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Pediatrics_Nelson. should become familiar with the governing law in the state where they practice (see www.guttmacher.org/statecenter/updates/index.html ). Providing confidentiality is crucial, allowing for optimal care(especially for obtaining a history of risk behaviors). Whenassessing development and behavior, confidentiality can beachieved by meeting with the adolescent alone for at least part of each visit. However parents must be informed whenthe clinician has significant and immediate concerns aboutthe health and safety of the child. Often the clinician canconvince the adolescent to inform the parents directly abouta problem or can reach an agreement with the adolescentabout how the parents will be informed by the physician (seeChapter 67).


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Pediatrics_Nelson. Responses to open-ended questions often provide clues to underlying, unstated problems and identify the appropriate direction for further, more directed questions. Histories about developmental and behavioral problems are often vague and confusing; to reconcile apparent contradictions, the interviewer frequently must request clarification, more detail, or mere repetition. By summarizing an understanding of the information at frequent intervals and by recapitulating at the close of the visit, the interviewer and patient and family can ensure that they understand each other.


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Pediatrics_Nelson. If the clinician’s impression of the child differs markedlyfrom the parent’s description, there may be a crucial parental concern or issue that has not yet been expressed, eitherbecause it may be difficult to talk about (e.g., marital problems), because it is unconscious, or because the parent overlooks its relevance to the child’s behavior. Alternatively thephysician’s observations may be atypical, even with multiplevisits. The observations of teachers, relatives, and other regular caregivers may be crucial in sorting out this possibility. The parent also may have a distorted image of the child,rooted in parental psychopathology. A sensitive, supportive,and noncritical approach to the parent is crucial to appropriate intervention. More information about referral and intervention for behavioral and developmental issues is covered inChapter 10.


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Pediatrics_Nelson. Health maintenance or supervision visits should consist of a comprehensive assessment of the child’s health and of theparent’s/guardian’s role in providing an environment for optimalgrowth, development, and health. Bright Futures standardizeseach of the health maintenance visits and provides resourcesfor working with the children and families of different ages(see www.brightfutures.aap.org ). Elements of each visit includeevaluation and management of parental concerns; inquiryabout any interval illness since the last physical, growth, development, and nutrition; anticipatory guidance (including safetyinformation and counseling); physical examination; screening tests; and immunizations (Table 9-1). The Bright Futures’“Recommendations for Preventive Pediatric Health Care,” found at http://brightfutures.aap.org/clinical_practice.html , summarizes requirements and indicates the ages that specificprevention measures should be undertaken, including riskscreening and performance items for


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Pediatrics_Nelson. , summarizes requirements and indicates the ages that specificprevention measures should be undertaken, including riskscreening and performance items for specific measurements.Bright Futures is now the enforced standard for the Medicaid


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Pediatrics_Nelson. Concerns (parent’s or child’s) Past problem follow-up Immunization and screening test update Routine care (e.g., eating, sleeping, elimination, and health habits) Developmental progress Behavioral style and problems Caregiving schedule for caregiver who lives at home Parent-child and sibling-child interactions Extended family role Family stresses (e.g., work, move, finances, illness, death, marital and other interpersonal relationships) Family supports (relatives, friends, groups) Caregivers outside of the family Peer interaction School and work Recreational activities and the Children’s Health Insurance Program, along with manyinsurers. Health maintenance and immunizations now are covered without co-pays for insured patients as part of the PatientProtection and Affordable Care Act.


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Pediatrics_Nelson. Children usually are quite healthy and only the following screening tests are recommended: newborn metabolic screening with hemoglobin electrophoresis, hearing and vision evaluation, anemia and lead screening, and tuberculosis testing. Children born to families with dyslipidemias or early heart disease should also be screened for lipid disorders. (Items marked by a star in Bright Futures’ recommendations should be performed if a risk factor is found.) Sexually experienced adolescents should be screened for sexually transmissible infections. When an infant or child begins care after the newborn period, the pediatrician should perform any missing screening tests and immunizations.


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Pediatrics_Nelson. Every state in the United States mandates newborn metabolic screening. Each state determines its own priorities and procedures, but the following diseases are usually included in metabolic screening: phenylketonuria, galactosemia, congenital hypothyroidism, maple sugar urine disease, and organic aciduria (see Section 10). Many states now screen for cystic fibrosis, testing for immunoreactive trypsinogen. If that test is positive, then a deoxyribonucleic acid (commonly referred to as DNA) analysis for cystic fibrosis mutations is performed. Children with hemoglobinopathies are at higher risk for infection and complications from anemia, which early detection may prevent or ameliorate. Infants with sickle cell disease are begun on oral penicillin prophylaxis to prevent sepsis, the major cause of mortality in these infants (see Chapter 150).


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Pediatrics_Nelson. Because speech and language are central to a child’s cognitive development, the hearing screening is performed before discharge from the newborn nursery. An infant’s hearing is tested by placing headphones over the infant’s ears and electrodes on the head. Standard sounds are played, and the transmission of the impulse to the brain is documented. If abnormal, a further evaluation is indicated, using evoked response technology of sound transmission. Hearing and Vision Screening of Older Children


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Pediatrics_Nelson. Inferences about hearing are drawn from asking parents aboutresponses to sound and speech and by examining speech andlanguage development closely. Inferences about vision maybe made by examining gross motor milestones (children withvision problems may have a delay) and by physical examination of the eye. Parental concerns about vision should be sought untilthe child is 3 years of age and about hearing until the child is4 years of age. If there are concerns, definitive testing shouldbe arranged. Hearing can be screened by auditory evokedresponses, as mentioned for newborns. For toddlers and olderchildren who cannot cooperate with formal audiologic testingwith headphones, behavioral audiology may be used. Sounds ofa specific frequency or intensity are provided in a standard environment within a soundproof room, and responses are assessedby a trained audiologist. Vision may be assessed by referral to apediatric ophthalmologist and by visual evoked responses.


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Children 3 Years of Age and Older

Pediatrics_Nelson. Children 3 Years of Age and Older


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Pediatrics_Nelson. At various ages, hearing and vision should be screened objectively using standard techniques as specified in the Bright Futures’ recommendations. Asking the family and child about any concerns or consequences of poor hearing or vision accomplishes subjective evaluation. At 3 years of age, children are screened for vision for the first time if they are developmentally able to be tested. Many children at this age do not have the interactive language or interpersonal skills to perform a vision screen; these children should be re-examined at a 3to 6-month interval to ensure that their vision is normal. Because most of these children do not yet identify letters, using a Snellen eye chart with standard shapes is recommended. When a child is able to identify letters, the more accurate letter-based chart should be used. Audiologic testing of sounds with headphones should be begun on the fourth birthday (although Head Start requires that pediatricians attempt the hearing screening at 3 years


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Pediatrics_Nelson. chart should be used. Audiologic testing of sounds with headphones should be begun on the fourth birthday (although Head Start requires that pediatricians attempt the hearing screening at 3 years of age). Any suspected audiologic problem should be evaluated by a careful history and physical examination, with referral for comprehensive testing. Children who have a documented vision problem, failed screening, or parental concern should be referred, preferably to a pediatric ophthalmologist.


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Pediatrics_Nelson. Children are screened for anemia at ages when there is a higher incidence of iron deficiency anemia. Infants are screened at birth and again at 4 months if there is a documented risk, such as low birth weight or prematurity. Healthy term infants usually are screened at 12 months of age because this is when a high incidence of iron deficiency is noted. Children are assessed at other visits for risks or concerns related to anemia (denoted by a ★ in the Bright Futures’ recommendations at http://brightfutures.aap.org/clinical_practice.html ).Any abnormalities detected should be evaluated for etiology.Anemic infants do not perform as well on standard developmental testing. When iron deficiency is strongly suspected, a therapeutic trial of iron may be used (see Chapter 150).


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Pediatrics_Nelson. Lead intoxication may cause developmental and behavioralabnormalities that are not reversible, even if the hematologicand other metabolic complications are treated. Although theCenters for Disease Control and Prevention (CDC) recommends environmental investigation at blood lead levels of20 μg/dL on a single visit or persistent 15 μg/dL over a 3-month period, levels of 5 to 10 μg/dL may cause learning problems. Risk factors for lead intoxication include living in older homes withcracked or peeling lead-based paint, industrial exposure, use offoreign remedies (e.g., a diarrhea remedy from Central or SouthAmerica), and use of pottery with lead paint glaze. Because ofthe significant association of lead intoxication with poverty, theCDC recommends blood lead screening at 12 and 24 months.In addition, standardized screening questions for risk of leadintoxication should be asked for all children between 6 months and 6 years of age (Table 9-2). Any positive or suspect responseis an indication


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Pediatrics_Nelson. standardized screening questions for risk of leadintoxication should be asked for all children between 6 months and 6 years of age (Table 9-2). Any positive or suspect responseis an indication for obtaining a blood lead level. Capillary bloodsampling may produce false-positive results, thus, a venousblood sample should be obtained. County health departments,community organizations, and private companies provide leadinspection and detection services to determine the source of thelead. Standard decontamination techniques should be used toremove the lead while avoiding aerosolizing the toxic metal thata child might breathe or creating dust that a child might ingest(see Chapters 149 and 150).


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Pediatrics_Nelson. The prevalence of tuberculosis is increasing, largely as a resultof the adult human immunodeficiency virus (HIV) epidemic.Children often present with serious and multisystem disease(miliary tuberculosis). All children should be assessed for risk oftuberculosis at health maintenance visits, especially after 1 yearof age. The high-risk groups, as defined by the CDC, are listedin Table 9-3. In general the standardized purified protein derivative intradermal test is used with evaluation by a health care provider 48 to 72 hours after injection. The size of induration, notthe color of any mark, denotes a positive test. For most patients, Does the child spend any time in a building built before 1960 (e.g., home, school, barn) that has cracked or peeling paint? Is there a brother, sister, housemate, playmate, or community member being followed or treated (or even rumored to be) for lead poisoning?


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Pediatrics_Nelson. Is there a brother, sister, housemate, playmate, or community member being followed or treated (or even rumored to be) for lead poisoning? Does the child live with an adult whose job or hobby involves exposure to lead (e.g., lead smelting and automotive radiator repair)? Does the child live near an active lead smelter, battery recycling plant, or other industry likely to release lead? Does the family use home remedies or pottery from another country? Close contact with persons known to have tuberculosis (TB), positive TB test, or suspected to have TB Foreign-born persons from areas with high TB rates (Asia, Africa, Latin America, Eastern Europe, Russia) High-risk racial or ethnic minorities or other populations at higher risk (Asian, Pacific Islander, Hispanic, African American, Native American, groups living in poverty [e.g., Medicaid recipients], migrant farm workers, homeless persons, substance abusers)


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Pediatrics_Nelson. Infants, children, and adolescents exposed to adults in high-risk categories 10 mm of induration is a positive test. For HIV-positive patients,those with recent tuberculosis contacts, patients with evidenceof old healed tuberculosis on chest film, or immunosuppressedpatients, 5 mm is a positive test (see Chapter 124). The CDC hasapproved (in adults) the QuantiFERON-TB Gold Test, whichhas the advantage of needing one office visit only.


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Pediatrics_Nelson. Children and adolescents who have a family history of cardiovascular disease or have at least one parent with a high blood cholesterol level are at increased risk of having high blood cholesterol levels as adults and increased risk of coronary heart disease. The American Academy of Pediatrics (AAP) recommends dyslipidemia screening in the context of regular health care for at-risk populations (Table 9-4) by obtaining a fasting lipid profile. The recommended screening levels are the same for all children 2 to 18 years. Total cholesterol of less than 170 mg/dL is normal, 170 to 199 mg/dL is borderline, and greater than 200 mg/dL is elevated. In addition, in 2011, the AAP endorsed the National Heart, Lung, and Blood Institute of the National Institutes of Health recommendation to test all children between ages 9 and 11.


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Pediatrics_Nelson. Annual office visits are recommended for adolescents. A full adolescent psychosocial history should be obtained in confidential fashion (see Section 12). Part of this evaluation is acomprehensive sexual history that often requires creative questioning. Not all adolescents identify oral sex as sex, and some adolescents misinterpret the term sexually active to mean that one has many sexual partners or is very vigorous during intercourse. The questions, “Are you having sex?” and “Have youever had sex?” should be asked. In the Bright Futures guidelines, any child or adolescent who has had any form of sexualintercourse should have at least an annual evaluation (moreoften if there is a history of high-risk sex) for sexually transmitted diseases by physical examination (genital warts, genitalherpes, and pediculosis) and laboratory testing (chlamydia,gonorrhea, syphilis, and HIV) (see Chapter 116). Youngwomen should be assessed for human papillomavirus and precancerous lesions by Papanicolaou


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Pediatrics_Nelson. and pediculosis) and laboratory testing (chlamydia,gonorrhea, syphilis, and HIV) (see Chapter 116). Youngwomen should be assessed for human papillomavirus and precancerous lesions by Papanicolaou smear at 21 years of age.


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Pediatrics_Nelson. Immunization records should be checked at each office visit, regardless of the reason. Appropriate vaccinations should be administered (see Chapter 94). Risk screening at ages 2, 4, 6, 8, 10 and annually in adolescence: 1. Children and adolescents who have a family history of high cholesterol or heart disease 2. Children whose family history is unknown 3. Children who have other personal risk factors: obesity, high blood pressure, or diabetes


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Pediatrics_Nelson. Many families in the United States, particularly poor families and ethnic minorities, underuse dental health care. Pediatricians may identify gross abnormalities, such as large caries, gingival inflammation, or significant malocclusion. All children should have a dental examination by a dentist at least annually and a dental cleaning by a dentist or hygienist every 6 months. Dental health care visits should include instruction about preventive care practiced at home (brushing and flossing). Other prophylactic methods shown to be effective at preventing caries are concentrated fluoride topical treatments (dental varnish) and acrylic sealants on the molars. Pediatric dentists recommend beginning visits at age 1 year to educate families and to screen for milk bottle caries. Some recommend that pediatricians apply dental varnish to the children’s teeth, especially in communities that do not have pediatric dentists. Fluoridation of water or fluoride supplements in communities that do not


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Pediatrics_Nelson. pediatricians apply dental varnish to the children’s teeth, especially in communities that do not have pediatric dentists. Fluoridation of water or fluoride supplements in communities that do not have fluoridation are important in the prevention of cavities (see Chapter 127).


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Pediatrics_Nelson. Plotting a child’s growth on the standard charts is a vital component of the nutritional assessment. A dietary history should be obtained because the content of the diet may suggest a risk of nutritional deficiency (see Chapters 27 and 28). Anticipatory guidance is information conveyed to parents verbally, in written materials, or even directing parents to certain Internet websites to assist them in facilitating optimal growth and development for their children. Anticipatory guidance that is age relevant is another part of the Bright Futures guidelines. Bright Futures has a “toolkit” that includes the topics and one-page handouts for families (and for older children) about the highest yield issues for the specific age. Table 9-5 summarizes representative issues that might be discussed. It is important to review briefly the safety topics previously discussed at other visits for reinforcement. Age-appropriate discussions should occur at each visit.


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Pediatrics_Nelson. The most common cause of death for infants 1 month to 1 year of age is motor vehicle crashes. No newborn should be discharged from a nursery unless the parents have a functioning and properly installed car seat. Many automobile dealerships offer services to parents to ensure that safety seats are installed properly in their specific model. Most states have laws that mandate use of safety seats until the child reaches 4 years of age or at least 40 pounds in weight. The following are age-appropriate recommendations for car safety: Infants and toddlers should ride in a rear-facing safety seat until they are 2 years of age, or until they reach the highest weight or height allowed by the safety seat manufacturer. Toddlers and preschoolers over age 2 or who have outgrown the rear-facing car seat should use a forward-facing car seat with harness for as long as possible, up to the highest weight or height recommended by the manufacturer.


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Pediatrics_Nelson. School-age children, whose weight or height is above the forward-facing limit for their car seat, should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 ft 9 in. in height and are between 8 and 12 years of age. Older children should always use lap and shoulder seat belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. This is specifically to protect them from airbags, which may cause more injury than the crash in young children. The Back to Sleep initiative has reduced the incidence of sudden infant death syndrome (SIDS). Before the initiative, infantsroutinely were placed prone to sleep. Since 1992 when the AAPrecommended this program, the annual SIDS rate has decreasedby more than 50%. Another initiative is aimed at day care providers, because 20% of SIDS deaths occur in day care settings.


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Pediatrics_Nelson. See Table 9-5 as well as the Bright Futures’ recommendations (found at http://brightfutures.aap.org/clinical_practice.html )for presentation of age-appropriate activities that the pediatrician may advocate for families. Discipline means to teach, not merely to punish. The ultimate goal is the child’s self-control. Overbearing punishment to control a child’s behavior interferes with the learning process and focuses on external control at the expense of the development of self-control. Parents who set too few reasonable limits may be frustrated by children who cannot control their own behavior. Discipline should teach a child exactly what is expected by supporting and reinforcing positive behaviors and responding appropriately to negative behaviors with proper limits. It is more important and effective to reinforce good behavior than to punish bad behavior.


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Pediatrics_Nelson. Commonly used techniques to control undesirable behaviors in children include scolding, physical punishment, and threats. These techniques have potential adverse effects on children’s sense of security and self-esteem. The effectiveness of scolding diminishes the more it is used. Scolding should not be allowed to expand from an expression of displeasure about a specific event to derogatory statements about the child. Scolding also may escalate to the level of psychological abuse. It is important to educate parents that they have a good child who does bad things from time to time, so parents do not think and tell the child that he or she is “bad.”


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Pediatrics_Nelson. Frequent mild physical punishment (corporal punishment) may become less effective over time and tempt the parent to escalate the physical punishment, increasing the risk of child abuse. Corporal punishment teaches a child that in certain situations it is proper to strike another person. Commonly in households that use spanking, older children who have been raised with this technique are seen responding to younger sibling behavioral problems by hitting their siblings. Threats by parents to leave or to give up the child are perhaps the most psychologically damaging ways to control a child’s behavior. Children of any age may remain fearful and anxious about loss of the parent long after the threat is made; however many children are able to see through empty threats. Threatening a mild loss of privileges (no video games for 1 week or grounding a teenager) may be appropriate, but the consequence must be enforced if there is a violation.


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Pediatrics_Nelson. Birth and/ Crib safety Assess bonding and Back to sleep Exclusive breastfeeding Discuss parenting skills or 3−5 Hot water heaters attachment Crib safety encouraged Refer for parenting education days <120° F Identify family strife, lack of Formula as a second-best Car safety seats support, pathology 2 months Burns/hot liquids Reassess firearm safety Back to sleep Parent getting enough rest and managing returning to work Healthy snacks Read to child Discuss strategies to avoid interpersonal conflicts Avoiding media violence Avoiding fights and walking away Discuss conflict resolution techniques Junk food versus healthy eating Review school work Begin career discussions and college preparation (PSAT) Review substance abuse, sexuality, and violence regularly Discuss condoms, contraception options, including emergency contraception Discuss sexually transmitted diseases, HIV Providing no questions−asked ride home from at-risk situations


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Pediatrics_Nelson. HIV, Human immunodeficiency virus; PSAT, Preliminary Scholastic Aptitude Test. *Reassess means to review the issues discussed at the prior health maintenance visit.


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Pediatrics_Nelson. Parenting involves a dynamic balance between setting limits on the one hand and allowing and encouraging freedomof expression and exploration on the other. A child whosebehavior is out of control improves when clear limits on theirbehavior are set and enforced. However parents must agree on where the limit will be set and how it will be enforced. The limit and the consequence of breaking the limit mustbe clearly presented to the child. Enforcement of the limitshould be consistent and firm. Too many limits are difficultto learn and may thwart the normal development of autonomy. The limit must be reasonable in terms of the child’sage, temperament, and developmental level. To be effective,both parents (and other adults in the home) must enforce limits. Otherwise, children may effectively split the parentsand seek to test the limits with the more indulgent parent.In all situations, to be effective, punishment must be briefand linked directly to a behavior. More effective behavioralchange


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Pediatrics_Nelson. the parentsand seek to test the limits with the more indulgent parent.In all situations, to be effective, punishment must be briefand linked directly to a behavior. More effective behavioralchange occurs when punishment also is linked to praise of the intended behavior.


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Pediatrics_Nelson. Extinction is an effective and systematic way to eliminate a frequent, annoying, and relatively harmless behavior by ignoring it. First parents should note the frequency of the behaviorto appreciate realistically the magnitude of the problem and toevaluate progress. Parents must determine what reinforces thechild’s behavior and what needs to be consistently eliminated.An appropriate behavior is identified to give the child a positive alternative that the parents can reinforce. Parents shouldbe warned that the annoying behavior usually increases in frequency and intensity (and may last for weeks) before it decreaseswhen the parent ignores it (removes the reinforcement). A childwho has an attention-seeking temper tantrum should be ignoredor placed in a secure environment. This action may anger the child more, and the behavior may get louder and angrier. Eventually with no audience for the tantrum, the tantrums decreasein intensity and frequency. In each specific instance, when the


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Pediatrics_Nelson. anger the child more, and the behavior may get louder and angrier. Eventually with no audience for the tantrum, the tantrums decreasein intensity and frequency. In each specific instance, when the child’s behavior has become appropriate, he or she should be praised, and extra attention should be given. This is an effectivetechnique for early toddlers, before their capacity to understandand adhere to a timeout.


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Pediatrics_Nelson. The timeout consists of a short period of isolation immediately after a problem behavior is observed. Timeout interrupts the behavior and immediately links it to an unpleasant consequence. This method requires considerable effort by the parents because the child does not wish to be isolated. A parent may need to hold the child physically in timeout. In this situation, the parent should become part of the furniture and should not respond to the child until the timeout period is over. When established, a simple isolation technique, such as making a child stand in the corner or sending a child to his or her room, may be effective. If such a technique is not helpful, a more systematic procedure may be needed. One effective protocol for the timeout procedure involves interrupting the child’s play when the behavior occurs and having the child sit in a dull, isolated place for a brief period, measured by a portable kitchen timer (the clicking noises document that time is passing and the bell


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Pediatrics_Nelson. when the behavior occurs and having the child sit in a dull, isolated place for a brief period, measured by a portable kitchen timer (the clicking noises document that time is passing and the bell alarm at the end signals the end of the punishment). Timeout is simply punishment and is not a time for a young child to think about the behavior (these children do not possess the capacity for abstract thinking) or a time to de-escalate the behavior. The amount of timeout should be appropriate to the child’s short attention span. One minute per year of a child’s age is recommended. This inescapable and unpleasant consequence of the undesired behavior motivates the child to learn to avoid the behavior.


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Pediatrics_Nelson. Children with disabilities, severe chronic illnesses, congenital defects, and health-related educational and behavioral problems are children with special health care needs (SHCN). Many of these children share a broad group ofexperiences and encounter similar problems, such as schooldifficulties and family stress. The term children with special health care needs defines these children noncategorically,without regard to specific diagnoses, in terms of increasedservice needs. Approximately 19% of children in the UnitedStates younger than 18 years of age have a physical, developmental, behavioral, or emotional condition requiring services of a type or amount beyond those required by children,generally.


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Pediatrics_Nelson. The goal in managing a child with SHCN is to maximizethe child’s potential for productive adult functioning bytreating the primary diagnosis and by helping the patientand family deal with the stresses and secondary impairmentsincurred because of the disease or disability. Whenever a chronic disease is diagnosed, family members typicallygrieve, show anger, denial, negotiation (in an attempt toforestall the inevitable), and depression. Because the child with SHCN is a constant reminder of the object of this grief,it may take family members a long time to accept the condition. A supportive physician can facilitate the process ofacceptance by education and by allaying guilty feelings andfear. To minimize denial, it is helpful to confirm the family’s observations about the child. The family may not be ableto absorb any additional information initially, so writtenmaterial and the option for further discussion at a later dateshould be offered.


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Pediatrics_Nelson. The primary physician should provide a medical home to maintain close oversight of treatments and subspecialtyservices, provide preventive care, and facilitate interactions with school and community agencies. A major goal of family-centered care is for the family and child to feel in control. Although the medical management team usually directstreatment in the acute health care setting, the locus of control should shift to the family as the child moves into a moreroutine, home-based life. Treatment plans should allow thegreatest degree of normalization of the child’s life. As the child matures, self-management programs that provide health education, self-efficacy skills, and techniques such as symptommonitoring help promote good long-term health habits. Theseprograms should be introduced at 6 or 7 years of age or whena child is at a developmental level to take on chores and benefitfrom being given responsibility. Self-management minimizeslearned helplessness and the vulnerable child


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Pediatrics_Nelson. at 6 or 7 years of age or whena child is at a developmental level to take on chores and benefitfrom being given responsibility. Self-management minimizeslearned helplessness and the vulnerable child syndrome, both of which occur commonly in families with chronically ill ordisabled children.


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Pediatrics_Nelson. When developmental screening and surveillance suggest thepresence of significant developmental lags, the physician shouldtake responsibility for coordinating the further assessment ofthe child by the team of professionals and provide continuity ofcare. The physician should become aware of local facilities andprograms for assessment and treatment. If the child is at highrisk for delay (e.g., prematurity), a structured follow-up programto monitor the child’s progress may already exist. Under federallaw, all children are entitled to assessments if there is a suspecteddevelopmental delay or a risk factor for delay (e.g., prematurity,failure to thrive, and parental mental retardation [MR]). Special programs for children up to 3 years of age are developedby states to implement this policy. Developmental interventionsare arranged in conjunction with third-party payers with localprograms funding the cost only when there is no insurance coverage. After 3 years of age, development programs


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Pediatrics_Nelson. Developmental interventionsare arranged in conjunction with third-party payers with localprograms funding the cost only when there is no insurance coverage. After 3 years of age, development programs usually areadministered by school districts. Federal laws mandate that special education programs be provided for all children with developmental disabilities from birth through 21 years of age.


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Pediatrics_Nelson. Children with special needs may be enrolled in pre-K programs with a therapeutic core, including visits to the programby therapists, to work on challenges. Children who are of traditional school age (kindergarten through secondary school)should be evaluated by the school district and provided an individualized educational plan (IEP) to address any deficiencies. An IEP may feature individual tutoring time (resourcetime), placement in a special education program, placement inclasses with children with severe behavioral problems, or otherstrategies to address deficiencies. As part of the comprehensiveevaluation of developmental/behavioral issues, all childrenshould receive a thorough medical assessment. A variety ofother specialists may assist in the assessment and intervention,including subspecialist pediatricians (e.g., neurology, orthopedics, psychiatry, developmental/behavioral), therapists (e.g.,occupational, physical, oral-motor), and others (e.g., psychologists, early childhood


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Pediatrics_Nelson. pediatricians (e.g., neurology, orthopedics, psychiatry, developmental/behavioral), therapists (e.g.,occupational, physical, oral-motor), and others (e.g., psychologists, early childhood development specialists).


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Pediatrics_Nelson. The physician’s main goals in team assessment are to identify thecause of the developmental dysfunction, if possible (often a specific cause is not found), and identify and interpret other medicalconditions that have a developmental impact. The comprehensive history (Table 10-1) and physical examination (Table 10-2)include a careful graphing of growth parameters and an accuratedescription of dysmorphic features. Many of the diagnoses arerare or unusual diseases or syndromes. Many of these diseasesand syndromes are discussed further in Sections 9 and 24.


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Pediatrics_Nelson. The comprehensive neurologic examination is an excellent basis for evaluating motor function, but it should be supplemented by an adaptive functional evaluation (see Chapter 179). Observing the child at play aids assessment of function. Specialists in early childhood development and therapists (especially occupational and physical therapists who have experience with children) can provide excellent input into the evaluation of age-appropriate adaptive function. Information to Be Sought during the History Taking of a Child with Suspected Developmental Disabilities Parental concerns Parents are quite accurate in identifying development problems in their children. Current levels of Should be used to monitor child’s developmental progress functioning Temperament May interact with disability or may be confused with developmental delay Alcohol ingestion Fetal alcohol syndrome; index of caregiving risk


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Pediatrics_Nelson. Temperament May interact with disability or may be confused with developmental delay Alcohol ingestion Fetal alcohol syndrome; index of caregiving risk Exposure to medication, Development toxin (e.g., phenytoin); illegal drug, or toxin may be an index of caregiving risk Radiation exposure Damage to CNS Prenatal care Index of social situation Injuries, hyperthermia Damage to CNS Maternal illness Toxoplasmosis, Syphilis (Other in the (so-called “TORCH” mnemonic), Rubella, Cytomegalovirus, infections) Herpes simplex virus infections Gestational age, birth Biologic risk from prematurity and small weight for gestational age Labor and delivery Hypoxia or index of abnormal prenatal development APGAR scores Hypoxia, cardiovascular impairment Specific perinatal Increased risk of CNS damage adverse events Illness—seizures, Increased risk of CNS damage respiratory distress, hyperbilirubinemia, metabolic disorder mutation associated with developmental


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Pediatrics_Nelson. Illness—seizures, Increased risk of CNS damage respiratory distress, hyperbilirubinemia, metabolic disorder mutation associated with developmental Illnesses (e.g., Hereditary illness associated with metabolic diseases) developmental delay Family member died May suggest inborn error of metabolism young or unexpectedly or storage disease Family member requires Hereditary causes of developmental special education delay Resources available Necessary to maximize child’s potential (e.g., financial, social support) Educational level of Family may need help to provide parents stimulation. High-risk behaviors Increased risk for HIV infection; index of (e.g., illicit drugs, sex) caregiving risk Other stressors (e.g., May exacerbate child’s conditions or marital discord) compromise care Gender of child Important for X-linked conditions Developmental Index of developmental delay; milestones regression may indicate progressive condition.


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Pediatrics_Nelson. Gender of child Important for X-linked conditions Developmental Index of developmental delay; milestones regression may indicate progressive condition. associated with developmental delay or learning disabilities. Serious infections (e.g., May be associated with developmental meningitis) delay Toxic exposure (e.g., May be associated with developmental lead) delay Physical growth May indicate malnutrition; obesity, short stature, genetic syndrome Recurrent otitis media Associated with hearing loss and abnormal speech development Visual and auditory Sensitive index of impaired vision and functioning hearing Nutrition Malnutrition during infancy may lead to delayed development. Chronic conditions such May be associated with delayed as renal disease development or anemia


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Pediatrics_Nelson. Nutrition Malnutrition during infancy may lead to delayed development. Chronic conditions such May be associated with delayed as renal disease development or anemia Adapted and updated from Liptak G: Mental retardation and developmental disability. In Kliegman RM, editor: Practical Strategies in Pediatric Diagnosis and Therapy, Philadelphia, 1996, WB Saunders. CNS, Central nervous system; HIV, human immunodeficiency virus.


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Pediatrics_Nelson. Psychological Assessment Although a child should not be labeled as having a problem Psychological assessment includes the testing of cognitive abil-solely on the basis of a standardized test, these tests provide ity (Table 10-3) and the evaluation of personality and emotional important and reasonably objective data for evaluating a child’s well-being. The IQ and mental age scores, taken in isolation, progress within a particular educational program. are only partially descriptive of a person’s functional abilities,which are a combination of cognitive, adaptive, and socialskills. Tests of achievement are subject to variability based on Educational Assessment culture, educational exposures, and experience and must be Educational assessment involves the evaluation of areas of standardized for social factors. Projective and non-projective specific strengths and weaknesses in reading, spelling, written tests are useful in understanding the child’s emotional status. expression, and


Pediatrics_Nelson

Pediatrics_Nelson. for social factors. Projective and non-projective specific strengths and weaknesses in reading, spelling, written tests are useful in understanding the child’s emotional status. expression, and mathematical skills. Schools routinely screen


Pediatrics_Nelson

Pediatrics_Nelson. Information to Be Sought during the Physical Examination of a Child with Suspected Short stature Williams syndrome, malnutrition, Turner syndrome; many children with severe retardation have associated short stature. Macrocephaly Alexander syndrome, Sotos syndrome, gangliosidosis, hydrocephalus, mucopolysaccharidosis, subdural effusion Microcephaly Virtually any condition that can retard brain growth (e.g., malnutrition, Angelman syndrome, de Lange syndrome, fetal alcohol effects) Coarse, triangular, round, or flat face; hypotelorism or hypertelorism, slanted or short palpebral fissure; unusual nose, maxilla, and mandible Specific measurements may provide clues to inherited, metabolic, or other diseases such as fetal alcohol syndrome, cri du chat syndrome (5psyndrome), or Williams syndrome. Prominent Crouzon syndrome, Seckel syndrome, fragile X syndrome Cataract Galactosemia, Lowe syndrome, prenatal rubella, hypothyroidism


Pediatrics_Nelson

Pediatrics_Nelson. Prominent Crouzon syndrome, Seckel syndrome, fragile X syndrome Cataract Galactosemia, Lowe syndrome, prenatal rubella, hypothyroidism Cherry-red spot in Gangliosidosis (GM1), metachromatic macula leukodystrophy, mucolipidosis, Tay-Sachs disease, Niemann-Pick disease, Farber lipogranulomatosis, sialidosis III Chorioretinitis Congenital infection with cytomegalovirus, toxoplasmosis, or rubella Corneal cloudiness Mucopolysaccharidosis I and II, Lowe syndrome, congenital syphilis Pinnae, low set or Trisomies such as 18, Rubinstein-Taybi malformed syndrome, Down syndrome, CHARGE association, cerebro-oculo-facio-skeletal syndrome, fetal phenytoin effects Hearing Loss of acuity in mucopolysaccharidosis; hyperacusis in many encephalopathies CHARGE association, CATCH22, velocardiofacial syndrome, glycogenosis II, fetal alcohol effects, mucopolysaccharidosis I; chromosomal anomalies such as Down syndrome; maternal phenylketonuria; chronic cyanosis may impair cognitive development.


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Pediatrics_Nelson. Adapted and updated from Liptak G: Mental retardation and developmental disability. In Kliegman RM, Greenbaum LA, Lye PS, editors: Practical Strategies in Pediatric Diagnosis and Therapy, ed 2, Philadelphia, 2004, Saunders, p 540. CATCH-22, Cardiac defects, abnormal face, thymic hypoplasia, cleft palate, hypocalcemia, defects on chromosome 22; CHARGE, coloboma, heart defects, atresia choanae, retarded growth, genital anomalies, ear anomalies (deafness). Table 10-3 Tests of Cognition TEST AGE RANGE SPECIAL FEATURES INFANT SCALES Bayley Scales of Infant Development (3rd ed) 1–42 mo Mental, psychomotor scales, behavior record; weak intelligence predictor Cattell Infant Intelligence Scale 2–30 mo Used to extend Stanford-Binet downward Ordinal Scales of Infant Psychological Birth–24 mo Six subscales; based on Piaget’s stages; weak in predicting later Development Stanford-Binet Intelligence Scale (4th ed) 2 yr–adult Four area scores, with subtests and composite IQ score


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Pediatrics_Nelson. Stanford-Binet Intelligence Scale (4th ed) 2 yr–adult Four area scores, with subtests and composite IQ score McCarthy Scales of Children’s Abilities 2½–8½ yr 6–18 subtests; good at defining learning disabilities; strengths/weaknesses approach Wechsler Primary and Preschool Test of 2 ½–7¼ yr 11 subtests; verbal, performance IQs; long administration time; good at Intelligence–Revised (WPPSI-R) Merrill-Palmer Scale of Mental Tests 18 mo–4 yr 19 subtests cover language skills, motor skills, manual dexterity, and matching ability Stanford-Binet Intelligence Scale (4th ed) 2 yr–adult Four area scores, with subtests and composite IQ score Leiter International Performance Scale, Revised 2–20 yr Nonverbal measure of intelligence ideal for use with those who are cognitively delayed, non-English speaking, hearing impaired, speech impaired, or autistic


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Pediatrics_Nelson. Vineland Adaptive Behavior Scale – II (2nd ed) Birth–90 yr Interview/questionnaire; typical persons and blind, deaf, developmentally delayed, and retarded American Association on Mental Retardation 4–21 yr Useful in mental retardation, other disabilities (AAMR) Adaptive Behavioral Scale children with grouped tests to aid in problem identification and program evaluation. For the child with special needs, this screening ultimately should lead to individualized testing and the development of an IEP that would enable the child to progress comfortably in school. Diagnostic teaching, in which the child’s response to various teaching techniques is assessed, also may be helpful.


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Pediatrics_Nelson. Assessments of the environment in which the child is living, working, playing, and growing are important in understanding the child’s development. A home visit by a social worker, community health nurse, and/or home-based intervention specialist can provide valuable information about the child’s social milieu. Often the home visitor can suggest additional adaptive equipment or renovations if there are challenges at home. If there is a suspicion of inadequate parenting, and, especially, if there is a suspicion of neglect or abuse (including emotional abuse), the child and family must be referred to the local child protection agency. Information about reporting hotlines and local child protection agencies usually is found inside the front cover of local telephone directories (see Chapter 22). Intervention in the Primary Care Setting


Pediatrics_Nelson

Pediatrics_Nelson. Intervention in the Primary Care Setting The clinician must decide whether a problem requires referral for further diagnostic workup and management or whether management in the primary care setting is appropriate. Counseling roles required in caring for these children are listed in Table 10-4. When a child is young, much of the counseling interaction takes place between the parents and the clinician, and, as the child matures, direct counseling shifts increasingly toward the child. The assessment process may be therapeutic in itself. By assuming the role of a nonjudgmental, supportive listener, the clinician creates a climate of trust, allowing the family to express difficult or painful thoughts and feelings. Expressing emotions may allow the parent or caregiver to move on to the work of understanding and resolving the problem.


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Pediatrics_Nelson. Interview techniques may facilitate clarification of the problem for the family and for the clinician. The family’sideas about the causes of the problem and attempts at coping can provide a basis for developing strategies for problemmanagement that are much more likely to be implementedsuccessfully because they emanate, in part, from the family.The clinician shows respect by endorsing the parent’s ideaswhen appropriate; this can increase self-esteem and sense of competency. Educating parents about normal and aberrant development and behavior may prevent problems through early detection and anticipatory guidance and communicates the physician’s interest in hearing parental concerns. Early detection allows intervention before the problem becomes entrenched and associated problems develop.


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Pediatrics_Nelson. The severity of developmental and behavioral problems ranges from variations of normal to problematic responses to stressful situations to frank disorders. The clinician must try to establish the severity and scope of the patient’s symptoms so that appropriate intervention can be planned. For the child, behavioral change must be learned, not simply imposed. It is easiest to learn when the lesson is simple, clear, and consistent and presented in an atmosphere free of fear or intimidation. Parents often try to impose behavioral change in an emotionally charged atmosphere, most often at the time of a behavioral violation. Similarly clinicians may try to teach parents with hastily presented advice when the parents are distracted by other concerns or not engaged in the suggested behavioral change.


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Pediatrics_Nelson. Apart from management strategies directed specifically at the problem behavior, regular times for positive parent-child interaction should be instituted. Frequent, brief, affectionate physical contact over the day provides opportunities for positive reinforcement of desirable child behaviors and for building a sense of competence in the child and the parent. Most parents feel guilty when their children have a developmental/behavioral problem. Guilt may be caused by the fear that the problem was caused by inadequate parenting or by previous angry responses to the child’s behavior. If possible and appropriate, the clinician should find ways to alleviate guilt, which may be a serious impediment to problem solving.


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Pediatrics_Nelson. In many cases, a team of professionals is required to provide the breadth and quality of services needed to appropriately serve the child who has SHCN. The primary care physician should monitor the progress of the child and continually reassess that the requisite therapy is being accomplished. Educational intervention for a young child begins as home-based infant stimulation, often with an early childhood specialist (e.g., nurse/therapist), providing direct stimulation for the child and training the family to provide the stimulation. As the child matures, a center-based nursery program may be indicated. For the school-age child, special services may range from extra attention in the classroom to a self-contained special education classroom.


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Pediatrics_Nelson. Psychological intervention may be directed to the parent or family or, with an older child, primarily child-directed. Examples of therapeutic approaches are guidance therapies, such as directive advice giving, counseling to create their own solutions to problems, psychotherapy, behavioral management techniques, psychopharmacologic methods (from a psychiatrist), and cognitive therapy.


Pediatrics_Nelson

Pediatrics_Nelson. Motor intervention may be performed by a physical or occupational therapist. Neurodevelopmental therapy (NDT), the most commonly used method, is based on the concept that nervous system development is hierarchical and subject to some plasticity. The focus of NDT is on gait training and motor development, including daily living skills; perceptual abilities, such as eye-hand coordination; and spatial relationships. Sensory integration therapy is also used by occupational therapists to structure sensory experience from the tactile, proprioceptive, and vestibular systems to allow for adaptive motor responses.


Pediatrics_Nelson

Pediatrics_Nelson. Speech-language intervention by a speech and language therapist/pathologist (oral-motor therapist) is usually part of the overall educational program and is based on the tested language strengths and weaknesses of the child. Children needing this type of intervention may show difficulties in reading and other academic areas and develop social and behavioral problems because of their difficulties in being understood and in understanding others. Hearing intervention, performed by an audiologist (or an otolaryngologist), includes monitoring hearing acuity and providing amplification when necessary via hearing aids. Social and environmental intervention generally includesnursing or social work involvement with the family. Frequently the task of coordinating services falls to these specialists. Case managers may be in the private sector, fromthe child’s insurance or Medicaid plan, or part of a childprotection agency.


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Pediatrics_Nelson. Medical intervention for a child with a developmentaldisability involves providing primary care as well as specific treatment of conditions associated with the disability.Although curative treatment often is not possible, functionalimpairment can be minimized through thoughtful medicalmanagement. Certain general medical problems are foundmore frequently in delayed and developmentally disabledpeople (Table 10-5), especially if the delay is part of a knownsyndrome. Some children may have a limited life expectancy.Supporting the family through palliative care, hospice, andbereavement is another important role of the primary carepediatrician. SELECTED CLINICAL PROBLEMS: THE SPECIAL NEEDS CHILD


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Pediatrics_Nelson. SELECTED CLINICAL PROBLEMS: THE SPECIAL NEEDS CHILD MR is defined as significantly subnormal intellectual functioning for a child’s developmental stage, existing concurrently with deficits in adaptive behaviors (self-care, home living, communication, and social interactions). MR is defined statistically as cognitive performance that is two standard deviations below the mean (roughly below the 3rd percentile) of the general population as measured on standardized intelligence testing. The last known estimate of the prevalence of MR is that about 2% of the U.S. population is affected. Levels of MR from IQ scores derived from two typical tests are shown in Table 10-6. Caution must be exercised in interpretation because these categories do not reflect actual functional level of the tested individual. The etiology of the central nervous system insult resultingin MR may involve genetic disorders, teratogenic influences, Mild 50–69 50–55 to 70 Educable mentally retarded (EMR)


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Pediatrics_Nelson. The etiology of the central nervous system insult resultingin MR may involve genetic disorders, teratogenic influences, Mild 50–69 50–55 to 70 Educable mentally retarded (EMR) Moderate 35–49 35–40 to 50–55 Trainable mentally retarded (TMR) Severe 20–34 20–25 to 35–50 ICD-10, International Classification of Diseases (WHO), ed 10; WISC-IV, Wechsler Intelligence Scale for children, ed 4.


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Pediatrics_Nelson. Severe 20–34 20–25 to 35–50 ICD-10, International Classification of Diseases (WHO), ed 10; WISC-IV, Wechsler Intelligence Scale for children, ed 4. perinatal insults, acquired childhood disease, and environmental and social factors (Table 10-7). Mild MR correlates with socioeconomic status, although profound MR does not. Although a single organic cause may be found, each individual’s performance should be considered a function of theinteraction of environmental influences with the individual’s organic substrate. Behavioral difficulties resulting from the MRitself and from the family’s reaction to the child and the condition are common. More severe forms of MR can be traced to biologic factors. The earlier the cognitive slowing is recognized,the more severe the deviation from normal is likely to be.


Pediatrics_Nelson

Pediatrics_Nelson. The first step in the diagnosis and management of a child with MR is to identify functional strengths and weaknesses for purposes of medical and habilitative therapies. A history and physical examination may suggest a diagnostic approach that, then, may be confirmed by laboratory testing and/or imaging. Frequently used laboratory tests include chromosomal analysis and magnetic resonance imaging of the brain. Almost one third of individuals with MR do not have readily identifiable reasons for their disability. Significant visual impairment is a problem in many children. Partial vision (defined as visual acuity between 20/70 and 20/200) occurs in 1 in 500 school-age children in the United States. Legal blindness is defined as distant visual acuity of 20/200 or worse and affects about 35,000 children in the United States. Such impairment can be a major barrier to optimal development.


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Pediatrics_Nelson. The most common cause of severe visual impairment in children is retinopathy of prematurity (see Chapter 61). Congenital cataracts may lead to significant amblyopia. Cataracts also are associated with other ocular abnormalities and developmental disabilities. Amblyopia is a pathologic alteration of the visual system characterized by a reduction in visual acuity in one or both eyes with no clinically apparent organic abnormality that completely accounts for the visual loss. Amblyopia is due to a distortion of the normal clearly formed retinal image (from congenital cataracts or severe refractive errors); abnormal binocular interaction between the eyes as one eye competitively inhibits the other (strabismus); or a combination of both mechanisms. Albinism, hydrocephalus, congenital cytomegalovirus infection, and birth asphyxia are other significant contributors to blindness in children.


Pediatrics_Nelson

Pediatrics_Nelson. Sporadic events affecting embryogenesis, usually a stable developmental challenge Chromosomal changes (e.g., trisomy 21 syndrome) Prenatal influences (e.g., substance abuse, teratogenic medications, intrauterine TORCH infections) † No definite issue is identified, or multiple elements present, none of which is diagnostic (may be multifactorial) Dynamic influences, commonly associated with other challenges Deprivation (neglect) Parental mental illness Environmental intoxications (e.g., significant lead intoxication)* Impingement on normal intrauterine development or delivery; neurologic abnormalities frequent, challenges are stable or occasionally worsening Perinatal complications (e.g., prematurity, birth asphyxia, birth trauma) Preconceptual origin, variable expression in the individual infant, multiple somatic effects, frequently a progressive or degenerative course Inborn errors of metabolism (e.g., Tay-Sachs disease, Hunter disease, phenylketonuria)


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Pediatrics_Nelson. Inborn errors of metabolism (e.g., Tay-Sachs disease, Hunter disease, phenylketonuria) Single-gene abnormalities (e.g., neurofibromatosis or tuberous sclerosis) Other chromosomal aberrations (e.g., fragile X syndrome, deletion mutations such as Prader-Willi syndrome) Acute modification of developmental status, variable potential for functional recovery Infections (all can ultimately lead to brain damage, but most significant are encephalitis and meningitis) Cranial trauma (accidental and child abuse) Accidents (e.g., near-drowning, electrocution) Environmental intoxications (prototype is lead poisoning) TORCH, Toxoplasmosis, other (congenital syphilis), rubella, cytomegalovirus, and herpes simplex virus. *Some health problems fit in several categories (e.g., lead intoxication may be involved in several areas). †This also may be considered as an acquired childhood disease.


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Pediatrics_Nelson. †This also may be considered as an acquired childhood disease. Children with mild to moderate visual impairment usually have an uncorrected refractive error. The most common presentation is myopia or nearsightedness. Other causes are hyperopia (farsightedness) and astigmatism (alteration in the shape of the cornea leading to visual distortion). In children younger than 6 years, high refractive errors in one or both eyes also may cause amblyopia, aggravating visual impairment.


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Pediatrics_Nelson. The diagnosis of severe visual impairment commonly is madewhen an infant is 4 to 8 months of age. Clinical suspicion is based on parental concerns aroused by unusual behavior, such as lackof smiling in response to appropriate stimuli, the presence of nystagmus, other wandering eye movements, or motor delaysin beginning to reach for objects. Fixation and visual trackingbehavior can be seen in most infants by 6 weeks of age. Thisbehavior can be assessed by moving a brightly colored object(or the examiner’s face) across the visual field of a quiet but alertinfant at a distance of 1 ft. The eyes also should be examined forred reflexes and pupillary reactions to light. Optical alignment(binocular vision with both eyes consistently focusing on thesame spot) should not be expected until the infant is beyondthe newborn period. Persistent nystagmus is abnormal at anyage. If ocular abnormalities are identified, referral to a pediatricophthalmologist is indicated.


Pediatrics_Nelson

Pediatrics_Nelson. During the newborn period, vision may be assessed by physical examination and by visual evoked response. This test evaluates the conduction of electrical impulses from the optic nerve to the occipital cortex of the brain. The eye is stimulated by a bright flash of light or with an alternating checkerboard of black-and-white squares, and the resulting electrical response is recorded from electrodes strategically placed on the scalp, similar to an electroencephalogram. There are many developmental implications of visual impairment. Perception of body image is abnormal, and imitative behavior, such as smiling, is delayed. Delays in mobility may occur in children who are visually impaired from birth, although their postural milestones (ability to sit) usually are achieved appropriately. Social bonding with the parents also is often affected.


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Pediatrics_Nelson. Visually impaired children can be helped in various ways. Classroom settings may be augmented with resource-room assistance to present material in a nonvisual format. Fine motor activity development, listening skills, and Braille reading and writing are intrinsic to successful educational intervention for a child with severe visual impairment. Available @ StudentConsult.com


Pediatrics_Nelson

Pediatrics_Nelson. The clinical significance of hearing loss varies with its type (conductive versus sensorineural), its frequency, and its severity as measured in the number of decibels heard or the number of decibels of hearing lost. The most common cause of mild to moderate hearing loss in children is a conduction abnormality caused by acquired middle ear disease (acute and chronic otitis media). This abnormality may have a significant effect on the development of speech and language development, particularly if there is chronic fluctuating middle ear fluid. If hearing impairment is more severe, sensorineural hearing loss is more common. Causes of sensorineural deafness include congenital infections (e.g., rubella and cytomegalovirus), meningitis, birth asphyxia, kernicterus, ototoxic drugs (especially aminoglycoside antibiotics), and tumors and their treatments. Genetic deafness may be either dominant or recessive in inheritance; this is the main cause of hearing impairment in schools for the deaf.


Pediatrics_Nelson

Pediatrics_Nelson. antibiotics), and tumors and their treatments. Genetic deafness may be either dominant or recessive in inheritance; this is the main cause of hearing impairment in schools for the deaf. In Down syndrome, there is a predisposition to conductive loss caused by middle ear infection


Pediatrics_Nelson

Pediatrics_Nelson. Moderate 40–65 Chronic otitis media/ Conversation must be dB (ASA) middle ear effusions loud to be understood. Adapted and updated from Gottlieb MI: Otitis media. In Levine MD, Carey WB, Crocker AC, et al, editors: Developmental-Behavioral Pediatrics, Philadelphia, 1983, WB Saunders. ASA, Acoustical Society of America. and sensorineural loss caused by cochlear disease. Any hear-identifying hearing-impaired children. Universal screening of ing loss may have a significant effect on the child’s developing newborns is required prior to nursery discharge and includes communication skills. These skills then affect all areas of the the following: child’s cognitive and skills development (Table 10-8). • Auditory brainstem response (ABR) measures how


Pediatrics_Nelson

Pediatrics_Nelson. It is sometimes quite difficult to accurately determine the the brain responds to sound. Clicks or tones are played presence of hearing in infants and young children. Inquir-through soft earphones into the infant’s ears. Three ing about a newborn’s or infant’s response to sounds or even electrodes placed on the infant’s head measure the brain’s observing the response to sounds in the office is unreliable for response. • Otoacoustic emissions measure sound waves produced in the inner ear. A tiny probe is placed just inside the infant’s ear canal. It measures the response (echo) when clicks or tones are played into the infant’s ears.


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Pediatrics_Nelson. Both of these tests are quick (5 to 10 minutes), painless, and may be performed while the infant is sleeping or lying still. The tests are sensitive but not as specific as more definitive tests. Infants who do not pass these tests are referred for more comprehensive testing. Many of these infants have normal hearing on definitive testing. Infants who do not have normal hearing should be immediately evaluated or referred for etiologic diagnosis and early intervention.


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Pediatrics_Nelson. For children not screened at birth (such as children of immigrant parents) or children with suspected acquired hearing loss, later testing may allow early appropriate intervention. Hearing can be screened by means of an office audiogram, but other techniques are needed (ABR, behavior audiology) for young, neurologically immature or impaired, and behaviorally difficult children. The typical audiologic assessment includes pure-tone audiometry over a variety of sound frequencies (pitches), especially over the range of frequencies in which most speech occurs. Pneumatic otoscopic examination and tympanometry are used to assess middle ear function and the tympanic membrane compliance for pathology in the middle ear, such as fluid, ossicular dysfunction, and eustachian tube dysfunction (see Chapter 9).


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Pediatrics_Nelson. The treatment of conductive hearing loss (largely due tootitis media and middle ear effusions) is discussed in Chapter 105. Treatment of sensorineural hearing impairment may bemedical or surgical. If amplification is indicated, hearing aidscan be tuned preferentially to amplify the frequency ranges inwhich the patient has decreased acuity. Educational intervention typically includes speech-language therapy and teachingAmerican Sign Language. Even with amplification, many hear-ing-impaired children show deficits in processing auditoryinformation, requiring special educational services for helpingto read and for other academic skills. Cochlear implants are surgically implantable devices that provide hearing sensation toindividuals with severe to profound hearing loss. The implantsare designed to substitute for the function of the middle ear,cochlear mechanical motion, and sensory cells, transformingsound energy into electrical energy that initiates impulses inthe auditory nerve.


Pediatrics_Nelson

Pediatrics_Nelson. designed to substitute for the function of the middle ear,cochlear mechanical motion, and sensory cells, transformingsound energy into electrical energy that initiates impulses inthe auditory nerve. Cochlear implants are indicated for children older than 12 months with profound bilateral sensorineural hearing loss who have limited benefit from hearing aids,have failed to progress in auditory skill development, and haveno radiologic or medical contraindications. Implantation inchildren as young as possible gives them the most advantageous auditory environment for speech-language learning.


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Pediatrics_Nelson. Parents often bring the concern of speech delay to the physician’s attention when they compare their young child with others of the same age (Table 10-9). The most common causes of the speech delay are MR, hearing impairment, social deprivation, autism, and oral-motor abnormalities. If a problem is suspected based on screening with tests such as Ages and Stages Questionnaires or the Parents’ Evaluation of Developmental Status test (see Chapter 8) or other standard screening test (Early Language Milestone Scale), a referral to a specialized hearing and speech center is indicated. While awaiting Before 6 months, the child does not startle, blink, or change immediate activity in response to sudden, loud sounds. Before 6 months, the child does not attend to the human voice and is not soothed by his or her mother’s voice. By 6 months, the child does not babble strings of consonant and vowel syllables or imitate gurgling or cooing sounds.


Pediatrics_Nelson

Pediatrics_Nelson. By 6 months, the child does not babble strings of consonant and vowel syllables or imitate gurgling or cooing sounds. By 10 months, the child does not respond to his or her name. At 10 months, the child’s sound-making is limited to shrieks, grunts, or sustained vowel production. At 12 months, the child’s babbling or speech is limited to vowel sounds. By 15 months, the child does not respond to “no,” “bye-bye,” or “bottle.” By 15 months, the child does not imitate sounds or words. By 18 months, the child is not consistently using at least six words with appropriate meaning. By 21 months, the child does not respond correctly to “Give me . . . ,” “Sit down,” or “Come here” when spoken without gestural cues. By 23 months, two-word phrases that are spoken as single units (e.g., “whatszit,” “thankyou,” “allgone”) have not emerged. By 24 months, at least 50% of the child’s speech is not understood by familiar listeners.


Pediatrics_Nelson

Pediatrics_Nelson. By 24 months, at least 50% of the child’s speech is not understood by familiar listeners. By 24 months, the child does not point to body parts without gestural cues. By 24 months, the child is not combining words into phrases (e.g., “go bye-bye,” “go car,” “want cookie”). By 30 months, the child does not show understanding of spatial concepts: on, in, under, front, and back. By 30 months, the child is not using short sentences (e.g., “Daddy went bye-bye”). By 30 months, the child has not begun to ask questions (using where, what, why). By 36 months, the child’s speech is not understood by unfamiliar listeners. At any age, the child is consistently dysfluent with repetitions, hesitations; blocks or struggles to say words. Struggle may be accompanied by grimaces, eye blinks, or hand gestures. Adapted and updated from Weiss CE, Lillywhite HE: Communication Disorders: a handbook for prevention and early detection, St Louis, 1976, Mosby.


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Pediatrics_Nelson. Adapted and updated from Weiss CE, Lillywhite HE: Communication Disorders: a handbook for prevention and early detection, St Louis, 1976, Mosby. the results of testing or initiation of speech-language therapy, parents should be advised to speak slowly and clearly to the child (and avoid baby talk). Parents and older siblings should read frequently to the speech-delayed child. Speech disorders include articulation, fluency, and resonance disorders. Articulation disorders include difficulties producing sounds in syllables or saying words incorrectly tothe point that other people cannot understand what is beingsaid. Fluency disorders include problems such as stuttering,the condition in which the flow of speech is interrupted byabnormal stoppages, repetitions (st-st-stuttering), or prolonging sounds and syllables (ssssstuttering). Resonance or voice disorders include problems with the pitch, volume, or quality of achild’s voice that distract listeners from what is being said.


Pediatrics_Nelson

Pediatrics_Nelson. Language disorders can be either receptive or expressive. Receptive disorders refer to difficulties understanding or processing language. Expressive disorders include difficulty putting words together, limited vocabulary, or inability to use language in a socially appropriate way. Speech-language pathologists (speech or oral-motor therapists) assess the speech, language, cognitive communication, and swallowing skills of children; determine what types of communication problems exist; and identify the best way to treat these challenges. Speech-language pathologists skilled at working with infants and young children are also vital in training parents and infants in other oral-motor skills, such as how to feed an infant born with a cleft lip and palate.


Pediatrics_Nelson

Pediatrics_Nelson. Speech-language therapy involves having a speech-language specialist work with a child on a one-on-one basis, in a small group, or directly in a classroom to overcome a specific disorder using a variety of therapeutic strategies. Language intervention activities involve having a speech-language specialist interact with a child by playing and talking to him or her, using pictures, books, objects, or ongoing events to stimulate language development. Articulation therapy involves having the therapist model correct sounds and syllables for a child, often during play activities. Children enrolled in therapy early (<3 years of age) tend to have better outcomes than children who begin therapy later. Older children can make progress in therapy, but progress may occur more slowly because these children often have learned patterns that need to be modified or changed. Parental involvement is crucial to the success of a child’s progress in speech-language therapy.


Pediatrics_Nelson

Pediatrics_Nelson. Available @ StudentConsult.com Limp In-Toeing, Out-Toeing, and Toe-Walking Bowlegs and Knock-Knees Hypotonia and Weakness Cerebral palsy (CP) refers to a group of nonprogressive, but often changing, motor impairment syndromes secondary to anomalies or lesions of the brain arising before or after birth. The prevalence of CP at age 8 in the United States is 3.6 per 1000; prevalence is much higher in premature and twin births. Prematurity and low birth weight infants (leading to perinatal asphyxia), congenital malformations, and kernicterus are causes of CP noted at birth. Ten percent of children with CP have acquired CP, developing at later ages. Meningitis and head injury (accidental and nonaccidental) are the most common causes of acquired CP (Table 10-10). Nearly 50% of children with CP have no identifiable risk factors. As genomic medicine advances, many of these causes of idiopathic CP may be identified.


Pediatrics_Nelson

Pediatrics_Nelson. Most children with CP, except in its mildest forms, are diagnosed in the first 18 months of life when they fail to attain motor milestones or show abnormalities such as asymmetric Low socioeconomic status Prematurity Low birth weight/fetal growth retardation (<1500 g at birth) Maternal seizures/seizure disorder Treatment with thyroid hormone, estrogen, or progesterone Pregnancy complications Hemiparesis (hemiplegia)—predominantly unilateral impairment of the arm and leg on the same (e.g., right or left) side Diplegia—motor impairment primarily of the legs (often with some limited involvement of the arms; some authors challenge this specific type as not being different from quadriplegia) Quadriplegia—all four limbs (whole body) are functionally compromised.


Pediatrics_Nelson

Pediatrics_Nelson. Quadriplegia—all four limbs (whole body) are functionally compromised. gross motor function, hypertonia, or hypotonia. CP can be characterized further by the affected parts of the body (Table 10-11) and descriptions of the predominant type of motor disorder (Table 10-12). Comorbidities in these children often include epilepsy, learning difficulties, behavioral challenges, and sensory impairments. Many of these children have an isolated motor defect. Some affected children may be intellectually gifted. Treatment depends on the pattern of dysfunction. Physical and occupational therapy can facilitate optimal positioning and movement patterns, increasing function of the affected parts. Spasticity management also may include oral medications (dantrolene, benzodiazepines, and baclofen), botulinum toxin injections, and implantation of intrathecal baclofen pumps. Management of seizures, spasticity, orthopedic impairments, and sensory impairments may help improve


Pediatrics_Nelson

Pediatrics_Nelson. Spastic cerebral palsy: the most common form of cerebral palsy, it accounts for 70%–80% of cases. It results from injury to the upper motor neurons of the pyramidal tract. It may occasionally be bilateral. It is characterized by at least two of the following: abnormal movement pattern, increased tone, or pathologic reflexes (e.g., Babinski response, hyperreflexia). Dyskinetic cerebral palsy: occurs in 10%–15% of cases. It is dominated by abnormal patterns of movement and involuntary, uncontrolled, recurring movements. Ataxic cerebral palsy: accounts for <5% of cases. This form results from cerebellar injury and features abnormal posture or movement and loss of orderly muscle coordination or both. Dystonic cerebral palsy: also uncommon. It is characterized by reduced activity and stiff movement (hypokinesia) and hypotonia.


Pediatrics_Nelson

Pediatrics_Nelson. Dystonic cerebral palsy: also uncommon. It is characterized by reduced activity and stiff movement (hypokinesia) and hypotonia. Choreoathetotic cerebral palsy: rare now that excessive hyperbilirubinemia is aggressively prevented and treated. This form is dominated by increased and stormy movements (hyperkinesia) and hypotonia. Mixed cerebral palsy: accounts for 10%–15% of cases. This term is used when more than one type of motor pattern is present and when one pattern does not clearly dominate another. It typically is associated with more complications, including sensory deficits, seizures, and cognitive-perceptual impairments. educational attainment. CP cannot be cured, but a host of interventions can improve functional abilities, participation in society, and quality of life. Like all children, an assessment and reinforcement of strengths are important, especially for intellectually intact or gifted children who have simple motor deficits.


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Pediatrics_Nelson. Brosco J, Mattingly M, Sanders L: Impact of specific medical interventions on reducing the prevalence of mental retardation, Arch Pediatr Adolesc Med 160:302–309, 2006 for Children With Special Needs Project Advisory Committee: Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics 118(1):405–420, 2006 Daniels S, Greer F: Committee on Nutrition: Lipid screening and cardiovas cular health in childhood, Pediatrics 122:198–208, 2008 Gardner HG: American Academy of Pediatrics Committee on Injury, Vio lence, and Poison Prevention. Office-based counseling for unintentional injury prevention, Pediatrics 119(1):202–206, 2007 Hagan J, Shaw J, Duncan P: Bright Futures: guidelines for health supervision of infants, children, and adolescents, ed 3, Elk Grove Village IL, 2008, American Academy of Pediatrics Kliegman R, Behrman R, Jenson H, et al: Nelson Textbook of Pediatrics, ed 18,


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Pediatrics_Nelson. American Academy of Pediatrics Kliegman R, Behrman R, Jenson H, et al: Nelson Textbook of Pediatrics, ed 18, Philadelphia, 2007, Elsevier Sheila Gahagan, Yi Hui Liu, and Scott J. Brown 3 Infant crying, a sign of pain, distress, hunger, or fatigue, is interpreted by caregivers according to the context of the crying. The cry just after birth heralds the infant’s health and vigor. The screams of the same infant, 6 weeks later, may be interpreted as a sign of illness, difficult temperament, or poor parenting. Crying is a manifestation of infant arousal influenced by the environment and interpreted through the lens of the family, social, and cultural context. Crying is best understood by the characteristics of timing, duration, frequency, intensity, and modifiability of the cry (Fig. 11-1). Most infants cry little during the first 2 weeks of life, gradually increasing to 3 hours per day by 6 weeks and decreasing to 1 hour per day by 12 weeks.


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Pediatrics_Nelson. Cry duration differs by culture and infant care practices. For example, !Kung San hunter−gatherer infants, who are continuously carried and fed four times per hour, cry 50% less than infants in the United States. Crying may also relate to health status. Premature infants cry little before 40 weeks gestational age but tend to cry more than term infants at 6 weeks’ corrected age. Crying behavior in former premature infants also may be influenced by ongoing medical conditions, such as bronchopulmonary dysplasia, visual impairments, and feed-


Pediatrics_Nelson

Pediatrics_Nelson. Colic often is diagnosed using Wessel’s rule of threes—crying for more than 3 hours per day, at least 3 days per week, for more than 3 weeks. The limitations of this definition include the lack of specificity of the word crying (e.g., does this include fussing?) and the necessity to wait 3 weeks to make a diagnosis in an infant who has excessive crying. Colicky crying is often described as paroxysmal and may be characterized by facial grimacing, leg flexion, and passing flatus. Fewer than 5% of infants evaluated for excessive crying have an organic etiology. Because the etiology of colic is unknown, this syndrome may represent the extreme of the normal phenomenon of infant crying. Nonetheless evaluation of infants with excessive crying is warranted.


Pediatrics_Nelson

Pediatrics_Nelson. Cumulative incidence rates of colic vary from 5% to 19% in different studies. Girls and boys are affected equally. Studies vary byhow colic is defined and by data collection methodology, suchas maintaining a cry diary or actual recording of infant vocalizations. Concern about infant crying also varies by culture, andthis may influence what is recorded as crying or fussing. ing disorders. The duration of crying is often modifiable by caregiving strategies. Frequency of crying is less variable than duration of crying. At 6 weeks of age, the mean frequency of combined crying and fussing is 10 episodes in 24 hours. Diurnal variation in crying is the norm, with crying concentrated in the late afternoon and evening.


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Pediatrics_Nelson. The intensity of infant crying varies, with descriptionsranging from fussing to screaming. An intense infant cry(pitch and loudness) is more likely to elicit concern or evenalarm from parents and caregivers than an infant who fretsmore quietly. Pain cries of newborns are remarkably loud:80 dB at a distance of 30.5 cm from the infant’s mouth. Although pain cries have a higher frequency than hungercries, when not attended to for a protracted period, hungercries become acoustically similar to pain cries. Fortunatelymost infant crying is of a lesser intensity, consistent withfussing. Hours of fussing per day Figure 11-1 Distribution of total crying time among 80 infants studied from 2 to 12 weeks of age. Data derived from daily crying diaries recorded by mothers. (From Brazelton TB: Crying in infancy. Pediatrics 29:582, 1962.) Available @ StudentConsult.com


Pediatrics_Nelson

Pediatrics_Nelson. The clinician who evaluates a crying infant must differentiate serious disease from colic, which has no identifiable etiology. The history includes a description of the crying, including duration, frequency, intensity, and modifiability. Associated symptoms, such as leg flexion, facial grimacing, vomiting, or back arching, should be identified. Other important historical clues include the onset, diurnal pattern, any changes in quality, and triggers or activities that relieve crying. A review of systems can identify or eliminate other serious illnesses. Medical history also is important because infants with perinatal problems are at increased risk for neurologic causes of crying. Attention to the feeding history can reveal feeding-related problems, including hunger, air swallowing (worsened by crying), gastroesophageal reflux, and food intolerance. Questions concerning the family’s ability to handle the stress of the infant’s crying and their knowledge of infant soothing strategies


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Pediatrics_Nelson. by crying), gastroesophageal reflux, and food intolerance. Questions concerning the family’s ability to handle the stress of the infant’s crying and their knowledge of infant soothing strategies assist the clinician in assessing risk for parental mental health comorbidities and developing an intervention plan suitable for the family.


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Pediatrics_Nelson. The diagnosis of colic is made only when the physical examination reveals no organic cause for the infant’s excessive crying. The examination begins with vital signs, weight, length, and head circumference, looking for effects of systemic illness on growth. A thorough inspection of the infant is important to identify possible sources of pain, including skin lesions, corneal abrasions, hair tourniquets, skeletal infections, or signs of child abuse such as fractures (see Chapters 22 and 199). Infants with common conditions such as otitis media, urinary tract infections, mouth ulcerations, and insect bites may present with crying. A neurologic examination may reveal previously undiagnosed neurologic conditions, such as perinatal brain injuries, as the cause of irritability and crying. Observation of the infant during a crying episode is invaluable to assess the infant’s potential for calming and the parents’ skills in soothing the infant.


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Pediatrics_Nelson. Laboratory and imaging studies are reserved for infants in whom there are history or physical examination findings suggesting an organic cause for excessive crying. An algorithm for the medical evaluation of an infant with excessive crying inconsistent with colic is presented in Figure 11-2.


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Pediatrics_Nelson. The differential diagnosis for colic is broad and includes any condition that can cause pain or discomfort in the infant and conditions associated with nonpainful distress, such as fatigue or sensory overload. Cow’s milk protein intolerance, maternal drug effects (including fluoxetine hydrochloride via breastfeeding), and anomalous left coronary artery all have been reported as causes of persistent crying. In addition, situations associated with poor infant regulation, including fatigue, hunger, parental anxiety, and chaotic environmental conditions, may increase the risk of excessive crying. In most cases, the cause of crying in infants is unexplained. If the condition began before 3 weeks’ corrected age, the crying has a diurnal pattern consistent with colic (afternoon and evening clustering), the infant is otherwise developing and thriving, and no organic cause is found, a diagnosis of colic is indicated.


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Pediatrics_Nelson. Figure 11-2 Algorithm for medi-cal evaluation of infants with acute excessive crying. (From Barr RG, Hopkins B, Green JA, editors: Cry-ing complaints in the emergency department. In Crying as a Sign, a Symptom, and a Signal, London, 2000, MacKeith Press, p. 99.) INFANT WITH ACUTE EXCESSIVE CRYING History and physical examination Urinalysis and urine culture Assess pattern, observe 1–2 hours Crying ceases spontaneously Follow 24 hours in hospital or at home Consider idiopathic crying episode Crying persists Consider: Radiologic studies Chemistry tests Pulse oximetry Toxicology tests Lumbar puncture Continue observation, in hospital, until crying stops or diagnosis made History of recurrent episodes consistent with colic Treat for infantile colic Identify cause and treat Ensure appropriate follow-up Urinary tract infection


Pediatrics_Nelson

Pediatrics_Nelson. The management of colic begins with education and demystification. When the family and the physician are reassured that the infant is healthy, without infection, trauma, or underlying disease, education about the normal pattern of infant crying is appropriate. Learning about the temporal pattern of colic can be reassuring; the mean crying duration begins to decrease at 6 weeks of age and decreases by half by 12 weeks of age. Colic does not always resolve by 3 months of age. Approximately 15% of infants with colic continue to have excessive crying after 3 months of age.


Pediatrics_Nelson

Pediatrics_Nelson. Helping families develop caregiving schedules for the infant’sfussy period is useful. Techniques for calming infants includesoothing vocalizations or singing, swaddling, slow rhythmicrocking, walking, white noise, and gentle vibration (e.g., a ridein a car). Giving caregivers permission to allow the infant to restwhen soothing strategies are not working may alleviate over-stimulation in some infants; this also relieves families of guiltand allows them a wider range of responses to infant crying.Avoidance of dangerous soothing techniques, such as shaking the infant or placing the infant on a vibrating clothes dryer(which has resulted in injury from falls), should be stressed.


Pediatrics_Nelson

Pediatrics_Nelson. Medications, including phenobarbital, diphenhydramine, alcohol, simethicone, dicyclomine, and lactase, are of no benefit in reducing colic and should be avoided. Parents, especially from Mexico and Eastern Europe, often use chamomile, fennel, vervain, licorice, and balm-mint teas. These teas have not been studied scientifically as remedies for colic. Families should be counseled to limit the volume of tea given because it displaces milk from the infant’s diet and may limit caloric intake. In most circumstances, dietary changes are not effective in reducing colic but should be considered in certain specific circumstances. There is rationale for change to a non-cow’s milk formula if the infant has signs of cow’s milk protein colitis. If the infant is breastfeeding, the mother can eliminate dairy products from her diet.


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Pediatrics_Nelson. There is no evidence that infants with colic have adverse longterm outcomes in health or temperament after the neonatal period. Similarly infantile colic does not have untoward longterm effects on maternal mental health. When colic subsides, the maternal distress resolves. Rarely cases of child abuse have been associated with inconsolable infant crying.


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Pediatrics_Nelson. Much can be done to prevent colic, beginning with education ofprospective parents about the normal pattern of infant crying.Prospective parents often imagine that their infant will cry onlybriefly for hunger. Increased contact and carrying of the infantin the weeks before the onset of colic may decrease the duration of crying episodes. Similarly other soothing strategies may be more effective if the infant has experienced them before theonset of excessive crying. Infants who have been tightly swaddled for sleep and rest during the first weeks of life often calmto swaddling during a crying episode; this is not true for infantswho have not experienced swaddling before a crying episode.Parents also can be coached to learn to read their infant’s cues of hunger, discomfort, boredom, or overstimulation. It is important to understand that there are times when the infant’s cry isnot interpretable, and caregivers can do only their best.


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Pediatrics_Nelson. A temper tantrum, defined as out-of-control behavior, including screaming, stomping, hitting, head banging, falling down,and other violent displays of frustration, can include breath-holding, vomiting, and serious aggression, including biting.Tantrums are seen most often when the young child experiences frustration, anger, or simple inability to cope with a situation. Temper tantrums can be considered normal behavior in1to 3-year-old children, when the temper tantrum period is ofshort duration and the tantrums are not manipulative in nature. Temper tantrums are believed to be a normal human developmental stage. Child temperament may be a determinant of tantrum behavior.


Pediatrics_Nelson

Pediatrics_Nelson. Temper tantrums are believed to be a normal human developmental stage. Child temperament may be a determinant of tantrum behavior. This behavior is common in children 18 months to 4 years of age. In U.S. studies, 50% to 80% of 2to 3-year-old children have had regular tantrums, and 20% are reported to have daily tantrums. The behavior appears to peak late in the third year of life. Approximately 20% of 4-year-olds are still having regular temper tantrums, and explosive temper occurs in approximately 5% of school-age children. Tantrums occur equally in boys and girls during the preschool period.


Pediatrics_Nelson

Pediatrics_Nelson. Temper tantrums are the most commonly reported behavioral problem in 2and 3-year-old children. The typical frequency of tantrums is approximately one per week, with a great deal of variability (Fig. 12-1). The duration of each tantrum is 2 to 5 minutes, and duration increases with age (Fig. 12-2). Helping the family identify the typical antecedents of the child’s tantrums is essential to evaluation and intervention. A child who has tantrums only when he or she misses a routine nap can be treated differently than a child who has frequent tantrums related to minor difficulties or disappointments. The evaluation of a child who is having temper tantrums requires a complete history, including perinatal and developmental information. Careful attention to the child’s daily routines may reveal problems associated with hunger, fatigue, inadequate physical activity, or overstimulation. A social No. of Tantrums per Week


Pediatrics_Nelson

Pediatrics_Nelson. No. of Tantrums per Week Figure 12-1 Mean tantrum frequency per week. Children 1 to tantrum behavior (in terms of actual tantrum duration and continued manifestation after the normal tantrum age). These children include former premature infants and children with autism,traumatic brain injury, cognitive impairment, and Prader-Williand Smith-Magenis syndromes. Children with rare conditions,such as congenital adrenal hyperplasia and precocious puberty,also may present with severe and persistent tantrums. Childrenwith intellectual disability may exhibit tantrums when theirdevelopmental age is comparable to 3 to 4 years.


Pediatrics_Nelson

Pediatrics_Nelson. Intervention begins with parental education about temper tantrums, stressing that tantrums are a normal developmental phase. Parents may have unwarranted concerns about their 4 years of age who have tantrums typically have four to nine tantrums child’s mental health. The clinician can help parents understand per week. their role in helping the child move toward self-regulation of frustration and anger. The environment can be structured to limit toddler frustration; age-inappropriate demands on the 5.0 child; and hunger, fatigue, loneliness, or hyperstimulation. It 4.5 is important to review the child’s daily routine to understand 4.0 whether the child’s tantrums are communicating essential unmet needs. Children who behave well all day at day care 3.5 3.0 2.5 2.0 1.5 1.0 0.5


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Pediatrics_Nelson. Figure 12-2 Mean duration of tantrums. The typical duration of a and exhibit temper tantrums at home in the evening may be signaling fatigue or need for parental attention. Identification of underlying stress is the cornerstone of treatment because many stressors can be eliminated. Parents may consider some changes in the home environment so that they do not have to say “No” to the child as frequently. In some cases, parents inadvertently reinforce tantrum behavior by complying with the child’s demands. The child’s behavior can be seen as manipulative or simply as learned behaviorfrom a prior successful experience. Parental ambivalence aboutacceptable toddler behavior also may lead to inconsistent expectations and restrictions. Helping parents clarify what behavior isallowed and what is off limits can avert the temptation to give inwhen the child screams loudly or publicly.


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Pediatrics_Nelson. Distraction is an effective means of short-circuiting impending tantrums. Physically removing the child from an environment that is associated with the child’s difficulty is sometimes helpful. Further behavioral interventions are recommended only after engaging in strategies to help the child gain control by meeting basic needs, altering the environment, and anticipating meltdowns. Recommended behavioral strategies include behavior modification with positive and negative reinforcement or extinction. During the first week of any behavioral intervention, tantrum behavior may increase. Parents must be warned that it will probably get worse before it gets better. At the same time that parents are working to extinguish or decrease the tantrums, it is important that they provide positive reinforcement for good behavior.


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Pediatrics_Nelson. Providing parents with knowledge about the temper tantrum stage and strategies for assisting the child with emotional regulation is recommended at a health care maintenance visit between 12 and 18 months of age. Regular routines for sleeping, eating, and physical activity in a childproofed home (or day care center) provided by well-rested and psychologically healthy parents (or caregivers) usually result in a quick transition through this challenging period. tantrum increases with the age of the child. history is important, because family stress can exacerbate or prolong what begins as a normal developmental phase. The coexistence of other behavioral problems, such as sleep problems, learning problems, and social problems, suggests the possibility of a more serious mental health disorder.


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Pediatrics_Nelson. The physical examination focuses on discovering an underlying illness that could decrease the child’s ability to self-regulate. A thorough examination of the skin to identify childabuse is recommended (see Chapter 22). The neurologic examination identifies underlying brain disorders. Dysmorphic features may reveal a genetic syndrome. Behavioral observations reveal a child’s ability to follow instructions, play with age-appropriate toys, and interact with parents and the clinician. Laboratory studies screening for iron deficiency anemia and lead exposure are important. Other laboratory and imaging studies are performed only when the history and physical examination suggest a possible underlying etiology. Some children with excessive tantrums should have a formal developmental evaluation.