously but no current, prominent, positive symptoms. To meet criteria for diagnosing schizophrenia, clinical symptoms should be present for at least 6 months. If symptoms are present for less than 1 month, the condition is called a brief psychotic disorder. If symptoms are present for more than 1 month but less than 6 months, a diagnosis of schizophreniform disorder is made. Psychotic symptoms that do not meet full diagnostic criteria for schizophrenia but are clinically significant are diagnosed as psychotic disorder not otherwise specified. There are several disorders that have to be distinguished from schizophrenia. These include the following: Schizoaffective disorder is diagnosed when a person has clear symptoms of schizophrenia for at least 2 weeks without active symptoms of depression or mania. These affective syndromes occur at other times, even when psychotic symptoms are present.


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Pediatrics_Nelson. Major depression with psychotic features and bipolar disorder with psychotic features are diagnoses made when psychotic symptoms occur during the course of depression or mania only. Psychotic disorder due to a general medical condition describes psychotic symptoms that are judged to be the direct result of a general medical condition. Substance-induced psychotic disorders have psychotic symptoms related to drug or alcohol ingestion. Shared psychotic disorder, folie à deux, occurs when delusional symptoms from one person influence delusions, with similar content, in another person. Other disorders in the differential diagnoses are autism, childhood disintegrative disorder (Heller syndrome), Asperger syndrome, drug-induced psychosis, and organic brain disorders.


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Pediatrics_Nelson. No diagnostic tests or imaging studies are specific forschizophrenia. It is a clinical diagnosis of exclusion. Obtaining a family history with attention to mental illness is critical. The workup of schizophrenia includes physical and neurologic examinations, MRI, electroencephalography (torule out epilepsy, especially temporal lobe epilepsy), drugscreening, and metabolic screening for endocrinopathies.Evaluation to rule out Wilson disease and delirium is also indicated. Psychotic symptoms in younger children must bedifferentiated from manifestations of normal vivid fantasylife or abuse-related symptoms. Youth with posttraumatic stress disorder often have vivid recollections and nightmaresrelated to abuse but sometimes are less specific and caninclude nightmares with other negative topics. Psychological testing can be helpful in identifying psychotic thought processes.


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Pediatrics_Nelson. Treatment is based on a multimodal approach, including use of antipsychotic medications. First-line drugs are atypical antipsychotics (e.g., risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, and paliperidone). Second-line medications are typical antipsychotics (e.g., haloperidol, thiothixene, chlorpromazine, trifluoperazine, loxapine, and molindone). It is likely that the newer antipsychotics approved for adults will also work in youth. However, these are not yet approved in youth by the U.S. Food and Drug Administration. Anti-psychotics can be augmented with lithium or another mood stabilizer. Clozapine or electroconvulsive therapy is generally reserved for resistant cases.


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Pediatrics_Nelson. Psychosocial treatments, including skills training, supportive psychotherapy, behavior modification, and cognitive-behavioral therapy, are all appropriate and should be considered as needed for individual patients. Attention should be paid to psychoeducation for parents and the child about the disease and its treatments. School interventions are needed to ensure that any special learning needs are addressed. The course of illness for schizophrenia varies in exacerbations and remissions of psychotic symptoms. The poorest prognosis is seen if the onset is at an age younger than 13 years, with poor premorbid function, when marked negative symptoms are present, and when a family history of schizophrenia exists. American Psychiatric Association (APA): Practice guideline for the treatment of patients with panic disorder, ed 2, Washing ton (DC), 2009 Jan, American Psychiatric Association (APA).


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Pediatrics_Nelson. American Psychiatric Association (APA): Practice guideline for the treatment of patients with panic disorder, ed 2, Washing ton (DC), 2009 Jan, American Psychiatric Association (APA). Available from the PsychiatryOnline website. Available at http://psychiatryonline.org/content.aspx?bookid=28§ionid=1680635 Hagerman RJ, Berry-Kravis E, Kaufmann WE, et al: Advances in the treat ment of fragile X syndrome, Pediatrics 123(1):378–390, 2009 Huyser C, Veltman DJ, de Haan E, et al: Paediatric obsessive-compulsive disorder, a neurodevelopmental disorder? Evidence from neuroimaging, Neurosci Biobehav Rev. 33(6):818–830, 2009 Ibeziako PI, Shaw J, DeMaso DR: Psychosomatic illness. In Kliegman RM, Stanton BF, St. Geme J, et al: Nelson Textbook of Pediatrics, 20, ed 19, Philadelphia, 2011, Elsevier, pp 67–69 Ponniah K, Hollon SD: Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review, Depress Anxiety 26(12):1086–1109, 2009


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Pediatrics_Nelson. Ponniah K, Hollon SD: Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review, Depress Anxiety 26(12):1086–1109, 2009 Shattuck PT, Durkin M, Maenner M, et al: Timing of identification among children with an autism spectrum disorder: findings from a popu lation-based surveillance study, J Am Acad Child Adolesc Psychiatry 48(5):474–483, 2009 Silber TJ: Somatization disorders: diagnosis, treatment, and prognosis, Pedi atr Rev 32(2):56–63, 2011 quiz 63−64 Cindy W. Christian and Nathan J. Blum 5


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Pediatrics_Nelson. Silber TJ: Somatization disorders: diagnosis, treatment, and prognosis, Pedi atr Rev 32(2):56–63, 2011 quiz 63−64 Cindy W. Christian and Nathan J. Blum 5 Failure to thrive (FTT) is a descriptive term given to malnourished infants and young children who fail to meet expected standards of growth. FTT is most often used to describe malnutrition related to environmental or psychosocial causes. In many children with inadequate growth, however, organic and environmental contributors coexist, underscoring the importance of assessing potential medical, nutritional, developmental, psychosocial, and environmental contributors in all cases.


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Pediatrics_Nelson. FTT is often diagnosed by weight that falls or remains below the 3rd percentile for age; decreases, crossing two major percentile lines on the growth chart over time; or is less than 80% of the median weight for the height of the child. Caveats to these definitions exist. According to growth chart standards, 3% of the population naturally falls below the 3rd percentile. These children, who typically have short stature or constitutional delay of growth, usually are proportional (normal weight for height). Additionally in the first few years of life, large fluctuations in percentile position can occur in normal children. Changes in weight should be assessed in relation to height (length) and head circumference.


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Pediatrics_Nelson. Weight that decreases from a disproportionately high percentile to one that is proportional causes no concern, but weight that decreases to a disproportionately low percentile is of concern. Allowances must be made for prematurity; weight corrections are needed until 24 months of age, height corrections until 40 months of age, and head circumference corrections until 18 months of age. Although some growth variants can be difficult to distinguish from FTT, growth velocity and height-for-weight determinations can be useful in distinguishing the cause. In children with FTT, malnutrition initially results in wasting (deficiency in weight gain). Stunting (deficiency in linear growth) generally occurs after months of malnutrition, and head circumference is spared except with chronic, severe malnutrition. FTT that is symmetric (proportional weight, height/length, and head circumference) suggests long-standing malnutrition, chromosomal abnormalities, congenital infection, or teratogenic


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Pediatrics_Nelson. malnutrition. FTT that is symmetric (proportional weight, height/length, and head circumference) suggests long-standing malnutrition, chromosomal abnormalities, congenital infection, or teratogenic exposures. FTT is a common problem in pediatrics, affecting 5% to 10% of young children, 3% to 5% of children admitted to hospitals, and 15% of children living in poverty and foster care.


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Pediatrics_Nelson. Because possible causes of growth failure are diverse and oftenmultifactorial, the management of FTT begins with a carefulsearch for its etiology (Table 21-1). The common causes ofFTT vary by age, which should be reflected in the evaluation(Table 21-2). In most cases, a comprehensive history and physical examination are sufficient to suggest or eliminate medicaldisease as the primary cause of FTT. Medical diseases are diagnosed in fewer than 50% of children hospitalized for growthfailure and even less frequently in children managed in the outpatient setting. Growth failure is often a manifestation of moreextensive family problems. It is clinically useful to categorize thecauses of malnutrition into inadequate nutritional intake, inadequate nutrient absorption, or increased metabolic demand. Available @ StudentConsult.com Failure to Thrive


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Pediatrics_Nelson. A medical history should include prenatal history prematurity, birth size (weight, length, and head circumference), as well as family and travel history. Indicators of medical diseases, such as vomiting, diarrhea, fever, respiratory symptoms, and fatigue, should be noted. A careful diet history is essential. Lactation problems in breastfed infants and improper formula preparation are frequent causes of growth failure early in infancy. It is crucial to evaluate intake of solid foods and liquids for older infants and children. Due to parental dietary beliefs, some children have inappropriately restricted diets; others drink excessive amounts of fruit juice, leading to malabsorption or anorexia. The child’s daily meal schedule (timing, frequency, location) should also be noted. Mealtime practices, especially distractions that interfere with completing meals, can influence growth. A complete psychosocial assessment of the child and family is required. Child factors (temperament,


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Pediatrics_Nelson. practices, especially distractions that interfere with completing meals, can influence growth. A complete psychosocial assessment of the child and family is required. Child factors (temperament, development), parental factors (depression, domestic violence, social isolation, mental retardation, substance abuse), and environmental and societal factors (poverty, unemployment, illiteracy, lead toxicity) all may contribute to growth failure.


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Pediatrics_Nelson. A complete physical examination and developmental screening should assess signs of inflicted injury; oral or dental problems; indicators of pulmonary, cardiac, or gastrointestinal Cystic fibrosis and other causes of pancreatic insufficiency Celiac disease Other malabsorption syndromes Gastrointestinal reflux Chromosomal abnormalities, genetic syndromes Congenital heart disease Gastrointestinal abnormalities (e.g., pyloric stenosis, malrotation) Vascular rings Upper airway obstruction Dental caries Congenital immunodeficiency syndromes Human immunodeficiency virus Tuberculosis Hepatitis Urinary tract infection, chronic sinusitis, parasitic infection Thyroid disease Adrenal or pituitary disease Aminoaciduria, organic aciduria Galactosemia


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Pediatrics_Nelson. Thyroid disease Adrenal or pituitary disease Aminoaciduria, organic aciduria Galactosemia Celiac disease Food intolerance Child neglect Delayed introduction of age-appropriate foods Juice consumption disease; and dysmorphic features that may suggest a genetic or teratogenic cause for growth failure. A complete neurologic examination may reveal spasticity or hypotonia, which can have untoward effects on feeding and growth. Physical findings related to malnutrition include decreased subcutaneous fat, decreased muscle mass, dermatitis, hepatomegaly, cheilosis, or edema (see Chapter 30). Additionally children with FTT have more otitis media, respiratory, and gastrointestinal infections than age-matched controls; severely malnourished children are at risk for a variety of serious infections.


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Pediatrics_Nelson. The history and physical examination findings should guidethe laboratory evaluation. Simple screening tests are recommended to identify common illnesses that cause growth failureand to search for medical problems resulting from malnutrition. Initial tests may include a complete blood count; screening for iron deficiency anemia and lead toxicity; urinalysis,urine culture, and serum electrolytes to assess renal infection ordysfunction; thyroid stimulating hormone; liver function tests;and a protein purified derivative test to screen for tuberculosis.Human immunodeficiency virus testing may also be indicated.For children with diarrhea, abdominal pain, or malodorousstools, a stool sample for culture and ova and parasites may be indicated. A review of the child’s newborn screen may also bewarranted. Observation during feeding and home visitation, ifpossible, is of great diagnostic value in assessing feeding problems, food preferences, mealtime distractions, unusual or disruptive


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Pediatrics_Nelson. bewarranted. Observation during feeding and home visitation, ifpossible, is of great diagnostic value in assessing feeding problems, food preferences, mealtime distractions, unusual or disruptive parent-child interactions, and the home environment.


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Pediatrics_Nelson. Treatment must address the child’s nutritional requirementsand the social issues of the family. Initial treatment should focuson the nutritional and medical management of the child whileengaging the family in the treatment plan. Parents of malnourished children may feel personally responsible and threatenedby the diagnosis of FTT. Parents may be so depressed or dysfunctional they cannot focus on their child’s needs; they maynot recognize the psychosocial and family contributors to themalnutrition. These issues can have a profound effect on thesuccess of treatment, and they need to be addressed.


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Pediatrics_Nelson. Children with mild malnutrition whose cause is easily identified can be managed by the primary care physician and family. In more challenging cases, a multidisciplinary team, including pediatricians, nutritionists, developmental specialists, nurses, and social workers, improves nutritional outcome in children with FTT. Most children with FTT can be treated in the outpatient setting. Children with severe malnutrition, underlying diagnoses that require hospitalization for evaluation or treatment, or whose safety is in jeopardy because of maltreatment require hospitalization. Admitting children to the hospital to induce and document weight gain is not recommended unless intensive outpatient evaluation and intervention has failed or the social circumstances are a contraindication for attempting outpatient management.


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Pediatrics_Nelson. Nutritional management is the cornerstone of treatment, regardless of the etiology. Children with FTT may require more than 1.5 times the expected calorie and protein intake for their age for catch-up growth. Children with FTT who are anorexic and picky eaters may not be able to consume this amount in volume and require calorically dense foods. For formula-fed infants, the concentration of formula can be adjusted appropriately (Table 21-3). For toddlers dietary changes should include increasing the caloric density of favorite foods by adding butter, oil, sour cream, peanut butter, or other high-calorie foods. High-calorie oral supplements (30 cal/oz) are often well tolerated by toddlers. In some cases, specific carbohydrate, fat, or protein additives are used to boost calories by increasing calories without increasing volume requirements. Additionally vitamin and mineral supplementation is needed, especially during catch-up growth. In general the simplest and least costly approach to


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Pediatrics_Nelson. calories without increasing volume requirements. Additionally vitamin and mineral supplementation is needed, especially during catch-up growth. In general the simplest and least costly approach to dietary change is warranted.


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Pediatrics_Nelson. Depending on the severity of the malnutrition, initiation of catch-up growth may take 2 weeks. Initial weight gain two to three times normal growth can be seen. Weight improvement precedes improvement in stature. For children with chronic, severe malnutrition, many months are needed to reverse all trends in growth. Although many children with FTT eventually reach normal size, they remain at risk for developmental, learning, and behavioral problems. Malnutrition causes defects in host defenses. Children with FTT may suffer from a malnutrition-infection cycle, in which 5.5 scoops powdered formula 8 27 kcal/oz 13 oz liquid concentrate 6 27 kcal/oz From Jew R, editor: Department of Pharmacy Services Pharmacy Handbook and Formulary, 2000–2001. Hudson, Ohio, 2000, Department of Pharmacy Services, p 422. *Final concentrations are reached by adding formula to water. One scoop of powdered formula = one measuring tablespoon. For healthy infants, formulas are prepared to provide 20 kcal/oz.


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Pediatrics_Nelson. recurrent infections exacerbate malnutrition, leading to greatersusceptibility to infection. Children with FTT must be evaluated and treated promptly for infection and followed closely.


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Pediatrics_Nelson. During starvation, the body slows metabolic processes and growth to minimize the need for nutrients and uses its stores of glycogen, fat, and protein to maintain normal metabolic requirements. The body also generally maintains homeostasis and normal serum concentrations of electrolytes. With the rapid reinstitution of feeding after starvation, fluid and electrolyte homeostasis may be lost. Changes in serum electrolyte concentrations and the associated complications are collectively termed the refeeding syndrome. These changes typically affect phosphorus, potassium, calcium, and magnesium and can result in life-threatening cardiac, pulmonary, or neurologic problems. Infants and children with marasmus, kwashiorkor, and anorexia nervosa and those who have had prolonged fasting are at risk for refeeding syndrome. Refeeding syndrome can be avoided by slow institution of nutrition, close monitoring of serum electrolytes during the initial days of feeding, and prompt replacement of depleted


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Pediatrics_Nelson. refeeding syndrome. Refeeding syndrome can be avoided by slow institution of nutrition, close monitoring of serum electrolytes during the initial days of feeding, and prompt replacement of depleted electrolytes.


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Pediatrics_Nelson. Occasionally children who live in psychological deprivation develop short stature with or without concomitant FTT or delayed puberty, a syndrome called psychosocial short stature. The signs and symptoms include polyphagia, polydipsia, hoarding and stealing of food, gorging and vomiting, drinking from toilet bowls, and other notable behaviors. Affected children are often shy and passive and are typically depressed and socially withdrawn. Endocrine dysfunction is often identified in affected children, who may have decreased growth hormone secretion and a muted response to exogenous growth hormone. Removal of the child from the adverse environment typically results in rapid improvement in endocrine function and subsequent rapid somatic and pubertal growth of the child. The prognosis for children with psychosocial short stature depends on the age at diagnosis and the degree of psychological trauma. Early identification and removal from the environment portends a healthy prognosis. Those


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Pediatrics_Nelson. with psychosocial short stature depends on the age at diagnosis and the degree of psychological trauma. Early identification and removal from the environment portends a healthy prognosis. Those diagnosed in later childhood or adolescence may not reach their genetic potential for growth and have a poorer psychosocial prognosis.


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Pediatrics_Nelson. Few social problems have as profound an impact on the well-being of children as child abuse and neglect. Each year in the United States, 3 million reports of suspected maltreatment are made to child welfare agencies. Approximately 1 million of these reports are substantiated after investigation by Child Protective Services (CPS). These reports represent only a small portion of the children who suffer from maltreatment. Parental surveys indicate that several million adults admit to physical violence against their children each year, and many more adults report abusive experiences as children. Federal and state laws define child abuse and neglect. Each state determines the process of investigating abuse, protecting children, and holding perpetrators accountable for their actions or inactions. Adverse childhood events, such as child abuse and neglect, increase the risk of the individual’s developing behaviors in adolescence and adulthood that predict adult morbidity and early mortality.


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Pediatrics_Nelson. Adverse childhood events, such as child abuse and neglect, increase the risk of the individual’s developing behaviors in adolescence and adulthood that predict adult morbidity and early mortality. The ability to recognize child maltreatment and effectively advocate for the protection and safety of a child is a great challenge in pediatric practice that can have a profound influence on the health and future well-being of a child.


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Pediatrics_Nelson. Child abuse is parental behavior destructive to the normal physical or emotional development of a child. Because personal definitions of abuse vary according to religious and cultural beliefs, individual experiences, and family upbringing, various physicians have different thresholds for reporting suspected abuse to CPS. In every state, physicians are mandated by law to identify and report all cases of suspected child abuse and neglect. It is the responsibility of CPS to investigate reports of suspected abuse to ensure the ongoing safety of the child. State laws also define intentional or reckless acts that cause harm to a child as crimes. Law enforcement investigates crimes such as sexual abuse and serious physical abuse or neglect for possible criminal charges against a perpetrator.


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Pediatrics_Nelson. Child abuse and neglect are often considered in broad categories that include physical abuse, sexual abuse, emotional abuse, and neglect. Neglect is the most common, accounting for approximately half of the reports made to child welfare agencies. Child neglect is defined by omissions that prevent a child’s basic needs from being met. These needs include adequate food, clothing, supervision, housing, health care, education, and nurturance. Child abuse and neglect result from a complex interaction of individual, family, and societal risk factors. Although some risk factors, such as parental substance abuse, maternal depression, and domestic violence, are strong risk factors for maltreatment, they are better considered as broadly defined markers to alert a physician to a potential risk, rather than determinants of specific abuse and neglect.


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Pediatrics_Nelson. The ability to identify victims of child abuse varies by the ageof the patient and the type of maltreatment sustained. Childrenwho are victims of sexual abuse are often brought for medical care after the child makes a disclosure, and the diagnosis isstraightforward. Physically abused infants may be brought for medical evaluation of irritability or lethargy, without a disclosure of trauma. If the infant’s injuries are not severe or visible, the diagnosis may be missed. Approximately one third of infantswith abusive head trauma initially are misdiagnosed by unsuspecting physicians, only to be identified after sustaining furtherinjury. Although physicians are inherently trusting of parents, aconstant awareness of the possibility of abuse is needed. Available @ StudentConsult.com


Pediatrics_Nelson

Pediatrics_Nelson. The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that approximately 1500 children are fatally injured each year. Although mothers are most frequently reported as the perpetrators of physical abuse, serious injuries, such as head or abdominal trauma, are more likely to be inflicted by fathers or maternal boyfriends. The diagnosis of physical abuse can be made easily if the child is battered, has obvious external injuries, or is capable of providing a history of the abuse. In many cases, the diagnosis is not obvious. The history provided by the parent is often inaccurate because the parent is unwilling to provide the correct history or is a nonoffending parent who is unaware of the abuse. The child may be too young or ill to provide a history of the assault. An older child may be too scared to do so or may have a strong sense of loyalty to the perpetrator.


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Pediatrics_Nelson. A diagnosis of physical abuse initially is suggested by a history that seems incongruent with the clinical presentation ofthe child (Table 22-1). Although injury to any organ systemcan occur from physical abuse, some injuries are more common. Bruises are universal findings in healthy ambulatorychildren but also are among the most common injury identified in abused children. Bruises suggestive of abuse includethose that are patterned, such as a slap mark on the face orlooped extension cord marks on the body (Fig. 22-1). Bruises A child presents for medical care with significant injuries, and a history of trauma is denied, especially if the child is an infant or toddler. The history provided by the caregiver does not explain the injuries identified. The history of the injury changes significantly over time. A history of self-inflicted trauma does not correlate with the child’s developmental abilities. There is an unexpected or unexplained delay in seeking medical care.


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Pediatrics_Nelson. A history of self-inflicted trauma does not correlate with the child’s developmental abilities. There is an unexpected or unexplained delay in seeking medical care. Multiple organ systems are injured, including injuries of various ages. The injuries are pathognomonic for child abuse. Figure 22-3 A, Metaphyseal fracture of the distal tibia in a 3-month-old infant admitted to the hospital with severe head injury. There also is periosteal new bone formation of that tibia, perhaps from a previous injury. B, Bone scan of same infant. Initial chest x-ray showed a single fracture of the right posterior fourth rib. A radionuclide bone scan performed 2 days later revealed multiple previously unrecognized fractures of the posterior and lateral ribs. C, Follow-up radiographs 2 weeks later showed multiple healing rib fractures. This pattern of fracture is highly specific for child abuse. The mechanism of these injuries is usually violent squeezing of the chest.


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Pediatrics_Nelson. in healthy children generally are distributed over bony prominences; bruises that occur in an unusual distribution, such as isolated to the torso, ears or neck, should raise concern. Bruises in nonambulatory infants are unusual, occurring inless than 2% of healthy infants seen for routine medical care.Occasionally a subtle bruise may be the only external clue toabuse and can be associated with significant internal injury. Burns are common pediatric injuries and usually represent preventable unintentional trauma (see Chapter 44). Approximately 10% of children hospitalized with burns are victims of abuse. Inflicted burns can be the result of contact with hot objects (irons, radiators, or cigarettes) but more commonly the result of scalding injuries (Fig. 22-2). Hot tap water burns in infants and toddlers are sometimes the result of intentional immersion injuries, which often occur around toilet training


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Pediatrics_Nelson. Figure 22-1 Multiple looped cord marks on a 2-year-old abused child who presented to the hospital with multiple untreated burns to the back, arms, and feet. issues. These burns have clear lines of demarcation, uniformity of burn depth, and characteristic pattern. Inflicted fractures occur more commonly in infants and young children. Although diaphyseal fractures are most common in abuse, they are nonspecific for inflicted injury. Fractures that should raise suspicion for abuse include fractures that are unexplained; occur in young, nonambulatory children; or involve multiple bones. Certain fractures have a high specificity for abuse, such as rib, metaphyseal, scapular, vertebral, or other unusual fractures (Fig. 22-3). Some metabolic diseases can be confused with abuse and should be considered in the differential diagnosis when appropriate.


Pediatrics_Nelson

Pediatrics_Nelson. Abdominal injury is an uncommon but serious form of physical abuse. Blunt trauma to the abdomen is the primary mechanism of injury, and infants and toddlers are the most common victims. Injuries to solid organs, such as the liver or pancreas, predominate and hollow viscus injury occurs more commonly with inflicted trauma than accidental. Even Figure 22-2 A 1-year-old child brought to the hospital with a history that she sat on a hot radiator. Suspicious injuries such as this require a full medical and social investigation, including a skeletal survey to look for occult skeletal injuries and a child welfare evaluation. Figure 22-4 Acute subdural hemorrhage in the posterior interhemi-spheric fissure in an abused infant.


Pediatrics_Nelson

Pediatrics_Nelson. Figure 22-4 Acute subdural hemorrhage in the posterior interhemi-spheric fissure in an abused infant. in severe cases of trauma, there may be no bruising to the abdominal wall. The lack of external trauma, along with the usual inaccurate history, can cause delay in diagnosis. A careful evaluation often reveals additional injuries. Abdominal trauma is the second leading cause of mortality from physical abuse, although the prognosis is generally good for children who survive the acute assault.


Pediatrics_Nelson

Pediatrics_Nelson. Abusive head trauma is the leading cause of mortality and morbidity from physical abuse. Most victims are young; infants predominate. Shaking and blunt impact trauma cause injuries. The perpetrators are most commonly fathers and boyfriends, and the trauma typically is precipitated by the perpetrator’s intolerance to a crying, fussy infant. Victims present with neurologic symptoms ranging from lethargy and irritability to seizures, apnea, and coma. Unsuspecting physicians misdiagnose approximately one third of infants, and of these, more than 25% are reinjured before diagnosis. A common finding on presentation is subdural hemorrhage, often associated with progressive cerebral edema (Fig. 22-4). Hypoxic-ischemic injury is a significant contributor to the pathophysiology of the brain injury. Associated findings include retinal hemorrhages (seen in many, but not all, victims) and skeletal trauma, including rib and classic metaphyseal fractures. At the time of diagnosis, many head-injured


Pediatrics_Nelson

Pediatrics_Nelson. Associated findings include retinal hemorrhages (seen in many, but not all, victims) and skeletal trauma, including rib and classic metaphyseal fractures. At the time of diagnosis, many head-injured infants have evidence of previous injury. Survivors are at high risk for permanent neurologic sequelae.


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Pediatrics_Nelson. The extensive differential diagnosis of physical abuse depends on the type of injury (Table 22-2). For children who present with pathognomonic injuries to multiple organ systems, an exhaustive search for medical diagnoses is unwarranted. Children with unusual medical diseases have been incorrectly diagnosed as victims of abuse, emphasizing the need for careful, objective assessments of all children. All infants and young toddlers who present with suspicious Genetic diseases Ehlers-Danlos syndrome Familial dysautonomia (with congenital indifference to pain) Vasculitis Henoch-Schönlein purpura Dermatologic Phytophotodermatitis Stevens-Johnson syndrome Fixed drug eruption Epidermolysis bullosa Severe diaper dermatitis, including Ex-Lax ingestion Hematologic disorders Vitamin K deficiency (hemorrhagic disease of the newborn) Hemophilia Glutaric aciduria type I, Menkes kinky hair syndrome


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Pediatrics_Nelson. Hematologic disorders Vitamin K deficiency (hemorrhagic disease of the newborn) Hemophilia Glutaric aciduria type I, Menkes kinky hair syndrome From Christian CW: Child abuse physical. In Schwartz MW, editor: The 5-minute Pediatric Consult, ed 3, Philadelphia, 2003, Lippincott Williams & Wilkins. *The differential diagnosis of physical abuse varies by the type of injury and organ system involved. injuries should undergo a skeletal survey looking for occult or healing fractures. One third of young infants with multiple fractures, facial injuries, or rib fractures may have occult head trauma. Brain imaging may be indicated for these infants.


Pediatrics_Nelson

Pediatrics_Nelson. Child sexual abuse is the involvement of children in sexual activities that they cannot understand, for which they are developmentally unprepared and cannot give consent to, and that violates societal taboos. Sexual abuse can be a single event, but more commonly it is chronic. Most perpetrators are adults or adolescents who are known to the child and who have real or perceived power over the child. Most sexual abuse involves manipulation and coercion and does not involve physical violence. Although assaults by strangers occur, they are infrequent. Perpetrators are more often male than female and include parents, relatives, teachers, family friends, members of the clergy, and other individuals who have access to children. All perpetrators strive to keep the child from disclosing the abuse and often do so with coercion or threats.


Pediatrics_Nelson

Pediatrics_Nelson. Approximately 80% of victims are girls, although the sexual abuse of boys is underrecognized and underreported. Children generally come to attention after they have made a disclosure of their abuse. They may disclose to a nonoffending parent, sibling, relative, friend, or teacher. Children commonly delay disclosure for many weeks, months, or years after their abuse, especially if the perpetrator has ongoing access to the child. Sexual abuse also should be considered in children who have behavioral problems, although no behavior is pathognomonic. Hypersexual behaviors should raise the possibility of abuse, although some children with these behaviors are exposed to inappropriate sexual behaviors on television or videos or by witnessing adult sexual activity. Sexual abuse occasionally is recognized by the discovery of an unexplained vaginal, penile, or anal injury or by the discovery of a sexually transmitted infection.


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Pediatrics_Nelson. In most cases, the diagnosis of sexual abuse is made by the history obtained from the child. In cases in which the sexual abuse has been reported to CPS or the police (or both), and the child has been interviewed before the medical visit, a complete, forensic interview at the physician’s office is not needed. Many communities have systems in place to ensure quality investigative interviews of sexually abused children. However if no other professional has spoken to the child about the abuse, or the child makes a spontaneous disclosure to the physician, the child should be interviewed with questions that are open-ended and non-leading. In all cases, the child should be questioned about medical issues related to the abuse, such as timing of the assault and symptoms (bleeding, discharge, or genital pain).


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Pediatrics_Nelson. The physical examination should be complete, with careful inspection of the genitals and anus. Most sexually abused children have a normal genital examination at the time of the medical evaluation. Genital injuries are seen more commonly in children who present for medical care within 72 hours of their most recent assault and in children who report genital bleeding, but they are diagnosed in only 5% to 10% of sexually abused children. Many types of sexual abuse (fondling, vulvar coitus, oral genital contact) do not injure genital tissue, and genital mucosa heals so rapidly and completely that injuries often heal by the time of the medical examination. For children who present within 72 hours of the most recent assault, special attention should be given to identifying acute injury and the presence of blood or semen on the child. Injuries to the oral mucosa, breasts, or thighs should not be overlooked. Forensic evidence collection is needed in a few cases and has the greatest yield when


Pediatrics_Nelson

Pediatrics_Nelson. of blood or semen on the child. Injuries to the oral mucosa, breasts, or thighs should not be overlooked. Forensic evidence collection is needed in a few cases and has the greatest yield when collected in the first 24 hours after an acute assault. Few findings are diagnostic of sexual assault, but findings with the most specificity include acute, unexplained lacerations or ecchymoses of the hymen, posterior fourchette or anus, complete transection of the hymen, unexplained anogenital scarring, or pregnancy in an adolescent with no other history of sexual activity.


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Pediatrics_Nelson. The laboratory evaluation of a sexually abused child is dictated by the child’s age, history, and symptoms. Universalscreening for sexually transmitted infections for prepubertalchildren is unnecessary because the risk of infection is lowin asymptomatic young children. The type of assault, identityand known medical history of the perpetrator, and the epidemiology of sexually transmitted infections in the communityalso are considered. Many clinicians use nucleic acid amplification testing to screen for sexually transmitted infectionsin sexually abused children because these tests have excellentsensitivity while maintaining good specificity for STIs in children and adolescents. The diagnosis of most sexually transmitted infections in young children requires an investigationfor sexual abuse (see Chapter 116).


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Pediatrics_Nelson. The management of child abuse includes medical treatment for injuries and infections, careful medical documentation of verbal statements and findings, andongoing advocacy for the safety and health of the child(Fig. 22-5). Parents always should be informed of thesuspicion of abuse and the need to report to CPS, focusing on the need to ensure the safety and well-beingof the child. Crimes that are committed against childrenalso are investigated by law enforcement, so the policebecome involved in some, but not all, cases of suspectedabuse. Physicians occasionally are called to testify in courthearings regarding civil issues, such as dependency and custody, or criminal issues. Careful review of the medicalrecords and preparation for court are needed to provide aneducated, unbiased account of the child’s medical condition and diagnoses.


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Pediatrics_Nelson. The prevention of child maltreatment is a great challenge.There are a few partially successful primary prevention programs. Visiting home nursing programs that begin during pregnancy and continue through early childhood may reducethe risk of abuse and neglect. Physician training in screening for risk factors in parents has shown to be supportive offamilies and reduce child maltreatment in some populations.Ultimately physicians always need to remain cognizant of thediagnosis, aware of their professional mandates, and willingto advocate on behalf of these vulnerable patients. Is there a history of trauma? Is the mechanism accidental? Are the injuries diagnostic of abuse? Does the child have injuries? Is history consistent Yes Yes NoNo with injuries? Can caregiver provide adequate accidental mechanism? Is there an unexplained delay in seeking medical care? Consider reporting (see B) Confirmed by workup? Do other medical conditions explain findings?


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Pediatrics_Nelson. Yes No Was the child injured by a parent or caregiver? Report to Child Protective Services Report to police No reporting needed Did the child sustain serious injury or illness as a result of abuse or neglect? Did the child sustain serious injury or illness as a result of abuse or neglect? NoYes Yes No Report to police No further reporting needed Figure 22-5 A, Approach to initiating the civil and criminal investigation of suspected abuse. B, Reporting to Child Protective Services (CPS) or law enforcement or both in child abuse cases. CPS reports are required when a child is injured by a parent, by an adult acting as a parent, or by a caregiver of the child. The police investigate crimes against children committed by any person, including parents or other caregivers. (From Christian CW: Child abuse. In Schwartz MW, editor: Clinical Handbook of Pediatrics, ed 3, Baltimore, 2003, Lippincott Williams & Wilkins, pp 192−193.)


Pediatrics_Nelson

Pediatrics_Nelson. The development of sexuality occurs throughout a child’s life. Sexuality includes gender roles, gender identity, sexual orientation, and sexual behaviors. It is influenced by biologic and social factors and individual experience. Pediatricians are likely to be consulted if parents have a concern about their child’s sexual development. A pediatrician who provides an open and nonjudgmental environment may be a valuable resource for an adolescent with questions about heterosexual behaviors, homosexuality, or gender identity (Table 23-1).


Pediatrics_Nelson

Pediatrics_Nelson. Sexual behaviors occur throughout childhood. Early in life, male infants can have erections and female infants are capable of vaginal lubrication. During the preschool period, masturbation occurs in both sexes. Between 2 and 3 years of age, children identify themselves as a boy or a girl, but the understanding that one is always a male or always a female may not develop until 4 to 5 years of age. Stating that one wants to be a member of the opposite sex and pretending to be a member of the opposite sex are not unusual behaviors in this age group. Preschool children need to begin to learn that genitals and sexual behaviors are private; it is common for preschool children to touch their genitals in public, show their genitals to others, or undress in public. It would be highly unusual for a preschool child to imitate intercourse or other adult sexual behaviors. If this behavior is occurring, the child should be evaluated for exposure to inappropriate sexual material and possible sexual


Pediatrics_Nelson

Pediatrics_Nelson. preschool child to imitate intercourse or other adult sexual behaviors. If this behavior is occurring, the child should be evaluated for exposure to inappropriate sexual material and possible sexual abuse (see Chapter 22).


Pediatrics_Nelson

Pediatrics_Nelson. Most elementary school–age children show a strong and consistent gender identity, and their behaviors (gender roles) reflect this. If a child this age is engaging in cross sex gender role behaviors, parents may be concerned about teasing and the possibilityof their child having a homosexual sexual orientation. This concern is particularly likely if a boy is engaged in effeminate behaviors that are generally viewed as less socially acceptable than a


Pediatrics_Nelson

Pediatrics_Nelson. Gender identity Perception of oneself as male or female Gender role Behaviors and appearance that signal to others of being male or female Heterosexual Sexual attraction to members of the opposite sex with weak attraction to members of the same sex Homosexual Sexual attraction to members of the same sex with weak attraction to members of the opposite sex girl acting as a “tomboy.” By this age, dressing as a member of theopposite sex and, particularly, stating a desire to be the oppositesex are uncommon, but playing with toys designed for the opposite sex remains common. In assessing parental concerns aboutatypical gender role behaviors, the type of behavior exhibitedand its consistency should be considered. Reassurance that thebehavior is consistent with typical development is appropriatewhen these behaviors are part of a flexible repertoire of male andfemale gender role behaviors. Reassurance is appropriate if thebehaviors occur in response to a stress, such as the birth of an infant


Pediatrics_Nelson

Pediatrics_Nelson. these behaviors are part of a flexible repertoire of male andfemale gender role behaviors. Reassurance is appropriate if thebehaviors occur in response to a stress, such as the birth of an infant of the opposite sex or divorce of the parents. In contrastif these behaviors occur as a consistent and persistent pattern ofnearly exclusive interest in behaviors typical of the gender roleopposite that of the child’s anatomic sex, referral for evaluationfor gender identity disorder (GID) would be appropriate.


Pediatrics_Nelson

Pediatrics_Nelson. The biologic, social, and cognitive changes during adolescence place a focus on sexuality. Becoming comfortable with one’s sexuality is one of the principal developmental tasks of this period and is likely to include questioning and experimentation. Almost half of high school students report that they have had sexual intercourse. Ten to 25% have at least one homosexual experience, with this behavior being reported more commonly by boys than girls. Although many adolescents have sexual experiences with a same-sex partner, only a few have a homosexual sexual orientation by late adolescence. When adolescents develop a consistent sexual orientation is probably affected by many different factors (societal, family, individual). Some adolescents report that they are certain of their sexual orientation in the early teenage years, whereas for others this does not develop until later. By 18 years of age, only a small proportion of individuals report being uncertain of their sexual orientation.