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Pediatrics_Nelson. GID is characterized by intense and persistent cross-gender identification and discomfort with one’s own sex. In children these feelings may be manifested by behaviors such as cross-dressing, stating that one wants to be or is the opposite sex, and a strong and almost exclusive preference for cross-sex roles, games, and playmates. The onset of these behaviors often can be traced back to the preschool period. However referral for evaluation typically occurs at school age or later, when it becomes clear that the behaviors do not represent a transient phase, and the behaviors may begin to interfere with social relationships. Forty to 80% of children with GID will have a bisexual or homosexual sexual orientation as adults. However there is no reliable way to predict adult sexual orientation, and there is no evidence that parental behavior would alter the developmental pathway toward homosexual or heterosexual behavior.


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Pediatrics_Nelson. In adults GID may be characterized by a belief that one was born the wrong sex and by a persistent desire to live and be treated as the opposite sex. Adults may request hormones or surgical procedures to alter sexual characteristics to simulate the other sex, but, when these procedures are done in individuals who have completed puberty, they often fail to fully achieve the appearance of the desired gender. Long-term follow-up studies of children with GID suggest that only 2% to 20% have GID as adults, but gender dysphoria that intensifies with the onset of puberty is likely to persist. In 2009 the Endocrine Society published guidelines that recommended considering reversible suppression of puberty using gonadotropin releasing hormone analogs at Tanner stages 2 through 3 for individuals with GID because this allows the adolescent more time to decide whether to begin cross-sex hormone treatment.


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Pediatrics_Nelson. Identical twins (even twins raised in separate families) show a higher concordance rate for sexual orientation than would be expected by chance alone, but nowhere near 100%, as would be expected if genetics alone determined sexual orientation. Some studies have found differences in the size of certain brain regions in homosexual individuals, but the findings are inconsistent. The levels of androgens and estrogens have not been found to differ in homosexual and heterosexual adults. Although it is well documented that parents tend to treat boys and girls differently, if, or how, these interactions affect sexual orientation is unknown.


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Pediatrics_Nelson. It is currently estimated that about 1% to 4% of adults identify themselves as homosexual. Given the prevalent negative societal attitudes toward homosexuality, these children are at high risk for having a negative self-esteem, being isolated, being verbally harassed, and often being physically assaulted. Although sexual behaviors, not sexual orientation, determine risk of sexually transmitted infections, homosexual male adolescents engage in high-risk behaviors despite the threat of infection from the human immunodeficiency virus (HIV). For medical and psychosocial reasons, health care providers need to provide an environment in which adolescents feel comfortable discussing their sexual orientation (Table 23-2).


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Pediatrics_Nelson. Acknowledging that one is homosexual and disclosing it to one’s parents is often extremely stressful. Although many parents come to accept their child’s homosexuality, some parents, particularly those who view this behavior as immoral, may reject their child. Homosexual youth are at a high risk for homelessness. Adolescents need to be made aware that even parents who eventually come to accept their child’s homosexuality initially may be shocked, fearful about their child’s well-being, or upset about the loss of the adulthood they had expected for their child. Parents may need to be reassured that they did not cause their child to have a homosexual orientation. Likewise they may need to be informed that therapies designed to change sexual orientation not only are language (e.g., partner as opposed to husband/wife)


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Pediatrics_Nelson. Ensure that one uses gender-neutral questions when asking about dating or sexual behaviors Display posters, brochures, and information that show concern for issues important to homosexual youth and their families Provide information about support groups and other resources for homosexual youth and their families Adapted from Perrin EC: Sexual Orientation in Child and Adolescent Health Care, New York, 2002, Kluwer Academic/Plenum Publishers. unsuccessful, but also often lead to the child having more feelings of guilt and a lower self-esteem. The health care provider should have knowledge of support groups and counselors who can discuss these issues with the adolescent or his or her parents when the information the health care provider offers is not sufficient.


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Pediatrics_Nelson. The homosexual youth is affected by how homosexuality is addressed in schools, by peers, and by other community groups. Unbiased information about homosexuality is often not available in these settings, and homophobic jokes, teasing, and violence are common. It is not surprising that homosexual youth and adults have higher rates of anxiety and mood disorders than are found in the general population. Increased rates of substance abuse and suicide are reported. Health care providers have an important role in detecting these problems.


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Pediatrics_Nelson. Although education about safe sexual practices should be part of all adolescent well-child visits, health care providers should be aware that certain sexual behaviors of homosexual males increase the risk of certain types of sexually transmitted infections. Anal intercourse is an efficient route for infection by hepatitis B virus, cytomegalovirus, and HIV. Proctitis caused by gonorrhea, chlamydia, herpes simplex virus, syphilis, or human papillomavirus may occur (see Chapter 116).


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Pediatrics_Nelson. A family is a dynamic system of interactions among biologically, socially, or legally related individuals; families have a unique power to promote or interfere with health and development. When a family functions well, interactions support the physical and emotional needs of all family members, and the family serves as a resource for an individual member who is having difficulty. Alternatively the problems of an individual member or the interactions among members may prevent the family from meeting the physical or emotional needs of one or more family members or, in the worst-case scenario, may cause physical or emotional harm to a member of the family. These situations are often referred to as family dysfunction.


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Pediatrics_Nelson. The functions that families carry out in support of their children can be categorized broadly as providing for physical needs, emotional support, education, and socialization (Table 24-1). Within these categories, all families have strengths and weaknesses. The amount of support that an individual child needs in these categories varies with the child’s development, personality, temperament, health status, experiences, and stressors. Too much and too little support can interfere with optimal child health and development. Most cases of child abuse involve the failure of the family to provide a safe environment for the child and, in cases of neglect, inappropriate support for the child’s physical, emotional, or social development. At the other extreme, overprotective parents may limit friendships and other growth-promoting experiences or seek excessive health care, as may occur in the vulnerable child syndrome. Parental perfectionism may create intense pressure on children related to


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Pediatrics_Nelson. and other growth-promoting experiences or seek excessive health care, as may occur in the vulnerable child syndrome. Parental perfectionism may create intense pressure on children related to achievement that may contribute to problems such as anxiety disorders.


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Pediatrics_Nelson. The traditional family consists of a married mother and father and their biologic children. The diversity in the structure of the family in the United States has increased dramatically; less than half of children now live in the traditional nuclear family. Today children may live with unmarried parents, single parents of either gender, a parent and a stepparent, grandparents, parents living as a same-sex couple, or foster care families. There is little evidence that family structure alone is a significant predictor of child health or development. Regardless of family structure, the presence of a loving adult or adults serving as a parent or parents committed to fulfilling a child’s physical, emotional, and socialization needs is the best predictor of good health and development. Different family structures create different types of family stresses.


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Pediatrics_Nelson. At any one point in time, approximately 30% of children are living in single parent families, and more than 40% of children are born to unmarried mothers. In some cases this is the mother’s choice, but often times this results from a young woman’s unplanned pregnancy. Children may also live in single-parent families because of divorce or the death of a parent (see Chapter 26). Although most single parent families are still headed by mothers, single-father families are increasing and in 2009 nearly 5% of children lived in single-father families.


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Pediatrics_Nelson. Single parents often have limited financial resources and social supports. For households headed by single mothers, the median income is only 40% of the income of two-parent families and for single fathers it is only 60% of the income of two parent families. Thus the frequency of children living in poverty is three to five times higher in single-parent families. These parents must also rely to a greater extent on other adults for child care. Although these adults may be sources of support for the single parent, they also may criticize the parent, decreasing confidence in parenting skills. Fatigue associated with working and raising a child may also make consistent parenting difficult. Single parents are likely to have less time for a social life or other activities, which may increase their isolation. When the increased burdens of being a single parent are associated with exhaustion, isolation, and depression, developmental and behavioral problems in the child are more likely.


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Pediatrics_Nelson. When the parent is a teenage mother, problems of parenting may be exacerbated further (see Section 12). Being a teenage parent is associated with lower educational attainment, lower paying jobs without much opportunity for autonomy or advancement, and lower self-esteem. They are even less likely than other single mothers to have any support from the child’s father. Children of adolescent mothers are at high risk for cognitive delays, behavioral problems, and difficulties in school. Referral to early intervention services or Head Start programs is important in these situations.


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Pediatrics_Nelson. When a single parent has good social supports, is able to collaborate well with other care providers, and has sufficient financial resources, he or she is likely to be successful in raising a child. Pediatricians can improve parental confidence through education about child development and behavior and validation of parenting behaviors. Empathetic understanding of the difficulties of being a single parent can have a healing effect or help a parent discuss difficulties that may suggest the need for a referral to other professionals. Children Living with Homosexual Parents


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Pediatrics_Nelson. Children Living with Homosexual Parents Many children with a gay or lesbian parent were conceived in the context of a heterosexual relationship. Some parents were unaware of their homosexuality at the time that they married, whereas others may view themselves as bisexual or marry despite the recognition that they are homosexual. Gay men and lesbian women also become parents on their own or in the context of an already established relationship with a same-sex partner through adoption, insemination, or surrogacy. Children living with homosexual parents may encompass many possible family structures.


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Pediatrics_Nelson. Parents in these families are likely to have concerns about how disclosure of the homosexuality and the associated social stigma will affect the child. In general earlier disclosure of a parent’s homosexuality to children, especially before adolescence, is associated with better acceptance. Most children of homosexual parents experience some social stigma associated with having a gay or lesbian parent; this may occur in the form of teasing by peers, disapproval from adults, and stress or isolation related to keeping the parent’s homosexuality a secret.


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Pediatrics_Nelson. Evidence suggests that having a homosexual parent does not cause increased problems in the parent-child relationship or the child’s social-emotional development. Gender and gender role behaviors are typical for the child’s age. Nonetheless distress related to teasing or maintaining the parent’s secret may be great for some children, especially in early adolescence when issues of peer acceptance, sexual identity, and separation from one’s parents are especially strong.


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Pediatrics_Nelson. Adoption is a legal and social process that provides full family membership to a child not born to the adoptive parents. Approximately 2% of children in the United States are adopted. A significant proportion of legal and informal adoptions are by stepparents or relatives of the child. Most adoptions in the United States involve U.S. parents adopting U.S. children, but shifting cultural trends have increased the diversity in the ways in which adoptions occur (e.g., international adoptions, single-parent adoptions, privately arranged adoptions, and the use of a surrogate parent). These types of adoption each raise unique issues for families and health care providers. Open adoptions in which the biologic parents and birth parents agree to interact are occurring with increased frequency and create new issues for the adoption triad (biologic parent, adoptive parent, and child).


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Pediatrics_Nelson. Pediatricians are in an ideal position to help adoptive parents obtain and evaluate medical information, consider the unique medical needs of the adopted child, and provide a source of advice and counseling from the preadoption period through the issues that may arise when the child is an adolescent. A preadoption visit may allow discussion of medical information that the prospective parents have received about the child and identify important missing information such as the medical history of the biologic family and the educational and social history of the biologic parents. The preadoption period is the time that families are most likely to be able to obtain this information. Depending on the preadoption history, there may be risks of infections, in utero substance exposure, poor nutrition, or inadequate infant care that should be discussed with adoptive parents.


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Pediatrics_Nelson. When the adopted child is first seen, screening for medical disorders beyond the typical age-appropriate screeningtests should be considered. If the child has not had the standard newborn screening tests, the pediatrician may need toobtain these tests. Documented immunizations should be reviewed and, if needed, a plan developed to complete theneeded immunizations (see Chapter 94). Children may be athigh risk for infection based on the biologic mother’s socialhistory or the country from which the child was adopted, including infection with human immunodeficiency virus, hepatitis B, cytomegalovirus, tuberculosis, syphilis, and parasites. A complete blood count may be needed to screen foriron deficiency.


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Pediatrics_Nelson. A knowledgeable pediatrician also can be a valuable sourceof support and advice about psychosocial issues. The pediatrician should help the adoptive parents think about how theywill raise the child while helping the child to understand thefact that he or she is adopted. Neither denial of nor intense focus on the adoption is healthy. Parents should use the term adoption around their children during the toddler years andexplain the simplest facts first. Children’s questions shouldbe answered honestly. Parents should expect the same orsimilar questions repeatedly, and that during the preschoolperiod the child’s cognitive limitations make it likely thechild will not fully understand the meaning of adoption. Aschildren get older, they may have fantasies of being reunitedwith their biologic parents, and there may be new challenges as the child begins to interact more with individuals outsideof the family. Families may want advice about difficulties created by school assignments such as


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Pediatrics_Nelson. parents, and there may be new challenges as the child begins to interact more with individuals outsideof the family. Families may want advice about difficulties created by school assignments such as creating a genealogicchart or teasing by peers. During the teenage years, the childmay have questions about his or her identity and a desire tofind his or her biologic parents. Adoptive parents may needreassurance that these desires do not represent rejectionof the adoptive family but the child’s desire to understandmore about his or her life. In general adopted adolescentsshould be supported in efforts to learn about their past, butmost experts recommend encouraging children to wait untillate adolescence before deciding to search actively for thebiologic parents.


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Pediatrics_Nelson. Although adopted children have a higher rate of school, learning, and behavioral problems, much of this increase is likely to be related to biologic and social influences before the adoption. The pediatrician can play an important role in helping families distinguish developmental and behavioral variations from problems that may require recommendations for early intervention, counseling, or other services.


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Pediatrics_Nelson. Foster care is a means of providing protection for children who require out-of-home placement, most commonly because of homelessness, parental inability to care for the child, parental substance abuse, or child neglect or abuse. From the late 1990s through 2005, over half a million children were in foster care, but between 2005 and 2010, the number of children living in foster care decreased by about 20%. These decreases were associated with changes in federal and state policies that have emphasized shortened stays in foster care, promoted more rapid adoptions, and expanded efforts to support troubled families.


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Pediatrics_Nelson. The 400,000 children in foster care are at extremely high risk for medical, nutritional, developmental, behavioral, and mental health problems. At the time of placement in foster care, most of these children have received incomplete medical care and have had multiple detrimental life experiences. Comprehensive assessments at the time of placement reveal many untreated acute medical problems, and nearly half of the children have a chronic illness. Developmental delays and serious behavioral or emotional disorders are common.


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Pediatrics_Nelson. Ideally foster care provides a healing service for these children and families, leading to reunification or adoption. Too often children experience multiple changes in placement within the foster care system, further exacerbating the problems foster children may have in forming a secure relationship with adult caregivers. Children may manifest this difficulty by resisting foster parents’ attempts to develop a close relationship. This detachment from the foster parent may be difficult for the foster parent to endure, which may perpetuate a cycle of placement failures. The trauma or neglect experienced that led to the need for foster care in combination with instability of placements causes enduring long-term difficulties. Foster care alumni report rates of anxiety disorders, depression, substance abuse, and posttraumatic stress disorder that are two to six times higher than in the general population. Furthermore although the protections of the foster care system often end at 18 years


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Pediatrics_Nelson. abuse, and posttraumatic stress disorder that are two to six times higher than in the general population. Furthermore although the protections of the foster care system often end at 18 years of age, these adolescents rarely have the skills and maturity needed to allow them to be successful living independently. Thus the Fostering Connections to Success and Increasing Adoptions Act of 2008 mandates that effective transition to adulthood planning be done with youth in foster care.


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Pediatrics_Nelson. The challenges for the foster care system are great. However when children are placed with competent and nurturing foster parents and provided coordinated care from skilled professionals, significant improvements in a child’s health status, development, and academic achievement usually occur.


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Pediatrics_Nelson. Failure to meet a child’s physical needs for protection or nutrition results in some of the most severe forms of family dysfunction (see Chapters 21 and 22). There are many other ways in which parental behaviors can interfere with a child having a healthy and safe environment, such as prenatal and postnatal substance abuse. Prenatal use of alcohol can damage the fetus resulting in spectrum disorders known as fetal alcohol spectrum disorders (FASD). At the most severe end of the spectrum, this teratogen causes fetal alcohol syndrome (FAS) characterized by in utero and postnatal growth retardation, microcephaly, intellectual disability, and a characteristic dysmorphic facial appearance. Other manifestations of FASD include birth defects and problems with coordination, attention, hyperactivity, impulsivity, learning, or behavior. Children with these difficulties may be diagnosed with alcohol-related neurodevelopmental disorder, alcohol-related birth defects, or partial FAS.


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Pediatrics_Nelson. Other substances also may affect the fetus, but investigation of these effects is complicated by the fact that often more than one substance is used, and nutrition and prenatal care are not optimal. Cigarette smoking during pregnancy is associated with lower birth weight and increased child behavioral problems. Use of cocaine in the perinatal period has been associated with prematurity, intracranial hemorrhages, and abruptio placentae. Exposure to opiates in utero can result in prematurity and a neonatal withdrawal syndrome. Investigations of the effects of cocaine and opiates on cognitive development have produced mixed results.


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Pediatrics_Nelson. Parental substance abuse after the child’s birth is associated with increased family conflict, decreased organization, increased isolation, and increased family stress related to marital and work problems. Family violence may be more frequent. Despite the fact that these parents often have difficulty providing discipline and structure, they may expect their children to be competent at a variety of tasks at a younger age than non-substance−abusing parents. This sets the children up for failure and contributes to increased rates of depression, anxiety, and low self-esteem. The parents’ more accepting attitude toward alcohol and drugs seems to increase the chance that their children will use substances during adolescence.


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Pediatrics_Nelson. Parents also may expose children directly to the harmful effects of other substances, such as exposure to second hand cigarette smoke, which is consistently associated with increased rates of childhood respiratory illnesses, otitis media, and sudden infant death syndrome. Despite these effects, only a few parents restrict smoking in their homes. There are many other ways in which parents may not physically protect their children. Failing to immunize children, to childproof the home adequately, and to provide adequate supervision are other examples.


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Pediatrics_Nelson. Parents’ attempts to provide too much protection for their child also can cause problems. One example of this is the vulnerable child syndrome in which a child who is ill early in life continues to be viewed as vulnerable by the parents despite that the child has fully recovered. Behavioral difficulties may result if parents are overindulgent and fail to set limits. Parental reluctance to leave the child may contribute to the child having separation anxiety. Parents may be particularly attentive to minor variations in bodily functions, leading them to seek excess medical care. If the physician does not recognize this situation, the child may be exposed to unnecessary medical procedures. Emotional Support, Education, and Socialization


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Pediatrics_Nelson. Emotional Support, Education, and Socialization Failure to meet a child’s emotional or educational needs can have a severe and enduring negative impact on child development and behavior. Infants need a consistent adult who learns to understand their signals and meets the infant’s needs for attention as well as food. As the adult caregiver learns these signals, he or she responds more rapidly and appropriately to the infant’s attempts at communication. Through this process, often referred to as attachment, the special relationship between parent and child develops. When affectionate and responsive adults are not consistently available, infants often are less willing to explore the environment and may become unusually clingy, angry, or difficult to comfort.


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Pediatrics_Nelson. Appropriate stimulation also is vital for a child’s cognitive development. Children whose parents do not read to them and do not play developmentally appropriate games with them have lower scores on intelligence tests and more school problems. In these situations, early intervention has been shown to be particularly effective in improving skill development and subsequent school performance. At the other extreme, there are increasing concerns that some parents may provide too much stimulation and scheduling of the child’s day. There may be such emphasis on achievement that children come to feel that parental love is contingent on achievement. There are concerns that this narrow definition of success may contribute to problems with anxiety and self-esteem for some children.


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Pediatrics_Nelson. Intimate partner violence (IPV) is a pattern of purposeful coercive behaviors aimed at establishing control of one partner over the other that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats. Such violence between adults affects the lives of millions of children each year. Children experience IPV by seeing or hearing the violence and its aftermath. Children who live in households with IPV often develop psychological and behavioral problems that interfere with their ability to function normally in school, at home, and with peers. They may be injured during violent outbursts, sometimes while attempting to intervene on behalf of a parent. Many children are victims of abuse themselves. It is estimated that there is at least a 50% concurrence rate between IPV and child abuse. Children who grow up in violent households learn that violence is appropriate in intimate relationships. A


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Pediatrics_Nelson. It is estimated that there is at least a 50% concurrence rate between IPV and child abuse. Children who grow up in violent households learn that violence is appropriate in intimate relationships. A history of having witnessed IPV as a child is a strong predictor for becoming a batterer in adulthood. In addition to sporadic outbursts of violence, children who live in households with IPV experience disruptive events that can overtly or subtly affect the child’s development. Although partner violence often occurs between male perpetrators and female victims, it may also occur bi-directionally and may be better conceptualized as family or interpersonal-violence. Violence may escalate during the peri-natal period.


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Pediatrics_Nelson. There is no particular behavioral consequence or disturbance that is specific to children who witness IPV. Some children are traumatized by fear for their caregiver’s safety and feel helpless. Others may blame themselves for the violence. Children may have symptoms of posttraumatic stress disorder,depression, anxiety, aggression, or hypervigilance. Older children may have conduct disorders, poor school performance, low self-esteem, or other nonspecific behaviors. Infants and young toddlers are at risk for disrupted attachment and routines around eating and sleeping. Preschoolers may show signs of regression, irritable behavior, or temper tantrums. During school-age years, children may show both externalizing (aggressive or disruptive) and internalizing (withdrawn and passive) behaviors. Because of family isolation, some children have no opportunity to participate in extracurricular activities at school and do not form friendships. Adolescents in homes where IPV is present have higher


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Pediatrics_Nelson. of family isolation, some children have no opportunity to participate in extracurricular activities at school and do not form friendships. Adolescents in homes where IPV is present have higher rates of school failure, substance abuse, and risky sexual behaviors. These adolescents are more likely than their peers to enter into a violent dating relationship.


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Pediatrics_Nelson. Because of the high concurrence of IPV and child abuse, asking about IPV is part of the screening for violence against children. Recognizing the importance of IPV screening in pediatric practice, the American Academy of Pediatrics has endorsed universal screening in this setting and suggests that intervening on behalf of battered women may be one of the most effective means of preventing child abuse. Without standardized screening, pediatricians may underestimate the IPV prevalence in their practices. Parents should not be screened together. Questions about family violence should be direct, nonjudgmental, and done in the context of child safety and anticipatory guidance (Table 25-1).


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Pediatrics_Nelson. Intervention is needed for caregivers who disclose IPV. It is appropriate to show concern and to provide available community resources. It is important to assess for the safety of the victim and the children. In some states, physicians are mandated to report IPV. Information for families that provides details about community resources and state laws is helpful. Youth violence is a leading cause of pediatric mortality in the United States. Homicide is the second leading cause of death for all children 1 to 19 years of age. Each year nearly 6000 children, primarily adolescents, are victims of homicide, and 4000 How are things at home and at school? Who lives with you? How do you get along with your family members? What do you like to do with them? What do you do if something is bothering you? Do you feel safe at home? Do people fight at home? What do they fight about? How do they fight?


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Pediatrics_Nelson. Do your friends get into fights often? How about you? When was your last physical fight? Have you ever been injured during a fight? Has anyone you know been injured or killed? Have you ever been forced to have sex against your will? Have you ever been threatened with a gun or a knife? How do you avoid getting in fights? Do you carry a weapon for self-defense? FOR THE PARENT Do you have any concerns about your child? Who helps with your children? How do you feel about your neighborhood? Do you feel safe at home? Is there any fighting or violence at home? Does anyone at home use drugs? Have you been frightened by your partner? Does your partner ever threaten you or hurt you?


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Pediatrics_Nelson. more commit suicide. Youth violence is a problem in urban, suburban, and rural communities and affects children across race and gender. Surveys of adolescents show that 30% to 40% of boys and 15% to 30% of girls report having committed a serious violent offense during childhood, including robbery, rape, aggravated assault, or homicide. Most of these crimes are not reported to the police, and the perpetrator is arrested in a few cases only. Although boys commit more crimes than girls, this gap has narrowed. Boys are much more likely to be arrested for their crimes. Self-reported violent events do not differ much between white and minority adolescents; the latter are more likely to be arrested for their crimes.


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Pediatrics_Nelson. Most violent youth begin to exhibit their violent behaviors during early adolescence. Bullying, which peaks in middle school, is a form of aggression in which a child repeatedly and intentionally intimidates, harasses, or physically harms another child. Technology-assisted bullying behavior or cyber-bullying has become a major concern. Psychosocial consequences of being bullied include depression and suicidal ideation. Children who bully others are more likely to be involved with other problem behaviors, such as smoking and alcohol use. Bullying and being bullied are both associated with higher rates of weapon carriage and fighting. Although most bullies Exposure to TV violence Low IQ Poor parent-child relations Antisocial parents Parents’ positive evaluation of peers Abusive, neglectful Low SES/poverty School Poor attitude Poor attitude Commitment to school


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Pediatrics_Nelson. Poor parent-child relations Antisocial parents Parents’ positive evaluation of peers Abusive, neglectful Low SES/poverty School Poor attitude Poor attitude Commitment to school From National Center for Injury Prevention and Control, Substance Abuse and Mental Health Services Administration: Youth violence: a report of the surgeon general. Rockville, MD, 2001, U.S. Department of Health and Human Services. SES, Socioeconomic status. *Bold = factors with strongest effect. †Males only.


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Pediatrics_Nelson. †Males only. do not progress into serious violent offenders, violent behavior that continues into high school years indicates the potential for severe violent behavior in adulthood. Another subset of violent youth begins at a very young age. These children tend to be more serious offenders, perpetrate more crimes, and more often continue their violence into adulthood. Most adolescent violence ends by young adulthood. Most violent youth are only intermittently violent. Frequent acts of violence are committed more commonly by youth who start their violence before the onset of puberty. These violent youth need to be evaluated for cognitive impairments or mental illness.


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Pediatrics_Nelson. Serious youth violence is not an isolated problem but usually coexists with other adolescent risk-taking behaviors, such as drug use, truancy and school dropout, early sexual activity, and gun ownership. Risk factors for youth violence are slightly different for children who begin their violence early in life compared with youth who begin during adolescence. Often these risk factors exist in clusters, and they tend to be additive. Although understanding risk factors for violence is crucial for developing prevention strategies, the risk factors do not predict whether a particular individual will become violent. For children who begin their violence early in life, the strongest risk factors are early substance abuse (<12 years of age) and perpetration of nonviolent, serious crimes during childhood. Additional risk factors include poverty, male gender, and antisocial behavior. For children who begin their violence during adolescence, individual risk factors are less important, whereas


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Pediatrics_Nelson. childhood. Additional risk factors include poverty, male gender, and antisocial behavior. For children who begin their violence during adolescence, individual risk factors are less important, whereas factors related to peer groups are most important. Gang membership, associating with antisocial or delinquent friends, being unpopular in school, and having weak ties to conventional peer groups are important risk factors for adolescent-onset violence (Table 25-2). The strength of the listed risk factors is not uniform, and some factors show a small effect only. Table 25-2 also lists protective factors that seem to buffer the effects of risk factors. One important protective factor is the child’s level of school connectedness, such as involvement in class and extracurricular activities, and how positively the child regards the school’s personnel. Another protective factor is the support of nonviolent family members and close friends.


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Pediatrics_Nelson. Violence prevention efforts that target risk and protective factors need to be developmentally appropriate. Education about the dangers of substance abuse should begin before the onset of puberty, whereas adolescent programs must consider the importance of peer group identification. Many violence prevention programs fail to show long-term effects. Effective violence prevention programs must address simultaneously individual, family, and environmental (school, peer group, social) risk factors; capitalize on the child’s strengths; involve family and other supports; and be implemented over an extended period.


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Pediatrics_Nelson. Dating violence and date rape are common. It is estimated that 15% to 40% of adolescents have experienced violence in a dating relationship. Adolescent women experience higher rates of sexual assault than any other age group. An acquaintance or partner of the victim perpetrates most adolescent sexual assaults. Risk factors for date rape include initiating dating at a young age, initiating early sexual activity, and having a history of past sexual abuse or victimization. A history of child abuse by parents or siblings increases the risk of dating violence. Adolescent boys who believe that it is appropriate to strike a girl if she insults or embarrasses him or intentionally tries to make him jealous are at risk for becoming perpetrators. Date-specific factors put some teens at risk for date rape, including who initiated the date, the date activities, which person drove, and who paid.


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Pediatrics_Nelson. Alcohol use is common in episodes of adolescent sexual assault, occurring in approximately 50% of cases. Drugs such as benzodiazepines, cocaine, and marijuana may also contribute. Flunitrazepam (Rohypnol) and gamma hydroxybutyrate are two commonly implicated drugs that cause sedation and amnesia, especially when used in conjunction with alcohol. Relatively few victims of date rape report the assault to law enforcement. Reporting rates are even lower when the victim knows the perpetrator. Women who report assaults to the police are more likely to receive timely medical care; it is likely that many sexually assaulted adolescents do not receive medical attention, putting them at risk for physical and mental health consequences. Routine adolescent health care should screen for adolescent dating violence, provide routine sexually transmitted infection evaluation, and be able to identify counseling resources for teens who are victims or perpetrators of dating violence (see Chapter 116).


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Pediatrics_Nelson. DIVORCE, SEPARATION, AND BEREAVEMENT The family is the child’s principal resource for meeting needs for protection, emotional support, education, and socialization. A variety of different disruptions may cause the child to be separated from his or her parents. At times these separations may be relatively brief but unexpected (e.g., a parent’s acute illness or injury). The separation may occur in the context of significant parental discord, as often occurs with a divorce. The death of a parent results in a permanent separation that may be anticipated or unanticipated. All of these disruptions cause significant stress for the child, with the potential for long-term adverse consequences. The child’s adaptation to these stresses is affected by the reasons for the separation and the child’s age, temperament, and available support systems.


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Pediatrics_Nelson. Approximately 40% to 50% of first marriages end in divorce. About half of these divorces occur in the first 10 years of marriage, so there are often young children in the family when the parents divorce. At least 25% of children experience the divorce or separation of their parents. Few events in childhood are as dramatic and challenging for the child as divorce. Divorce is likely to be accompanied by changes in behavioral and emotional adjustment. In the immediate post-divorce period, many children exhibit anger, noncompliance, anxiety, and depression. Children from divorced families require psychological help two to three times more frequently than children with married parents. Long-term studies suggest that in the absence of ongoing stressors, most children demonstrate good adjustment a few years after the divorce, but some have enduring difficulties.


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Pediatrics_Nelson. Divorce is not a single event, but a process that occurs over time. In most cases, marital conflict begins long before the physical or legal separation, and the divorce brings about permanent changes in the family structure. Multiple potential stressors for the child are associated with divorce, including parental discord before and after the divorce, changes in living arrangements and sometimes location, and changes in the child’s relationship with both parents.


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Pediatrics_Nelson. The child’s relationship with each parent is changed by the divorce. In the short-term, the parent is likely to experience new burdens and feelings of guilt, anger, or sadness that may disrupt parenting skills and family routines. Contact with the noncustodial parent may decline greatly. Parents may be perceived by their children as being unaware of the child’s distress around the time of the divorce. Pediatricians can help parents understand things they can do that will be reassuring to the child. Maintaining contact with both parents, seeing where the noncustodial parent is living, and, in particular, maintaining familiar routines are comforting to the child in the midst of the turmoil of a separation and divorce. The child should attend school and continue to have opportunities to interact with friends. Given the parents’ distress, assistance from the extended family can be helpful, but these family members may not offer to help for fear of “interfering.” It may be helpful for


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Pediatrics_Nelson. interact with friends. Given the parents’ distress, assistance from the extended family can be helpful, but these family members may not offer to help for fear of “interfering.” It may be helpful for pediatricians to encourage parents to ask for this assistance. Pediatricians should look for maladaptive coping responses. Some parents may respond to their increased burdens and distress by treating their children as friends with whom they share their distress. Alternatively they may place excessive responsibilities on the child or leave the child unsupervised for longer periods of time. Responses such as these increase the chance that the child will develop behavioral or emotional problems.


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Reaction to Divorce at Different Ages

Pediatrics_Nelson. Reaction to Divorce at Different Ages


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Pediatrics_Nelson. The child’s reaction to the divorce is influenced by the child’s age and developmental level. Although infants do not react directly to the divorce, they require special considerations in relation to custody and visitation because infants need a stable daily routine and regular contact with a primary caregiver to develop secure attachment. Separations from a primary caregiver should be brief. Increased infant irritability or listlessness and withdrawal may be signs of distress for an infant. Preschool children are characterized by having magical beliefs about cause and effects and an egocentric view of the world. They may believe that something they did caused the divorce, leading them to be particularly upset. They may engage in unusual behaviors that they believe will bring the parents back together again. At this age, parents need to deliver a clear message that the divorce was related to disagreements between the parents, that nothing the child did caused the divorce, and that


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Pediatrics_Nelson. back together again. At this age, parents need to deliver a clear message that the divorce was related to disagreements between the parents, that nothing the child did caused the divorce, and that nothing the child could do would bring the parents back together again. Preschool children may reason that if the parents left each other they also might leave the child. To counteract this fear of abandonment, children may need to be reassured that although parents separated, they will not abandon the child and that the child’s relationship with both parents will endure.


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Pediatrics_Nelson. School-age children have a concrete understanding of cause and effect; if something bad happened, they understand that something caused it to happen. However they are not likely to understand fully the subtleties of parental conflict or the idea that multiple factors contribute to a conflict. Children at this age may still worry that something they did caused the divorce. They may express more anger than younger children and often feel rejected. Many young school-age children worry about what will happen to one or both parents. School performance often deteriorates. Older elementary school–age children may believe that one parent was wronged by the other. This belief, in conjunction with their concrete understanding of cause and effect, allows children to be easily co-opted by one parent to take sides against the other. Parents need to understand this vulnerability and resist the temptation to support their child in taking sides.


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Pediatrics_Nelson. Adolescents may respond to the divorce by acting out, becoming depressed, or experiencing somatic symptoms. Adolescents are developing a sense of autonomy, a sense of morality, and the capacity for intimacy, and divorce may lead them to question previously held beliefs. They may be concerned about what the divorce means for their future and whether they too will experience marital failure. Questioning of previous beliefs in conjunction with decreased supervision may set the stage for risk-taking behaviors, such as truancy, sexual behaviors, and alcohol or drug use. Outcome of Divorce


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Pediatrics_Nelson. One of the best predictors of children’s adaptation to divorceis whether the physical separation is associated with adecrease in the child’s exposure to parental discord. In mostcases, divorced parents still must interact with each otheraround the child’s schedule, child custody and support, andother parenting issues. These types of issues create the potential for the child to have ongoing exposure to significant discord between the parents. For example if one parent tends tokeep the child up much later than the bedtime at the otherparent’s house, sleep problems may develop. When childrenfeel caught in the middle of ongoing conflicts between theirdivorced parents, behavior or emotional problems are muchmore likely. Regardless of how angry parents are with each other, the parents should be counseled that they must shieldtheir child from this animosity. Clear rules about schedules,discipline, and other parenting roles is ideal, but in cases ofconflict it can also be helpful for the


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Pediatrics_Nelson. be counseled that they must shieldtheir child from this animosity. Clear rules about schedules,discipline, and other parenting roles is ideal, but in cases ofconflict it can also be helpful for the pediatrician to help aparent accept that he or she can only control his or her actionsand decisions related to the child. When parents have trouble resolving these issues, mediation may be helpful. Pediatricians need to be wary of parents’ attempts to recruit theminto custody battles to substantiate claims of poor parenting,unless the pediatrician has first-hand knowledge that the concerns are valid.


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Pediatrics_Nelson. Although the primary physical residence for most children is still with the mother, the court’s bias toward preferring mothers in custody decisions has decreased, and there is more emphasis on including both parents in the child’s life. In the early 1980s, 50% of children had no contact with their fathers 2 or 3 years after a divorce, whereas today only 20% to 25% of children have no contact with their father. Most states now allow joint physical or legal custody. In joint physical custody, the child spends a significant amount of time with each parent, and in joint legal custody, parents share authority in decision making. Although joint custody arrangements may promote the involvement of both parents in the child’s life, they also can be a vehicle through which parents continue to express their anger at each other. When parents have severe difficulty working together, joint custody is an inappropriate arrangement and has been associated with deterioration in the child’s


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Pediatrics_Nelson. to express their anger at each other. When parents have severe difficulty working together, joint custody is an inappropriate arrangement and has been associated with deterioration in the child’s psychological and social adjustment.


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Pediatrics_Nelson. Divorce often creates financial difficulties. Family income usually declines in the first year after the divorce. Only about half of mothers who have child support awards receive the full amount, and one fourth receive no money at all. These financial changes may have multiple adverse affects on the child. A move to a new house may require the child to attend a new school disrupting peer relationships and other potential supports. The child may spend more time in child care if one or both parents have to increase work hours. Role of the Pediatrician


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Pediatrics_Nelson. Pediatricians may be confronted with issues related to marital discord before the divorce, may be consulted around the time of the divorce, or may be involved in helping the family to manage issues in the years after the divorce. The pediatrician can be an important voice in helping the parents understand and meet the child’s needs (Table 26-1). Before the divorce, parents may wonder what they should tell their children. Children should be told of the parents’ decision before the physical separation. The separation should be presented as a rational step in managing marital conflict and should prepare the child for the changes that will occur. Parents should be prepared to answer children’s questions, and they should expect that the questions will be repeated over the next months. Once parents have told children of the separation, it may be confusing to the child if the parents continue to appear to live together and may raise false hopes that the parents will not divorce.


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Pediatrics_Nelson. Many parents report not feeling like their life had stabilizeduntil 2 to 3 years or more after the divorce, and for some thedivorce remains a painful issue 10 years later. The child’s emotional adjustment to divorce is closely predicted by the parents’adjustment so parents should be encouraged to get help forthemselves if they are struggling emotionally after a divorce. Table 26-1 General Recommendations for Pediatricians to Help Children During Separation, Divorce, or Death of a Close Relative Acknowledge and provide support for grief that the parent/ caregiver is experiencing. Help parent/caregiver consider child’s needs. Encourage parent/caregiver to maintain routines familiar to the child. Encourage continued contact between child and his or her friends. If primary residence changes, the child should take transitional objects, familiar toys, and other important objects to the new residence.


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Pediatrics_Nelson. If primary residence changes, the child should take transitional objects, familiar toys, and other important objects to the new residence. Minimize frequent changes in caregivers, and for infants keep brief the times spent away from primary caregiver. Have parent/caregiver reassure the child that he or she will continue to be cared for. Have parent/caregiver reassure the child that he or she did not cause the separation, divorce, or death (especially important in preschool children). Encourage parent/caregiver to create times or rituals that allow the child to discuss questions and feelings if the child wishes.


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Pediatrics_Nelson. Encourage parent/caregiver to create times or rituals that allow the child to discuss questions and feelings if the child wishes. Although most children ultimately show good adjustment to thedivorce, some have significant acting-out behaviors or depression that requires referral to a mental health professional. Some parents need the assistance of a mediator or family therapist tohelp them stay focused on their child’s needs. In the most contentious situations, a guardian ad litem may need to be appointedby the court. This individual is usually a lawyer or mental healthprofessional with the power to investigate the child and family’sbackground and relationships to make a recommendation to thecourt as to what would be in the best interests of the child.


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Pediatrics_Nelson. Children experience separations from their primary caregiver for a variety of reasons. Brief separations, such as those to attend school, camp, or other activities, are nearly a universal experience. Many children experience longer separations for a variety of reasons, including parental business trips, military service, or hospitalization. Child adjustment to separation is affected by child factors, such as the age of the child and the child’s temperament; factors related to the separation, such as the length of and reason for the separation, whether the separation was planned or unplanned; and factors related to the caregiving environment during the separation, such as how familiar the child is with the caregiver and whether the child has access to friends and familiar toys and routines.


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Pediatrics_Nelson. Children between 6 months and 3 to 4 years of age often havethe most difficulty adjusting to a separation from their primarycaregiver. Older children have cognitive and emotional skillsthat help them adjust. They may be better able to understandthe reason for the separation, communicate their feelings, andcomprehend the passage of time, allowing them to anticipatethe parent’s return. For older children, the period immediatelybefore a planned separation may be particularly difficult if thereason for the separation causes significant family tension, as itmay in the case of hospitalization or military service.


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Pediatrics_Nelson. If parents anticipate a separation, they should explain the reason for the separation and, to the extent possible, give concrete information about when they will be in contact with the child and when they will return home. If the child can remain at home with a familiar and responsive caregiver, this is likely to help adjustment. If children cannot remain at home, they should be encouraged to take with them transitional objects, such as a favorite blanket or stuffed animal, familiar toys, and important objects such as a picture of the parent. Maintenance of familiar family routines and relationships with friends should be encouraged.


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Pediatrics_Nelson. Death of a close family member is a sad and difficult experience. When a child loses a parent, it is a devastating experience. This experience is not rare. By 15 years of age, 4%of children in the United States experience the death of a parent. This experience is likely to alter forever the child’s view of the world as a secure and safe place. Similar to theother separations, a child’s cognitive development and temperament along with the available support systems affectthe child’s adjustment after the death of a parent. Many ofthe recommendations in Table 26-1 are helpful. The deathof a parent or close family member also brings up someunique issues. Explaining Death to a Child


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Pediatrics_Nelson. Explaining Death to a Child Children’s understanding of death changes with their cognitive development and experiences (see Chapter 4). Preschool children often do not view death as permanent and may have magical beliefs about what caused death. As children become older, they understand death as permanent and inevitable, but the concept that death represents the cessation of all bodily functions and has a biologic cause may not be fully appreciated until adolescence.


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Pediatrics_Nelson. Death should not be hidden from the child. It should be explained in simple and honest terms that are consistent withthe family’s beliefs. The explanation should help the child tounderstand that the dead person’s body stopped functioningand that the dead person will not return. Preschool childrenshould be reassured that nothing they did caused the individual to die. One should be prepared to answer questionsabout where the body is and let the child’s questions helpdetermine what information the child is prepared to hear.False or misleading information should be avoided. Comparisons of death to sleep may contribute to sleep problems inthe child.


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Pediatrics_Nelson. There are many possible reactions of children to the death of a parent or close relative. Sadness and a yearning to be with the dead relative are common. Sometimesa child might express a wish to die so that he or she canvisit the dead relative, but a plan or desire to commit suicide is uncommon and would need immediate evaluation. A decrease in academic functioning, lack of enjoymentwith activities, and changes in appetite and sleep can occur.About half of children have their most severe symptomsabout 1 month after the death, but for many the most severesymptoms in reaction to the death do not occur until 6 to12 months after the death. Should the Child Attend the Funeral?


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Pediatrics_Nelson. Should the Child Attend the Funeral? Children often find it helpful to attend the funeral. It may help the child to understand that the death occurred and provide an opportunity to say good-bye. Seeing others express their grief and sadness may help the child to express these feelings. Going to the funeral helps prevent the child from having fears or fantasies about what happened at the funeral. If the child is going to attend the funeral, he or she should be informed of what will happen. If a preschool-age child expresses a desire not to attend the funeral, he or she should not be encouraged to attend. For older children, it may be appropriate to encourage attendance, but a child who feels strongly about not wanting to go to the funeral should not be required to attend. Bair-Merritt M: Intimate partner violence, Pediatr Rev 31:145–150, 2001 Cole S, Lanham J: Failure to thrive: an update, Am Fam Physician 83(7): 829–834, 2011


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Pediatrics_Nelson. Bair-Merritt M: Intimate partner violence, Pediatr Rev 31:145–150, 2001 Cole S, Lanham J: Failure to thrive: an update, Am Fam Physician 83(7): 829–834, 2011 Dubowitz H, Feigelman S, Lane W, et al: Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SIIK) Model, Pediatrics 123:858–864, 2009 Kellogg: ND and the Committee on Child Abuse and Neglect. The evaluation of sexual behaviors in children, Pediatrics 124:992–998, 2009 Kleinsorge C, Civitz LM: Impact of divorce on children: developmental considerations, Pediatr Rev 33:147–155, 2012 Minnes S, Lang A, Singer L: Prenatal tobacco, marijuana, stimulant, and opiate exposure: outcomes and practical implications, Addict Sci Clin Pract 6:57–70, 2011 Reece RM, Christian CW, editors: Child abuse: medical diagnosis and management, ed 3, Elk Grove Village, Ill, 2009, American Academy of Pediatrics. (Role of the pediatrician in youth violence prevention. Pediat rics 124:393−402, 2009


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Pediatrics_Nelson. Pediatrics. (Role of the pediatrician in youth violence prevention. Pediat rics 124:393−402, 2009 Sedlak AJ, Mettenburg J, Basena M, et al: Fourth national incidence study of child abuse and neglect (NIS–4): report to Congress. U.S. Department of Health and Human Services, Administration for Children and Families. Washington, DC, 2010, (website). www.acf.hhs.gov/sites/default/files/opre/nis4_report_congress_full_pdf_ jan2010.pdf. Accessed October 8, 2012. Shonkoff JP, Thomas Boyce W, McEwen BS: Neuroscience, molecular biol ogy, and the childhood roots of health disparities: building a new frame work for health promotion and disease prevention, JAMA 301:2252–2259, Smith GA and the Committee on Injury, Violence, and Poison Prevention. Policy Statement. Role of the pediatrician in youth violence prevention. Pediatrics 124(1):393–402, 2009


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Pediatrics_Nelson. Smith GA and the Committee on Injury, Violence, and Poison Prevention. Policy Statement. Role of the pediatrician in youth violence prevention. Pediatrics 124(1):393–402, 2009 Spack NP, Edwards-Leeper L, Feldman HA, et al: Children and adolescents with gender identity disorder referred to a pediatric medical center, Pediatrics 129:418–425, 2012 April O. Buchanan and Maria L. Marquez Proper nutrition in infancy is essential for normal growth, resistance to infections, long-term adult health, and optimal neurologic and cognitive development. Healthy nutrition is especially important during the first 6 months, a period of exceptionally accelerated growth and high nutrient requirements relative to body weight (see Chapter 5). Breastfeeding is associated with a reduced risk of many diseases in infants, children, and mothers (for more details visit http://www.nutrition.gov/


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Pediatrics_Nelson. Human milk and breastfeeding are the ideal and normative standards for infant feeding and nutrition. The American Academy of Pediatrics (AAP) recommends human milk as the sole source of nutrition for the first 6 months of life, with continued intake for the first year, and as long as desired thereafter. Breastfeeding has shortand long-term advantages for infant neurodevelopment. Pediatric health care providers should approach breastfeeding at multiple levels (individual, community, social, and political) to reach the goals of “Healthy People in 2020”; its targets include 82% of infants with any breastfeeding, 23.7% of infants with exclusive breastfeeding for the first 6 months of life, and lactation support at work of 38%. In collaboration with national and global organizations, including the AAP, World Health Organization (WHO), UNICEF, the Centers for Disease Control and Prevention (CDC), and the Joint Commission, hospitals are asked to promote and facilitate breastfeeding.


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Pediatrics_Nelson. The first 2 days of breastfeeding, and perhaps the first hour of life, may determine the success of breastfeeding. The current rate of breastfeeding initiation for the total U.S. population is 75% (Figure 27-1). There is greater emphasis to improve and standardize hospital practices with “Baby Friendly” programs for breastfeeding support. The Department of Health and Human Services and theCDC recognize that breastfeeding offers infants, mothers,and society compelling advantages in industrialized and developing countries. Human milk feeding decreases the incidence and severity of diarrhea, respiratory illnesses, otitis media, bacteremia, bacterial meningitis, and necrotizingenterocolitis. There are beneficial effects of feeding preterm infants with human milk on long-term neurodevelopment (IQ) in preterm infants. Preterm breastfed infants also have a lower readmission rate in the first year of life.


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Pediatrics_Nelson. Mothers who breastfeed experience both shortand longterm health benefits. Decreased risk of postpartum hemorrhages, more rapid uterine involution, longer period of amenorrhea, and decreased postpartum depression have been observed. Similarly, there is an association between a long lactation of 12 to 23 months (cumulative lactation of all pregnancies) and a significant reduction of hypertension, hyperlipidemia, cardiovascular disease, and diabetes in the mother. Cumulative lactation of more than 12 months also correlates with reduced risk of ovarian and breast cancer.


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Pediatrics_Nelson. Adequacy of milk intake can be assessed by voidingand stooling patterns of the infant. A well-hydrated infantvoids six to eight times a day. Each voiding should soak, notmerely moisten, a diaper, and urine should be colorless. By5 to 7 days, loose yellow stools should be passed at least fourtimes a day. Rate of weight gain provides the most objectiveindicator of adequate milk intake. Total weight loss after birthshould not exceed 7%, and birth weight should be regained by10 days. The mean feeding frequency during the early weekspostpartum is 8 to 12 times per day. An infant may be adequately hydrated while not receiving enough milk to achieveadequate energy and nutrient intake. Telephone follow-up isvaluable during the interim between discharge and the firstdoctor visit to monitor the progress of lactation. A follow-upvisit should be scheduled by 3 to 5 days of age, and again by 2 weeks of age.


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Pediatrics_Nelson. In the newborn period, elevated concentrations of serumbilirubin are present more often in breastfed infants than in formula-fed infants (Chapter 62). Feeding frequency duringthe first 3 days of life of breastfed infants is inversely relatedto the level of bilirubin; frequent feedings stimulate meconium passage and excretion of bilirubin in the stool. Infantswho have insufficient milk intake and poor weight gain in thefirst week of life may have an increase in unconjugated bilirubin secondary to an exaggerated enterohepatic circulationof bilirubin. This is known as breastfeeding jaundice. Attention should be directed toward improved milk productionand intake. The use of water supplements in breastfed infantshas no effect on bilirubin levels and is not recommended. 0 Rate of initiation Rate of 6 months Rate of exclusive of breastfeeding of any breastfeeding breastfeeding for 6 months


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Pediatrics_Nelson. 0 Rate of initiation Rate of 6 months Rate of exclusive of breastfeeding of any breastfeeding breastfeeding for 6 months Figure 27-1 The 2010 and 2020 Healthy People Targets and the current 2012 rates of breastfeeding initiation, 6 months of any breastfeeding, and 6 months of exclusive breastfeeding in the United States. After the first week of life in a breastfed infant, prolongedelevated serum bilirubin may be due to presence of anunknown factor in milk that enhances intestinal absorptionof bilirubin. This is termed breast milk jaundice, which is a diagnosis of exclusion and should be made only if an infantis otherwise thriving, with normal growth and no evidenceof hemolysis, infection, biliary atresia, or metabolic disease(Chapter 62). Breast milk jaundice usually lasts no morethan 1 to 2 weeks. The American Academy of Pediatrics recommends vitamin D supplementation (400 IU/day startingsoon after birth), and, when needed, fluoride after 6 monthsfor breastfed infants.


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Pediatrics_Nelson. Breast tenderness, engorgement, and cracked nipples arethe most common problems encountered by breastfeedingmothers. Engorgement, one of the most common causes oflactation failure, should receive prompt attention because milk supply can decrease quickly if the breasts are not adequately emptied. Applying warm or cold compresses to thebreasts before nursing and hand expression or pumping ofsome milk can provide relief to the mother and make the areola easier to grasp by the infant. Nipple tenderness requiresattention to proper latch-on and positioning of the infant.Supportive measures include nursing for shorter periods,beginning feedings on the less sore side, air drying the nipples well after nursing, and applying lanolin cream after eachnursing session. Severe nipple pain and cracking usually indicate improper latch-on. Temporary pumping, which is well tolerated, may be needed. Meeting with a lactation consultantmay help minimize these problems and allow the successfulcontinuation


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Pediatrics_Nelson. usually indicate improper latch-on. Temporary pumping, which is well tolerated, may be needed. Meeting with a lactation consultantmay help minimize these problems and allow the successfulcontinuation of breastfeeding.


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Pediatrics_Nelson. If a lactating woman reports fever, chills, and malaise, mastitis should be considered. Treatment includes frequent and complete emptying of the breast and antibiotics. Breastfeeding usually should not be stopped because the mother’s mastitis commonly has no adverse effects on the breastfed infant. Tuberculosis (active) Should not breastfeed; expressed milk may be provided to child. Varicella Should not breastfeed; expressed milk may be provided to child. H1N1 influenza Should not breastfeed; expressed milk may be provided to child. Herpes simplex infection of Should not breastfeed; expressed the breast milk may be provided to child. virus (HIV) mothers are not recommended to breastfeed. In developing countries women are recommended to combine breastfeeding with antiretroviral therapy (ART) for 6 months.


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Pediatrics_Nelson. virus (HIV) mothers are not recommended to breastfeed. In developing countries women are recommended to combine breastfeeding with antiretroviral therapy (ART) for 6 months. Use of phencyclidine (PCP), Recommended to stop use cocaine, or amphetamines of drugs as it can affect infant neurobehavioral development. Mothers enrolled in supervised methadone programs are encouraged to breastfeed. Alcohol Limit ingestion to less than 0.5 mg of alcohol per kg of body weight due to association with motor development. Radiopharmaceutical agents Express milk before exposure to feed infant. Express milk and discard during therapies. Radioactivity may be present in milk from 2 to 14 days, depending on agent. Consult with nuclear medicine expert. Antineoplastic and Substitute formula. immunosuppressive agents Modified from Eidelman AI, Schanler RJ: American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk, Pediatrics 129(3):827–841, 2012.


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Pediatrics_Nelson. Modified from Eidelman AI, Schanler RJ: American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk, Pediatrics 129(3):827–841, 2012. Untreated mastitis may also progress to a breast abscess. If an abscess is diagnosed, treatment includes incision and drainage, antibiotics, and regular emptying of the breast. Nursing from the contralateral breast can be continued with a healthy infant. If maternal comfort allows, nursing can continue on the affected side. Maternal infection with human immunodeficiency virus (HIV) is considered a contraindication for breastfeeding in developed countries. When the mother has active tuberculosis, syphilis, or varicella, restarting breastfeeding may be considered after therapy is initiated. If a woman has herpetic lesions on her breast, nursing and contact with the infant on that breast should be avoided. Women with genital herpes can breastfeed. Proper hand-washing procedures should be stressed.


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Pediatrics_Nelson. There are limited numbers of medical contraindications for breastfeeding, including pediatric metabolic disorders such as galactosemia, and infants with phenylketonuria, although infants with the latter may alternate breastfeeding with special protein-free or modified formulas. Maternal contraindications are shown in Table 27-1. Any drug prescribed therapeutically to newborns usually canbe consumed via breast milk without ill effect. The factors that determine the effects of maternal drug therapy on the nursinginfant include the route of administration, dosage, molecularweight, pH, and protein binding. Few therapeutic drugs are absolutely contraindicated; these include radioactive compounds, antimetabolites, lithium, and certain antithyroid drugs.The mother should be advised against the use of unprescribeddrugs, including alcohol, nicotine, caffeine, or “street drugs.”


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Pediatrics_Nelson. Maternal use of illicit or recreational drugs is a contraindication to breastfeeding. If a woman is unable to discontinue drug use, she should not breastfeed. Expression of milk for a feeding or two after use of a drug is not acceptable. Breastfed infants of mothers taking methadone (but no alcohol or other drugs) as part of a treatment program generally have not experienced ill effects.


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Pediatrics_Nelson. Cow’s milk–based formulas are the vast majority of commercial formulas. Most milk-based formulas have added iron, which the AAP recommends, and parents should use only iron-fortified formula unless advised otherwise by theprimary health care provider. Infant formula manufacturershave begun to examine the benefits of adding a variety ofnutrients and biological factors to infant formula to mimicthe composition and quality of breast milk. These includelong-chain polyunsaturated fatty acids, nucleotides, prebiotics, and probiotics. Soy-based formulas, which sometimes have added iron, may be used for newborns who maybe allergic to cow’s milk. However, some newborns allergicto cow’s milk are also allergic to the protein in soy formulas. There are hypoallergenic formulas for infants who can’ttolerate the basic formulas, such as those with allergies tomilk or soy proteins. The proteins in these hypoallergenicformulas are broken down to their basic components andare therefore easier to digest


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Pediatrics_Nelson. the basic formulas, such as those with allergies tomilk or soy proteins. The proteins in these hypoallergenicformulas are broken down to their basic components andare therefore easier to digest (Table 27-2). Specialized formulas are designed for premature, low birth weight babies.The carbohydrate is generally lactose, although lactose-freecow’s milk–based formulas are available. The caloric density of formulas is 20 kcal/oz (0.67 kcal/mL), similar to thatof human milk. A relatively high-fat and calorically densediet (human milk or formula) is needed to deliver adequate


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Pediatrics_Nelson. Table 27-2 Composition of Breast Milk, Breast Milk after Freezing and Pasteurization, and Representative Infant Formulas COMPONENT BREAST MILK BREAST MILK AFTER FREEZING AND PASTEURIZING STANDARD FORMULA SOY FORMULA HYPOALLERGENIC FORMULA Protein 1.1 per dL Reduced 1.5 per dL 1.7 per dL 1.9 per d/L Fat 4.0 per dL 4.0 per dL 3.6 per dL 3.6 per dL 3.8–3.3 per d/L Carbohydrate 7.2 per dL 7.2 per dL 6.9–7.2 per dL 6.8 per dL 6.9–7.3 per d/L Sodium 8.0 mg/L 8.0 mg/L 6.5–8.3 mg/L 13 mg/L 14 mg/L Monoglycerides Present Present Added to some Added to some Added to some formulas formulas formulas Free fatty acids Present Present Added to some Added to some Added to some formulas formulas formulas Linoleic acid Present Present Added to some Added to some Added to some formulas formulas formulas


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Pediatrics_Nelson. Linoleic acid Present Present Added to some Added to some Added to some formulas formulas formulas Alpha-linoleic acid Present Present Added to some Added to some Added to some formulas formulas formulas calories (around 18 to 30 oz per day). Formula-fed infants are at higher risk for obesity later in childhood; this may berelated to self regulation of volumes ingested by the newbornsand infants.


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Pediatrics_Nelson. By approximately 6 months, complementary feeding ofsemisolid foods is suggested. By this age, an exclusivelybreastfed infant requires additional sources of severalnutrients, including protein, iron, and zinc. Cereals commonly are mixed with breast milk, formula, or water andlater with fruits. To help identify possible allergies or foodintolerances that may arise when new foods are added tothe diet, single-grain cereals (rice, oatmeal, barley) are recommended as starting cereals. If juice is given, it shouldbe started only after 6 months of age, be given in a cup (asopposed to a bottle), and limited to 4 oz daily of 100% natural unsweetened juice. An infant should never be put tosleep with a bottle or cup filled with milk, formula, or juicebecause this can result in Early Childhood Caries (ECC)(see Chapter 127).


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Pediatrics_Nelson. Green vegetables bring nutrients, vitamin, minerals, and micronutrients. Children should get two to three servings of vegetables. For infants with a strong family history of food allergy, foods with high allergic potential, such as fish, peanuts, tree nuts, dairy products, and eggs, should probably be avoided. All foods with the potential to obstruct the young infant’s main airway should be avoided in general until 4 years of age or older. Because of the risk of infant botulism, honey should not be given before 1 year of age.


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Pediatrics_Nelson. Commercially prepared or homemade foods help meet the nutritional needs of the infant. If the introduction of solid foods is delayed, nutritional deficiencies can develop, and oral sensory issues (texture and oral aversion) may occur. General signs of readiness include the ability to hold the head up, maturity (around double the birth weight), opening their mouths wide, showing eager anticipation of eating food and interest in foods, sitting unassisted, bringing objects to the mouth, and the ability to track a spoon. The choice of foods to meet micro-nutrient needs is less critical for formula.


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Pediatrics_Nelson. Caries are tooth infections that start as early as when the deciduous teeth (baby teeth) have erupted. A tooth cavity is caused by a combination of sugar and bacteria in the mouth. Eating a healthy diet and brushing regularly will control sugar and bacteria. Rubbing infant gums with a wet washcloth can be the first step in oral hygiene. There are also ergonomically designed tooth brushes, comfortable and safe for infants, used to rub their gums and create the habit of oral hygiene. A variety of feeding habits beyond nursing and bottle feeding are implicated as causes of dental caries in childhood that can lead to problems with adult teeth and health. This infection can be prevented by healthy food choices and habits starting in infancy. Exposure to different textures and the process of self-feeding are important neurodevelopmental experiences for infants. A healthy diet is recommended to take full advantage of the child’s developmental milestones and for the child’s well-being. For


Pediatrics_Nelson

Pediatrics_Nelson. self-feeding are important neurodevelopmental experiences for infants. A healthy diet is recommended to take full advantage of the child’s developmental milestones and for the child’s well-being. For the first 2 months it is important to set the stage by making distinctions between sleeping and feeding time. At 4 to 6 months of age, beginning to actively separate mealtime from bedtime is recommended.


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Pediatrics_Nelson. Learning healthy eating behaviors at an early age is an important preventive measure because of the association of diet with several chronic and noncommunicable diseases (NCDs), such as obesity, diabetes, and cardiovascular disease, which may account for approximately 60% of all deaths worldwide. These diseases share risk factors that can be modified by lifestyle changes such as eating less processed food and increasing physical activity. Diets high in fruits and vegetables together with increased physical activity improve metabolic risk factors. The first 1000 days of life are an important time to engage in healthy nutrition behaviors that will promote well-being. Accelerated postnatal growth in infants and young children is an important risk factor for obesity; interventions should be aimed at identifying underlying causes for early prevention. For a discussion of nutrient needs for children and adolescents, see http://www.health.gov/dietaryguidelines


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Pediatrics_Nelson. The consumption of cow’s milk is ideally not introduced until approximately 1 year of age when it is better tolerated. Low-fat (2%) or whole milk is recommended until 2 years or age, after which fat-free or 1% milk is recommended. Excessive milk intake (more than 24 oz/day) should be avoided in toddlers because larger intakes may reduce the intake of a good variety of nutritionally important solid foods and also result in iron deficiency anemia; large intakes also may contribute to excessive caloric intake. Juice intake for toddlers and young children should be limited to 4 oz, and juice intake for children 7 to 18 years of age should be limited to 8 oz/day. Water and milk are the recommended drinks during the day.


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Pediatrics_Nelson. “ChooseMyPlate” by the U.S. Department of Agriculture canprovide parents with a general guideline for the types of foodsto be offered on a regular basis. A child should eat three mealsa day and two healthy snacks. A general rule for the quantity offood to offer to a child is one tablespoon per age of each foodprovided per meal, with more given if the child requests. As arule of thumb, children should not be eating more than an adultpalm per serving. By 1 year of age, infants should be eating mealswith the family, have a regular schedule of meals and snacks,and be encouraged to self-feed with appropriate finger foods.


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Pediatrics_Nelson. The “plate” image is divided into five sections: Fruits, Grains,Vegetables, Protein, and Dairy (Figure 28-1; Table 28-1). Halfof the “plate” should be vegetables and fruits, and the other halfgrains and proteins, with dairy on the side. The “plate” is simple,organized, and serves as a guide for healthy eating. A weekly recommendation for vegetable intake is also provided (Table 28-1).Other suggestions include the following: switch to fat free orlow-fat (1%) milk; make at least half of the grains whole insteadof refined grains; avoid oversize proportions; compare sodium(salt) in foods such as soup, bread, and frozen meals; choosefoods with lower sodium content; and drink water instead of sugary drinks. After 2 years, it is recommended that the fatintake gradually be reduced to approximately 30% and not lessthan 20% of calories. Replace proteins from red meat with a mixof fish, chicken, nuts, and legumes. Power struggles over eatingare common between parents and toddlers. The parent’s


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Pediatrics_Nelson. 30% and not lessthan 20% of calories. Replace proteins from red meat with a mixof fish, chicken, nuts, and legumes. Power struggles over eatingare common between parents and toddlers. The parent’s role is to decide the what, when, and where of the meals. The child’s role is to decide if, what, and how much to eat.


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Pediatrics_Nelson. Iron intake may be inadequate in some children between 1 and 3 years of age in the United States. Significant iron deficiency anemia exists in some high-risk minority or low-income www.ChooseMyPlate.gov *Including cabbage, cauliflower, green beans, lettuce, zucchini. Figure 28-1 “ChooseMyPlate” guidelines developed by the U.S. Department of Agriculture. (From www.ChooseMyPlate.gov populations of young children. Toddlers with excessive milk intakes (>32 oz/day) and/or those who consume little meat, green leaves rich in iron, or grains are at risk for iron deficiency.


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Pediatrics_Nelson. Teen nutrition can be a challenge. Ads for junk food and images of incredibly thin adolescents provide conflicting and unhealthy ideas about what they should eat. Girls ages 14 to 18 need anywhere from 1800 to 2400 calories per day, depending on their activity level and stage of development. Boys of the same age group need 2000 to 3200 calories daily. Poor eating habits may develop during adolescence. Skipped meals (especially breakfast), binge eating with friends or alone, dieting, and consumption of nutrient-poor, calorically dense foods are common problems. Excessive consumption of sugar from soda, fruit drinks, and specialty coffee and tea drinks may contribute to excess weight gain as well as tooth decay and may displace other needed nutrients. Poor calcium intake during adolescence may predispose the adult to future osteoporotic hip fracture. Osteoporosis (osteopenia) during adolescence caused by poor dietary calcium or vitamin D intake or poor absorption of ingested calcium in


Pediatrics_Nelson

Pediatrics_Nelson. may predispose the adult to future osteoporotic hip fracture. Osteoporosis (osteopenia) during adolescence caused by poor dietary calcium or vitamin D intake or poor absorption of ingested calcium in children and adolescents is a potential problem. Only 1 of 10 teenage girls and 1 of 4 teenage boys get enough calcium every day. Adolescents ages 9 to 18 need 1300 milligrams of calcium daily. Good sources include milk, yogurt, fortified orange juice, cheese, soybeans, and tofu.


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Pediatrics_Nelson. Inadequate iron intake may results in symptoms of fatigue and iron deficiency anemia. Iron needs increase during growth spurts, which is why teens are more likely to suffer from iron deficiency anemia. Teenage girls are especially prone to anemia. Student athletes are also vulnerable to inadequate iron intakes, severely restrictive eating patterns, and use of inappropriate nutritional and vitamin supplements. Adolescents should be counseled on specific and healthy dietary choices (see Chapter 70).


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Pediatrics_Nelson. Childhood obesity is an epidemic in the United States. Data indicate that approximately 17% of children in the United States ages 2 to 20 are obese (body mass index of ≥95th percentile) and more than 30% of U.S. adults are obese. Many obese children become obese adults, and the risk of remaining obese increases with age and degree of obesity. Obesity runs in families and is rarely related to genetic influences. The largest increases in the prevalence of obesity are seen in the most severely overweight classifications and in certain ethnic groups, such as African-American and Mexican-American children. In 2008, obesity cost the nation $147 billion in medical costs. The associations between obesity and television watching and excessive dietary intake as well as the different rates of obesity observed in urban versus rural areas support the important influence of environment. One important risk factor is maternal obesity during pregnancy. Children born to obese mothers are three to five


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Pediatrics_Nelson. observed in urban versus rural areas support the important influence of environment. One important risk factor is maternal obesity during pregnancy. Children born to obese mothers are three to five times more likely to be obese in childhood. Women who gain much more weight than recommended during pregnancy have children who have a higher BMI than normal in adolescence. Also, some small for gestational age (SGA) newborns have higher risks for abnormal postnatal weight gain and diabetes.


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Pediatrics_Nelson. Available @ StudentConsult.com Complications of obesity in children and adolescents can affect virtually every major organ system. High BMI increases the risk of metabolic and cardiovascular diseases and some cancers; it is also the most important modifiable risk factor for glycemia and diabetes. The history and physical examination should screen for many potential complications noted among obese patients (Table 29-1), in addition to specific syndromes associated with obesity (Table 29-2). Medical complications are often related to the degree of obesity and usually decrease in severity or resolve with weight reduction. Obesity is associated with the presence of precursors of coronary heart disease that are already evident in 12and 13-year-old children. Type 2 diabetes is also increasing in children. The diagnosis of obesity depends on the measurement of excess body fat. Actual measurement of body composition is not practical in most clinical situations.


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Pediatrics_Nelson. The diagnosis of obesity depends on the measurement of excess body fat. Actual measurement of body composition is not practical in most clinical situations. Psychosocial Peer discrimination, teasing, reduced college acceptance, isolation, depression, eating disorders (binge-eating), reduced job promotion* Growth Advance bone age, increased height, early menarche Cardiovascular Hypertension, cardiac hypertrophy, arrhythmias, ischemic heart disease,* sudden death* Orthopedic Slipped capital femoral epiphysis, Blount disease Metabolic Insulin resistance, type 2 diabetes mellitus, hypertriglyceridemia, hypercholesterolemia, gout,* hepatic steatosis, polycystic ovary disease, cholelithiasis *Complications unusual until adulthood.


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Pediatrics_Nelson. BMI (body mass index; BMI = wt (kg) ÷ Ht2 (m)) is a convenient screening tool that correlates fairly strongly with body fatness in children and adults. BMI age-specific and gender-specific percentile curves (for 2to 20-year-olds) allow an assessment of BMI percentile (available online at http://www.cdc.gov/growthcharts ). Table 29-3 provides BMI interpretation guidelines. For children younger than 2 years of age, weight-for-length measurements greater than 95th percentile may indicate overweight and warrant further assessment. A BMI for age and gender above the 95th percentile is strongly associated with excessive body fat and is associated with multiple cardiovascular disease risk factors. Early recognition of excessive rates of weight gain, overweight, or obesity in children is essential because the earlier the interventions, the more likely they are to be successful. Alström syndrome Hypogonadism, retinal degeneration, deafness, diabetes mellitus


Pediatrics_Nelson

Pediatrics_Nelson. Alström syndrome Hypogonadism, retinal degeneration, deafness, diabetes mellitus Carpenter syndrome Polydactyly, syndactyly, cranial synostosis, mental retardation Hyperinsulinism Nesidioblastosis, pancreatic adenoma, hypoglycemia, Mauriac syndrome Laurence-Moon-Bardet-Retinal degeneration, syndactyly, Biedl hypogonadism, mental retardation, autosomal recessive syndrome Muscular dystrophy Late onset of obesity Prader-Willi syndrome Neonatal hypotonia, normal growth immediately after birth, small hands and feet, mental retardation, hypogonadism; some have partial deletion of chromosome 15 Pseudohypoparathyroidism Variable hypocalcemia, cutaneous calcifications Turner syndrome Ovarian dysgenesis, lymphedema, web neck; XO chromosome *These diseases represent <5% of cases of childhood obesity. www.cdc.gov/healthyweight Routine evaluation at well-child visits should include the following: 1.


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Pediatrics_Nelson. www.cdc.gov/healthyweight Routine evaluation at well-child visits should include the following: 1. Anthropometric data, including weight, height, and calculation of BMI. Data should be plotted on age-appropriate and gender-appropriate growth charts and assessed for BMI trends (see Table 29-3). 2. Dietary and physical activity history (Table 29-4). Assess patterns and potential targets for behavioral change. 3. Physical examination. Assess blood pressure, adiposity distribution (central versus generalized), markers of comorbidities (acanthosis nigricans, hirsutism, hepatomegaly, orthopedic abnormalities), and physical stigmata of a genetic syndrome (explains fewer than 5% of cases). 4.


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Pediatrics_Nelson. 4. Laboratory studies. These are generally reservedfor children who are obese (BMI > 95th percentile),who have evidence of comorbidities, or both. Other studies should be guided by findings in the historyand physical examination. The American Academy ofPediatrics endorses the government guidelines from2011, which recommend that all 9to 11-year-olds bescreened for cholesterol. Other useful laboratory testsmay include hemoglobin A1c, fasting lipid profile,fasting glucose levels, liver function tests, and thyroidfunction tests (if there is a faster increase in weightthan height).


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Pediatrics_Nelson. The approach to therapy and aggressiveness of treatmentshould be based on risk factors, including age, severity ofoverweight and obesity, and comorbidities, as well as familyhistory and support. The primary goal for all children withuncomplicated obesity and fast-rising weight-for-height isto achieve healthy eating and activity patterns. For children with a secondary complication, specific treatment of thecomplication is an important goal. Childhood and adolescentobesity treatment programs can lead to sustained weight lossand decreases in BMI when treatment focuses on behavioral changes and is family centered. Concurrent changes in dietaryand physical activity patterns are most likely to provide success (Table 29-5).


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Pediatrics_Nelson. Goal setting needs to be specific and attainable. Instead of recommending that the child walk or bike to school, suggest walking or biking to school two or more days a week. Rather than recommending that a child watch less television, suggest watching no television on school days. It is important to keep it simple and set one or two short-term goals at a time. In addition, behavioral risk factors need to be identified, such as avoiding fast food when family life gets hectic. Helping the family think of healthy alternatives is important.


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Pediatrics_Nelson. Families need to be counseled on age-appropriate and healthy eating patterns, beginning with the promotion of breastfeeding. For infants, transition to complementary and table foods and the importance of regularly scheduled meals and snacks, versus grazing behavior, should be emphasized. Age-appropriate portion sizes for meals and snacks should be encouraged. Children should be taught to recognize hunger and satiety cues, guided by reasonable portions and healthy food choices by parents. Smaller bowls should be used, and children should never eat directly from a bag or box. No juices or soda should be the rule. Children should never be forced Limit screen time (television, computer games/Internet, video games) to <1–2 hours per day (no TV for child <2 yr of age) Consume five or more servings of fruits and vegetables per day Minimize consumption of sugar-sweetened beverages FAMILY □ Eat at table, as a family, at least five to six times per week


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Pediatrics_Nelson. Consume five or more servings of fruits and vegetables per day Minimize consumption of sugar-sweetened beverages FAMILY □ Eat at table, as a family, at least five to six times per week Allow child to self-regulate his or her meals and avoid overly restrictive feeding behaviors Do not reward children with food or drinks Limit what is available in vending machines Speak to patients about healthy weight and good nutrition GOVERNMENT □ Increase access to healthy food and eliminate food deserts to eat when they are not willing, and overemphasis on food as a reward should be avoided. “Choose My Plate” by the U.S. Department of Agriculture can provide parents with a general guideline for the types of foods to be offered on a regular basis, including fruits, vegetables, grains, protein, and dairy.


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Pediatrics_Nelson. The importance of physical activity should be emphasized. For some children, organized sports and school-based activities provide opportunities for vigorous activity and fun, whereas for others a focus on activities of daily living, such as increased walking, using stairs, and more active play may be better received. Time spent in sedentary behavior, such as television viewing and video/computer games, should be limited. Television in children’s rooms is associated with more television time and with higher rates of overweight, and the risks of this practice should be discussed with parents. Clinicians may need to help families identify alternatives to sedentary activities, especially for families with deterrents to activity, such as unsafe neighborhoods or lack of supervision after school. More aggressive therapies are considered only for those who have not responded to other interventions. Treatment includes Be able to count Decrease size of serving Small bowls (parent palm)


Pediatrics_Nelson

Pediatrics_Nelson. More aggressive therapies are considered only for those who have not responded to other interventions. Treatment includes Be able to count Decrease size of serving Small bowls (parent palm) Aim to change behaviors Avoid eating from the box Don’t focus on consumption of Decrease to 20 g of fat Eat fish once a week carbohydrates, fat, protein Eating fast food Eat less junk food Limit trips to McDonalds to once a week Fruits Buy fewer juices Have no juices in the refrigerator Increase eating fruits Keep a bowl of fruits in the kitchen Vegetables Increase eating veggies Have a bowl of veggies in the refrigerator