Berkowitz’s – Section II: Health Maintenance
Neonatal Examination and Nursery Visit
You are performing an examination on a 16-hour-old newborn who was born at 39 weeks’ gestation to a28-year-old healthy primigravida via normal spontaneous vaginal delivery. There were no complications at delivery and Apgar scores were 8 at 1 minute and 9 at5 minutes. The newborn weighed 7 lb, 1 oz (3,200 g) and was 19.7 inches (50 cm) long at birth with a head circumference of 34 cm. The mother received prenatal care beginning at 10 weeks’ gestation; had no prenatal problems, including infections; and used no drugs, alcohol, or tobacco during the pregnancy. Her blood type is O Rh-positive. She is negative for hepatitis B surface antigen, HIV, and group B streptococcus and nonreactive for syphilis. The father is also healthy.
On physical examination, the newborn is appropriate size for gestational age with a length and head circumference in the 50th percentile. Aside from small bilateral subconjunctival hemorrhages, the rest of the physical examination is entirely normal.
Questions
- 1. What parts of the maternal history are important to review before performing a newborn’s physical examination?
- 2. What further history is important for a complete newborn assessment?
- 3. What aspects of the physical examination of newborns are essential to explain to parents?
- 4. What physical findings mandate a more extensive workup prior to discharge?
- 5. What is the routine hospital course for a normal newborn?
- 6. What are important points to cover with parents at the time of discharge for a normal term newborn?
- 7. What laboratory studies, if any, should be performed prior to discharge?
Perinatal Maternal Mood and Anxiety Disorders: The Role of the Pediatrician
You are evaluating a 3-week-old newborn who is the product of a 39-week gestation to a 30-year-old gravida 1, para 1 mother who has been breastfeeding the newborn. Birth weight was 3,650 g, and the baby now weighs 3,380 g. The mother expresses concern about her ability to breastfeed. She also admits to being exhausted and feeling detached from the baby and overwhelmed by being a mom, something she had looked forward to since she was a little girl. She has difficulty concentrating and has no appetite. She asks you if it is normal to feel this way.
Questions
1. What is the spectrum of perinatal mood and anxiety disorders?
2. What are the signs and symptoms of peripartum depression?
3. What are the risks to newborns of mothers who experience peripartum depression and other mood disorders?
4. What is the role of the pediatrician in assessing mothers for perinatal mood and anxiety disorder?
5. What screening instruments are available to assist in assessing mothers for perinatal mood and anxiety disorders?
6. What are the risks and benefits of the use of psychopharmacology during pregnancy and postpartum?
7. What resources are available to offer to mothers who may be experiencing perinatal mood disorders?
Newborn Screening
A 1-week-old boy is brought to his pediatrician’s office for a positive newborn screening test result for congenital adrenal hyperplasia. The baby was a product of a 38-week gestation and was born by normal spontaneous vaginal delivery to a 30-year-old gravida 2, para 2 woman with an unremarkable pregnancy. Birth weight was 3,300 g, and the baby is feeding and acting appropriately. Family history is unremarkable, and the physical examination is normal.
Questions
1. What are the proposed benefits of newborn screening?
2. Which newborn screening tests are most commonly performed?
3. How are the results of newborn screening tests reported to physicians?
4. How should a patient with an abnormal newborn screening result be managed?
5. What are the most common causes of false-positive and false-negative results?
6. What are the ethical issues and future challenges surrounding newborn screening?
Caring for Twins and Higher-Order Multiples
An expectant mother visits you. She has been advised byher obstetrician that an ultrasound shows she is pregnant with twins. She asks about care of twins and what special considerations she should keep in mind as she looks forward to the delivery. In particular, she is concerned about the feeding schedule and whether she will be able to breastfeed.
Questions
1. What is the incidence of multiple births?
2. What is the difference between fraternal and identical twins?
3. What major medical problems may affect twins and higher-order multiples?
4. What developmental and behavioral problems are associated with raising multiples?
Circumcision
An expectant mother visits you prenatally. She talks about circumcision in addition to issues relating to breastfeeding and car passenger safety. Her husband is circumcised. She is unclear about the medical indications for circumcision and asks your opinion about circumcision in the newborn period.
Questions
1. What are the benefits of circumcision?
2. What are the indications for circumcision in older children?
3. What are the techniques used to perform circumcision?
4. What are the complications of circumcision?
Nutritional Needs
At a routine health maintenance visit, a mother asks if she may begin giving her 4-month-old daughter solid foods. The infant is taking about 4 to 5 oz of formula every 3 to 4 hours during the day (about 32 oz per day) and sleeps from 12:00 am to 5:00 am without awaking for a feeding. Her birth weight was 7 lb (3,182 g), and her present weight and length (13 lb [5,909 g] and 25″ [63.5 cm], respectively) are at the 50th percentile for age. The physical examination, including developmental assessment, is within normal limits.
Questions
1. What are some of the parameters that may be used to decide when infants are ready to begin taking solid foods?
2. Up to what age is human milk or infant formula alone considered adequate intake for infants?
3. At what age do infants double their birth weight? At what age do they triple their birth weight?
4. What problems are associated with the early introduction of solid foods?
Breastfeeding
A 25-year-old woman, pregnant with her first child, comes into your office with her husband for a prenatal visit. She would like to know what advice you can give her about breastfeeding. She expects a normal delivery, has had no breast surgery, and is not on any medications, but does smoke cigarettes occasionally. She plans to return to work when the baby is 4 months old.
Questions
1. What is the normal physiology of lactation?
2. What are the benefits of breastfeeding?
3. What are the contraindications to breastfeeding?
4. What management maximizes a mother’s success at breastfeeding?
5. How do you manage some of the common problems that may arise during breastfeeding?
Sleep: Normal Patterns and Common Disorders
During a routine 6-month health maintenance visit, a mother states that although her 6-month-old son falls asleep very easily at about 10:00 pm every night while breastfeeding, he wakes every 2 to 3 hours and cries until she nurses him back to sleep. A review of the dietary history reveals that the infant is breastfed about every 3 hours and was begun on rice cereal 2 weeks ago. His immunizations are current. The boy has no medical problems, and his physical examination is normal.
Questions
1. How old are most infants when they can begin to sleep through the night (at least 5 hours at a stretch) without a feeding?
2. What factors contribute to frequent nighttime awaking during infancy?
3. What advice can be given to parents to facilitate an infant’s sleeping through the night?
4. What are sleep disturbances experienced by older children and adolescents?
Oral Health and Dental Disorders
The parents of a 9-month-old girl bring her to the office because they are concerned that their daughter has no teeth yet. Growth and development have proceeded normally, and the physical examination is unremarkable.
Questions
1. What is the mean age and range for the eruption of the first tooth?
2. What is meant by mixed dentition?
3. When should oral hygiene using a toothbrush begin?
4. What are risk factors for dental caries?
5. What are the indications for the application of fluoride varnish?
Normal Development and Developmental Surveillance, Screening, and Evaluation
The parents of a 12-month-old are concerned that she is not walking yet. They report that she sat independently at 7 months and began crawling at 8 months. She can pull herself up to stand while holding on to furniture but is not cruising. Her birth and medical history are unremarkable.
The physical examination is within normal limits, and review of your records reveals no concerns on a developmental screening test administered at 9 months of age.
Questions
1. What are the major areas in which development is assessed?
2. What are the gross motor, fine motor, and personal/social milestones for a 12-month-old?
3. What developmental screening tests could you administer to further assess her development?
4. How is developmental delay in children defined?
Speech and Language Development: Normal Patterns and Common Disorders
The parents of a 3-year-old girl bring her to see you. They are concerned because their daughter has only an 8- to 10-word vocabulary and she does not put words together into phrases or sentences. They report that she seems to have no hearing problems; she responds to her name and follows directions well.
In general, she has been in good health. Her development, aside from delayed speech, is normal. During the physical examination, which is also normal, the girl does not speak.
Questions
1. What language skills should children have at 1, 2, and 3 years?
2. Approximately how many words should 3-year-olds have in their vocabulary?
3. By what age should children’s speech be intelligible to strangers at least 75% of the time?
4. What factors may be associated with delayed speech development?
5. What tests are used to assess children’s hearing, speech, and language development?
Literacy Promotion in Pediatric Practice
You are seeing a 6-month-old boy for the first time for a well-child visit. The child has a completely negative history and seems to be thriving. The patient’s mother works part-time as a housekeeper and his father is a seasonal worker in agriculture. The infant is up-to-date on his immunizations except for his 6-month shots. The family history is noncontributory, but his mother mentions that her 6-year-old daughter needs to repeat kindergarten.
Teachers have advised the mother that her oldest daughter is cooperative, but she has not mastered letters and early reading yet. Mother says she is not concerned because the teacher said with “a little more time” her daughter will be fine.
Questions
1. How are reading and language developmentally related?
2. What are the consequences of low literacy when children get older?
3. How are literacy and health outcomes related?
4. What are the components of the Reach Out and Read model?
Gifted Children
A 3-year-old girl is brought to your office for well-child care. Her parents believe that she may be gifted because she is much more advanced than her sister was when she was the same age. The parents report that their younger daughter walked at 11 months of age and was speaking in 2-word sentences by 18 months. She is very “verbal,” has a precocious vocabulary, and constantly asks difficult questions such as, “How do voices come over a radio?” The girl stays at home with her mother during the day but recently began going to a preschool program 2 mornings a week. She
enjoys preschool and plays well with children her own age.
She also likes to play with her sister’s friends from school. The girl is engaging and talkative. She asks questions about what you are doing during the examination and demonstrates impressive knowledge of anatomy. The physical examination is normal.
Questions
1. How are gifted children identified?
2. What characteristics are associated with giftedness?
3. What are the best approaches for dealing with the education of gifted children?
4. What is the role of the pediatrician in the management of gifted children?
Children and School: A Primer for the Practitioner
An 8-year-old boy is brought in by his parents in early April because his third-grade teacher informed them that he is currently failing in school and may not be promoted to the fourth grade. Review of his medical, developmental, and school histories reveals that he was a very colicky infant and continued to be difficult as a toddler. His language skills were somewhat delayed, although not enough to warrant a full evaluation. His preschool teacher felt that he was easily distracted when doing seat work. In kindergarten he had some difficulty learning all of his letters, numbers, and sounds. Early reading was difficult in kindergarten and first grade but improved by the end of the year.
Second grade was fairly good except for continued concerns about inattention and distractibility. By third grade he was struggling more, especially with writing, and not reaching grade level in several areas. He also continued to be inattentive and distractible in his classroom. Examination reveals a well-developed and wellnourished boy whose growth parameters are within normal
limits for his age. He appears somewhat anxious in the examination room, and when asked about school he tells you that he feels he is just not as smart as the other children in his class.
Questions
1. Should grade retention be considered when a child is failing in school?
2. What are the advantages and disadvantages of grade retention?
3. What is the differential diagnosis of school failure?
4. What steps should be taken at this time by the parents and the school for the boy in this scenario?
Immunizations
A 20-month-old boy who emigrated with his family from Botswana is brought in for a checkup. He has his World Health Organization Expanded Programme on Immunization card from his homeland showing that he received a BCG vaccine at birth; 3 doses of diphtheria, tetanus, and pertussis vaccine at 2, 4, and 6 months of age; 3 doses of live oral poliovirus vaccine at 2, 3, and 4 months of age; 3 doses of hepatitis B vaccine at birth and 2 and 9 months of age; and a monovalent measles vaccine at 9 months of age. It is August and his parents plan to enroll him in child
care and have brought him for a checkup. His parents report that he is a healthy boy with no immune problems.
They report that his uncle, who is infected with HIV, lives with them. The boy has had a 3-day history of a runny nose, cough, and tactile fever. His examination is normal other than mild clear coryza and a rectal temperature of 37.9°C (100.3°F). What immunizations may be given?
Questions
1. What are the different kinds of vaccines?
2. What are the mechanisms of action for live and inactivated vaccines?
3. What are the routinely recommended immunizations for healthy pediatric populations?
4. What are the considerations for immunizing selected pediatric populations, such as preterm infants, immunocompromised children, immigrants, international adoptees, and travelers?
5. What are reliable resources for up-to-date information about immunizations?
Health Maintenance in Older Children and Adolescents
Before a 13-year-old girl enters a new school, she is required to have a physical examination. She has not seen a physician in 5 years and has been healthy. Currently she has no medical complaints. Her examination is completely normal.
Questions
1. What are the important components of the history and physical examination in healthy older children and adolescents?
2. What immunizations are recommended for older children and adolescents?
3. What laboratory tests should be performed at health maintenance visits? Why?
Health Care for International Adoptees
Jaxon is a 14-month-old boy adopted from Thailand. His biological mother was a 26-year-old commercial sex worker who entered a maternity house during her pregnancy to receive care and to relinquish the baby for adoption. His mom reported that she was physically and sexually abused as a child and became a street child when she was 14 years old. She used illicit drugs 5 years ago but none since. She identifies the father as a European customer but has no other information. Jaxon was born at 32 weeks’ gestation and was placed in an incubator but did not have any respiratory problems. He has been in foster care in a Thai family’s home with his care supervised by an internationally respected adoption organization. He was selected by his parents at the age of 4 months, and they have received monthly progress reports on his growth, development, and medical status. Reportedly, he has had several “colds” and one ear infection but otherwise has been growing and developing well. Before departure to pick up Jaxon, his adoptive parents met with you to prepare for his arrival.
From the Bangkok airport, the parents placed a call to you because Jaxon would not stop crying. They report that on the morning that his foster mom left him with them, he cried quite a bit but had settled by bedtime and seemed to be adjusting well during the week. However, over the past 12 hours he hasn’t stopped crying and refuses to eat. They question if his discomfort is related to teething because he has been drooling, but they have not noticed any other symptoms. They are gravely concerned that he doesn’t like them and is having attachment difficulties.
Questions
1. What factors influence the prevalence of international adoption?
2. What are some of the potential health problems of international adoptees?
3. What is an appropriate medical evaluation for international adoptees?
4. What is the pediatrician’s role in caring for the child and newly formed family?
Health Care Needs of Children in Foster Care
A 13-year-old girl is brought to your office by her foster parent for a general physical examination. The foster parent states that the girl has been living in her home for the past 2 weeks. When she was initially brought by the social worker, she was wearing dirty clothes and smelled of cigarette smoke. There are no medical records and no immunization records available for your review, and the teen is not sure the last time she saw a doctor. The girl states that she often missed school to help take care of her sick grandmother. She gets very quiet when you ask about her family. She states she misses her younger sisters but does not mention anything about her mother. When asked about her mother, she states that she doesn’t care to see her because her mother “cares more about her boyfriend than she does me and my sisters.” The only history known by the foster parent is that the child was failing school because of frequent absences and that there were extensive
amounts of pornography and drug paraphernalia found in the home at the time of removal. The social worker also told the foster mother that there was an expired albuterol inhaler found in the home with the girl’s name on It. The foster parent states that the teen seems “sad” all the time, and 2 nights ago when asked about school, she began to cry and ran to her room. On physical examination, the patient is sad appearing and quiet but cooperative. Her weight is in the 25th percentile and her height is in the 50th percentile for her age. She has poor dentition with multiple dental caries. She has a few basilar wheezes on lung examination and has scattered bruises on her anterior shins, but no other abnormalities were noted.
Questions
1. What are the medical, psychologic, and behavioral issues that commonly affect children in the foster care system?
2. What is the role of the primary care pediatrician in providing a medical home for the child in foster care?
3. How does a child’s legal status as a child in foster care affect how medical care can be delivered?
4. What are the appropriate health care referrals and community resources to access for a patient who is in foster care?
Working With Immigrant Children and Their Families
A 7-year-old boy presents with vomiting and clinical signs of dehydration. The family thinks he has empacho (a Latin American folk illness). You tell the family that you suspect that he has viral gastroenteritis. You want to draw some blood studies and give him fluids intravenously. The parents are skeptical; they refuse the blood work and want to leave against medical advice.
Questions
1. What are the ways that different immigrant families view illness and health?
2. What are barriers to accessing health care that children in immigrant families face?
3. What questions help the physician understand the health beliefs of immigrant families?
4. What are the considerations when dealing with parents who do not speak English?
Well-Child Care for Children With Trisomy 21 (Down Syndrome)
6-month-old girl with trisomy 21 (Down syndrome) whom you have known since birth is brought to your office for well-child care. She and her parents have been doing well, although she has had several episodes of upper respiratory infections. Her medical history is significant for a small ventricular septal defect, which has since closed spontaneously, and one episode of otitis media at 5 months of age. Her weight gain has been good—along the 25th percentile on the trisomy 21 growth chart. She now sleeps through the night and has a bowel movement once a day. She has received all of the recommended immunizations for her age without any problems.
The infant smiles appropriately, grasps and shakes hand toys, and has some head control but is unable to roll from supine to prone position. Since she was 1 month old, she has been enrolled in an early intervention program. An occupational therapist visits her at home twice a month. On physical examination, she has typical facial features consistent with trisomy 21, a single palmar crease on each hand, and mild diffuse hypotonia. Her eyes have symmetric movement, and her tympanic membranes are clear. She has no cardiac murmurs.
Questions
1. What is the prevalence of trisomy 21 (Down syndrome) in the general population? What is the association of maternal age with trisomy 21?
2. What are the clinical manifestations of this syndrome?
3. What medical conditions are associated with trisomy 21 in the newborn period, during childhood, and in adolescence? When should screening tests for these conditions be performed?
4. What is the role of early intervention services for these patients and their families?
5. What specific psychosocial issues should be included in your anticipatory guidance and health education?
6. What is the prognosis for children with trisomy 21?
Well-Child Care for Preterm Infants
A 2½-month-old girl was discharged from the neonatal intensive care unit 2 weeks ago, where she had been since birth. She was the 780-g product of a 26-week gestation born via spontaneous vaginal delivery to a 32-year-old primigravida. The perinatal course was complicated by premature rupture of membranes and maternal amnionitis. Several aspects of the neonatal course were significant, including respiratory distress that required surfactant therapy and 2 weeks of endotracheal intubation; a grade 2 intraventricular hemorrhage diagnosed at 1 week of life; hyperbilirubinemia, which was treated with phototherapy; several episodes of apnea, presumably associated with the prematurity; and a history of poor oral intake with slow weight gain.
The infant’s parents have a few questions about her feeding schedule and discontinuing the apnea monitor, but they feel relatively comfortable caring for their daughter at home. She is feeding well (2 oz of 22 cal/oz post-discharge formula for premature infants every 2–3 hours) and is becoming progressively more alert according to the family. She sleeps on her back in a crib. The infant’s weight gain has averaged 25 g/day. The rest of the physical examination is normal, except for dolichocephaly and a left esotropia.
Questions
1. What constitutes well-child care in preterm infants?
2. What are the nutritional requirements of preterm infants in the months following discharge from the hospital?
3. What information must be considered in the developmental screening of preterm infants?
4. What immunization schedule is appropriate for preterm infants? Do they require any special immunizations?
5. What specific conditions or illnesses are more likely to affect preterm infants than term infants?
Care of Children With Special Health Care Needs
A 5-year-old girl with a physical disability is brought to your office for her first visit for a routine physical examination for school entrance. She was the result of a fullterm pregnancy complicated by an elevated screening a-fetoprotein and a subsequent fetal ultrasound that demonstrated a lumbar myelomeningocele and no hydrocephalus. Delivery was elective cesarean with Apgar scores of 9 at 1 minute and 9 at 5 minutes to a 25-year-old gravida 1, para 0–1 mother. The mother used no illicit drugs, alcohol, or any other medications during pregnancy but was not on vitamins or folate supplementation at the time of conception. At delivery, a low lumbar spinal malformation was noted without other malformations.
The quadriceps muscles were strong, but the feet demonstrated a rocker-bottom deformity. Shortly after birth the myelomeningocele malformation was closed by neurosurgery. The girl has had orthopedic surgical release of Achilles tendon contractions and is ambulatory with ankle-foot orthotics. She has a neurogenic bladder and requires intermittent catheterization.
She also has chronic constipation treated with a bowel regimen. Her cognitive function is age-appropriate. She will be entering a school program for the first time since moving to this community and has not established care with any specialists.
Questions
1. Why is early identification and intervention important for newborns, infants, and children with special health care needs (SHCN)?
2. What are the unique needs of newborns, infants, and children with SHCN?
3. What role do primary care practitioners play in the care of children with SHCN?
4. What are the appropriate referrals and resources for families of children with SHCN?
5. What specific psychosocial issues should be addressed whenever children with SHCN visit their primary care practitioners?
Reproductive Health
CASE STUDY
An 18-year-old female college student in good health comes in for a routine health maintenance visit during her spring break. She is unaccompanied by her parents and has no complaints, stating that she just needs a checkup. She enjoys college, passed all of her fall and winter classes, and has some new friends. She denies tobacco use but says most of her friends smoke. She occasionally drinks alcohol and has tried marijuana once. Although she is not sexually active, she is interested in discussing oral contraception. Her last menstrual period, which occurred 2 weeks ago, was normal. She is taking no medications. Her physical examination is entirely normal.
Questions
1. What issues are important to discuss with adolescents at reproductive health maintenance visits?
2. What are the indications for a complete pelvic examination?
3. When is a Papanicolaou test (Pap smear) indicated as a part of the reproductive health visit?
4. What methods of contraception are most successful in adolescent patients? What factors about each method should be considered?
5. What are the legal issues involved in prescribing contraception to minors in the absence of parental consent?
Providing Culturally Competent Care to Diverse Populations: Sexual Orientation and Gender Expression
Lynn Hunt, MD
CASE STUDY
The mother of an 11-year-old boy makes an appointment with you to discuss her son’s “behavior problems.” He is the youngest of 4 children and is doing well in fifth grade, but she is concerned that her son does not like typical “male” activities. He dropped out of Little League, won’t join other sports teams, and prefers riding his bike. In
addition, he still likes dressing up in costumes and prefers playing with girls rather than boys. She finally mentions that she is worried that he will be gay and is wondering what she can do to help her son develop “normally.”
Questions
1. What is meant by gender expression, sexual orientation, and gender identity?
2. What is the role of the pediatrician in counseling parents and patients about gender expression, sexual orientation, and gender identity?
3. What are some of the consequences of discrimination of sexual minority populations?
4. Are there programs that can change sexual orientation?
Injury Prevention
Sarah J. Atunah-Jay, MD, MPH, and Iris Wagman Borowsky, MD, PhD
CASE STUDY
A 16-year-old girl was brought to the emergency department after being rescued from her submerged vehicle. The girl was texting a friend while driving and crashed into a pond. After several weeks in the intensive care unit, she was transferred out for rehabilitative care from her injury.
Questions
1. How extensive is the injury problem in children?
2. What are the different methods of injury prevention? How could this particular injury have been prevented?
3. What injury prevention program has been developed by the American Academy of Pediatrics?
4. What are some general gu
Fostering Self-esteem
Rick Goldstein, MD
CASE STUDY
A 4-year-old girl is brought to the office for her annual physical examination. She has been healthy. Her mother expresses concern that her daughter is shy and does not always play well with other children. She has never participated in a child care program or group activities out of the home. She spends most of her time with her mother,
grandmother, and 7-year-old sister, with whom she gets along fairly well. Both parents work outside the home, her father full-time and her mother part-time. The girl’s medical history is unremarkable except for an episode of bronchiolitis at 8 months of age. She has ;reached all of her developmental milestones at appropriate ages, currently speaks well in sentences, is able to dress herself without supervision, and can balance on one foot with no difficulty. The physical examination is entirely normal. However, numerous times during the visit, the mother tells her daughter to “sit up straight,” “stop fidgeting,” and “act your age.” The mother rolls her eyes as she tells you, “She doesn’t know how to act.”
Questions
1. What is self-esteem?
2. How do parents or other caregivers affect the development of their children’s self-esteem positively and negatively?
3. What role does discipline play in the development of self-esteem?
4. How does illness affect self-esteem?
5. What suggestions can primary care physicians give parents and other caregivers to help foster positive self-esteem in children?
Sibling Rivalry
Carol D. Berkowitz, MD
CASE STUDY
An 8-year-old boy is brought to the office for an annual checkup. During the course of the evaluation, his mother complains that her son and his 6-year-old sister are always fighting. She says her son hits his sister and pulls her hair, and nothing she does prevents them from fighting. The boy is a B1 student and has no behavior problems
in school. The medical history and physical examination are completely normal.
Questions
1. What is sibling rivalry?
2. What is the physician’s role in counseling a family about sibling rivalry?
3. What is the role of anticipatory guidance in preparing older children for the birth of a new sister or brother?
4. How does birth order and gender affect sibling rivalry?
5. What are some of the unique considerations related to sibling rivalry between step-siblings?
6. What are some practical suggestions to share with parents about sibling rivalry?
Toilet Training
Sabrina D. Diaz, MA, MMFT, and Lynne M. Smith, MD
CASE STUDY
A 2-year-old boy is brought to the office for a well-child visit. His mother, who is about to begin toilet training her son, asks your advice. The mother says that by the time her daughter was 2 she was already toilet trained, and she wants to know if training her son will be any different. The boy was the product of a full-term pregnancy and a normal delivery. He has been in good health, and his immunizations are up-to-date. He is developmentally normal, uses some 2-word phrases, and has been walking since the age of 13 months. His physical examination is normal.
Questions
1. When should physicians begin discussing toilet training with parents?
2. What factors help determine children’s readiness to begin toilet training?
3. Is toilet training in boys different from toilet training in girls?
4. What are some of the methods used to toilet train children?
Crying and Colic
Geeta Grover, MD
CASE STUDY
The parents of a 2-week-old bring their son to the emergency department because he has been crying persistently for the past 4 hours. He has no history of fever, vomiting, diarrhea, upper respiratory tract infection, or change in feeding. The newborn is breastfed. On physical examination, the neonate appears well developed and well nourished. His weight is 7 lb, 7 oz—7 oz more than when he was born. Although he is fussy and crying, he is afebrile with normal vital signs. The remainder of the physical examination is within normal limits.
Questions
1. What is the normal crying pattern in newborns and young infants?
2. What is colic?
3. What conditions are associated with prolonged crying in newborns and young infants?
4. What are key factors in the history of crying newborns and infants?
5. What laboratory tests are indicated in crying newborns and infants?
6. What are a few of the management strategies that can be used by parents to soothe their crying or colicky newborns and infants?
Discipline
Carol D. Berkowitz, MD
CASE STUDY
A 3-year-old boy is being threatened with expulsion from preschool because he is biting the other children. His mother states that he is very active and aggressive toward other children. In addition, his language development is delayed. She is at her wit’s end about what to do. The birth history is normal, and the mother denies the use of drugs or cigarettes, but she drank socially before she realized she was pregnant. The medical and family histories are noncontributory, and the physical examination is normal.
Questions
1. What is the definition of discipline?
2. What are the 3 key components of discipline?
3. What strategies can parents use to discipline children?
4. What are the guidelines for using time-out?
5. What is meant by parental monitoring?
6. What is the relationship between corporal punishment and child abuse?
Temper Tantrums
Geeta Grover, MD
CASE STUDY
During a routine office visit, the parents of a 3-year-old boy express concern about his recent behavior. They report that whenever he is asked to do something he does not want to do, he throws a “fit.” He cries fiercely, falls to the floor, bangs his hands, and kicks his feet until his parents give in. He often displays such behavior at bedtime or mealtime if he is asked to turn off the television or eat
foods that he does not want. He has 2 to 3 such episodes per week. The parents state that their home life has not changed, and the boy’s teacher reports that he displays no such behaviors at preschool.
Questions
1. At what age are temper tantrums common in children?
2. How do parents’ reactions encourage or discourage temper tantrums?
3. What appropriate management strategies may help control such oppositional behavior?
4. What factors or aspects of such oppositional behavior indicate underlying pathology?
Breath-Holding Spells
Geeta Grover, MD
CASE STUDY
A 15-month-old girl is brought to the office because of parental concern about seizures. In the last month she has passed out momentarily 3 times. Each episode seems to be precipitated by anger or frustration on her part. Typically she cries, holds her breath, turns blue, and passes out. Each time she awakens within a few seconds and seems fine. The medical history and family history are unremarkable, and the physical examination is entirely within normal limits.
Questions
1. What are breath-holding spells (BHS)?
2. What is the differential diagnosis of BHS?
3. What, if any, laboratory studies are indicated in the evaluation of BHS?
4. What measures can be taken to prevent BHS? Are anticonvulsants necessary?
5. What, if any, are the long-term sequelae of BHS?
Fears, Phobias, and Anxiety
Carol D. Berkowitz, MD
CASE STUDY
A 5-year-old girl is brought into the office by her mother, who complains that her daughter has been afraid to sleep alone since the occurrence of an earthquake. The house did not sustain any significant damage, but the entire family was awakened. The mother says that the girl has become more timid. As nighttime approaches, she becomes particularly fearful. She will not stay in her bed, and she is comforted only by sleeping with her parents. In addition, the girl has begun bed-wetting since the earthquake, and the mother wonders whether she should put her daughter in diapers. The physical examination, including vital signs, is normal, except for the observation that the child is very clingy and whiny.
Questions
1. What are normal childhood fears?
2. When do these fears commonly occur?
3. What strategies are used to deal with these fears?
4. What are simple phobias? What are social phobias?
5. What is school phobia, and how is it best handled?
6. What are common anxiety disorders in children and adolescents?
7. How can families deal with childhood disturbances that emerge after natural and artificial disasters?
Thumb Sucking and Other Habits
Carol D. Berkowitz, MD
CASE STUDY
A 5-year-old boy is brought to the office because of thumb sucking. His mother claims that she has tried nearly everything, including tying his hands at night and using aversive treatments on his thumbs, but nothing has worked. She reports that her son has been teased at school and has few friends. He is in good general health, and his immunizations are up-to-date. His growth parameters are at the 50th percentile. Except for a callus on the right thumb, the physical examination is normal.
Questions
1. What are common habits in children?
2. What is the significance of transitional objects?
3. What are the consequences of common habits in children?
4. What are strategies used to break children of habits?
5. How does one differentiate benign habits from self-injurious behaviors?
Enuresis
Carol D. Berkowitz, MD
CASE STUDY
A 9-year-old boy who is in good general health is evaluated for a history of bed-wetting. He is the product of a normal pregnancy and delivery, and he achieved his developmental milestones at the appropriate time. The boy was toilet trained by the age of 3 years, but he has never been dry at night for more than several days at a time. Enuresis occurs at least 3 to 4 times a week even if he is fluid-restricted after 6:00 pm. The boy never wets himself during the day, has normal stools, and is an average student. His father had enuresis that resolved by the time he was 12 years old. The boy’s physical examination is entirely normal.
Questions
1. What conditions account for the symptoms of enuresis?
2. What is the appropriate evaluation of children with enuresis?
3. What is the relationship between enuresis and emotional stresses or psychosocial disorders?
4. What management plans are available for enuresis?
5. How do physicians decide which management technique is appropriate for which patients?
Encopresis
Carol D. Berkowitz, MD
CASE STUDY
A 7-year-old boy presents with the complaint of soiling his underpants. His mother states that he has never been completely toilet trained and that stooling accidents occur at least 2 to 3 times a week, mainly during the day. The boy rarely has a spontaneous bowel movement without assistance. He sits on the toilet for just a few minutes and passes small, pellet-like stools. His mother has never sought medical care before for this problem. The boy is very fidgety during the physical examination. His vital signs are normal and the child’s height and weight are at the 25th percentile. His abdomen is soft but distended, with palpable loops of stool-filled bowel. A small amount of stool is present around the anus and in the boy’s underpants. Digital examination of the rectum reveals hard stool. The rectal tone is normal, as is the rest of the physical examination.
Questions
1. What is the definition of encopresis?
2. What is the difference between retentive and non-retentive encopresis?
3. What are some physiological conditions that contribute to encopresis?
4. What conditions may be mistaken for encopresis?