Vol.29 No.

3 March 2008

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Journals and Professional Periodicals


PediatricsinReview姞 Vol.29 No.3 March 2008


Managing Sports Injuries
in the Pediatric Office
Jordan D. Metzl


Recognition of Autism Before Age 2 Years
Chris Plauche´ Johnson


Index of Suspicion
Courtney Peshkovsky, Robert J. Leggiadro, Lauren Kupersmith,
Seth Septer, Cristina Fernandez, Fernando Zapata

In Brief

103 Posttraumatic Stress Disorder
105 Enteral Feeding

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Answer Key: 1. B; 2. D; 3. B; 4. E; 5. A; 6. D; 7. E; 8. E

Internet-Only Article
Abstract appears on page 107.


American Academy of Pediatrics
Policy Statements on Bioethics:
Summaries and Commentaries: Part 2
Mark R. Mercurio, Marilyn A. Maxwell, Brenda Jean Mears,
Lainie Friedman Ross, Tomas J. Silber

Cover: The artwork on the cover of this month’s issue is
by one of the winners of our 2005 Cover Art Contest,
12-year-old Elizabeth Jayner of Ahoski, NC. Elizabeth’s
pediatrician is Charles Pierce, MD.


sports medicine

Managing Sports Injuries in the
Pediatric Office
Jordan D. Metzl, MD*

Author Disclosure
Dr Metzl did not
disclose any financial
relationships relevant
to this article.


After completing this article, readers should be able to:

1. Describe the current management of concussion.
2. Delineate the prescription for treatment of acute ankle injuries and prevention of
subsequent injuries.
3. Describe appropriate handling of neck injuries to avoid additional damage.
4. Discuss the likelihood of sustaining an ankle injury if the patient has had a previous
ankle injury.
5. Recognize which sports are more closely associated with head injury than others.

With increasing numbers of young athletes participating in sports activities across the
United States, the issues of sports participation, sports safety, and specific return-to-play
decisions have become more common in the pediatric office. Athletic patients and their
families are turning increasingly toward the pediatrician for guidance and safe decisionmaking regarding sports participation and injury prevention.
This article examines specific issues that pediatricians and pediatric residents in training
should encounter during the practice of general pediatric medicine. These issues include
concussion, cervical spine injury, and ankle injury. Case-based teaching examples are used
to illustrate teaching points.

Current Management of Concussion
Case #1: Head Injury
A 15-year-old soccer player comes to her pediatrician for follow-up 1 day after suffering a head
injury during a soccer game. She sustained a head-to-head collision with another player and
quickly developed a headache. She tried to continue playing but was having difficulty
remembering her position and on-field responsibilities. She did not lose consciousness. She came
off the field voluntarily, was evaluated by the athletic trainer on the sideline, and was removed
from the soccer game. Her parents were worried and took her to the emergency department,
where she was evaluated. A computed tomography scan was negative for subdural or epidural
Closed-head injury is a common medical problem in young athletes who play in highand medium-contact sports (Table 1). Unfortunately, the majority of concussive episodes
in young athletes are not reported, but the known incidence is approximately 300,000
cases per year in the United States. The actual number is much higher.
The head injury sustained by this adolescent soccer player raises a number of issues.
How extensive are her injuries, which may be subtle in the cognitive realm, and when
should she be expected to return completely to normal? How should her progress be
monitored? When can she resume practice and competition?

Concussion refers to a significant head injury that may cause a host of signs and symptoms,
including alterations in consciousness, confusion, amnesia, visual and hearing impairment,
irritability and mood changes, difficulties with balance, headache, lethargy, insomnia,
memory impairment, nausea, and vomiting.
*Assistant Professor, Department of Pediatrics, Hospital for Special Surgery, Cornell Medical College, New York, NY.
Pediatrics in Review Vol.29 No.3 March 2008 75

sports medicine

office management of sports injuries

Common Sports
Characterized by Level of
Table 1.

High-contact Sports

Martial Arts

Medium-contact Sports


Noncontact Sports

Weight Training

The Prague Conference on Concussion in 2004 defined concussion as “a complex pathophysiological
process affecting the brain, induced by traumatic biomechanical forces.” (1) The Conference also pointed out
that the impairment of neurologic function typically has
a rapid onset, is short-lived, and tends to resolve spontaneously. In addition, neuropathologic changes are indicative more of a functional derangement than of a
structural injury and typically are associated with neuroimaging studies that appear grossly normal. The sequential resolution of symptoms and cognitive functioning
was emphasized.
Guidelines for the management of concussion have
been available for many years and, until recently, were
based on systems that graded the injury, with loss of
consciousness being a major criterion. These guidelines
recommended return to activity based on the grade of
concussion. More recent thinking emphasizes waiting
until after symptoms have resolved before assigning severity; stresses physical and cognitive rest; and recommends a sequential, functional progression as symptoms
clear and do not return with exertion, with careful monitoring by a physician. (1)
The patient’s neurologic and cognitive status can be
assessed through a variety of methods. Neurologic examination is indicated from the initial evaluation through
the follow-up period. At one end of the spectrum, office
76 Pediatrics in Review Vol.29 No.3 March 2008

assessment of mental status and cognitive functioning
by use of a series of questions is part of neurologic
testing. Intensive neuropsychological testing also is available through appropriate specialists. A middle approach
involves the use of more formal instruments that can be
administered by primary care physicians or certified athletic trainers.
Several instruments are available for an intermediate
level of evaluation. One tool that has been constructed
using a number of other instruments is the Sport Concussion Assessment Tool (SCAT), which contains both a
medical evaluation and a checklist for the athlete, as well
as information about concussion. (1) When combined
with a neurologic examination, the SCAT can be useful
in the office setting.
An instrument used commonly by certified athletic
trainers is the Standardized Assessment of Concussion
(SAC), which can be employed for sideline evaluation.
This instrument can be ordered through a medical bookstore or purchased through the Internet. Based on a
scored scale, the SAC can be used to determine orientation, immediate memory, concentration, and delayed
item recall. These different parameters are tabulated,
providing a score that grossly assesses an athlete’s ability
to return to competition. In the office, findings on the
SAC can be combined with evaluation of the presence of
postconcussive symptoms such as ongoing headache,
dizziness, memory loss, and irritability and a neurologic
examination to assess the athlete’s ability to return to
Although the SCAT and SAC are good tests of cognitive functioning, they have a “ceiling effect,” meaning
that a patient could do well on these tests without having
recovered fully. For this reason, a number of computerized tests are available that provide a more accurate
assessment without the need for full neuropsychological
testing. A full discussion of these instruments is beyond
the scope of this article, but pediatricians should consult
with local sports medicine physicians and athletic trainers
to learn which tools are available and in use in their area.
For milder cases of concussion in which recovery is
steady and complete over a 7- to 10-day period, mental
status screening is necessary for monitoring, but the
computerized instruments should not be necessary because physical examination and self-report of symptoms
usually are sufficient. Primary care practitioners should
be equipped to manage these injuries.
For patients who sustain a concussion and have persistent signs and symptoms or whose symptoms recur on
exertion, both neuropsychological assessment and the
involvement of specialists may be indicated. Many ath-

demonstrates further the need to keep athletes out of any situation involving direct head trauma until recovery is complete. (1) The recommended steps for a logical and safe progression are: 1. including headache. and difficulty concentrating. Weightlifting is prohibited. The presence of this entity. In this entity. without a component of resistance. Prevention involves the creation of an increased awareness in coaches and athletic trainers who might be involved with the care of a young athlete who had a concussive predisposition in previous seasons. Activity should move through the following steps. the patient may participate in activities of daily living. it is important to advise both the athlete and his or her parents about the possibility of postconcussive syndrome. rapid and progressive brain injury resulting from a second episode of closed-head injury while the athlete still is symptomatic from the first episode. although rare. an athlete who still is recovering from an initial concussive episode is struck in the head. A repeated episode of concussion can result in a prolonged period of concussive and postconcussive symptoms and. be monitored carefully. followed by mental status testing. These symptoms can exist after any concussion. mental status change. and receive medical attention. 6. As in many types of injury that create a predisposition to future injury. is theorized by some to reduce the risk of concussion and should be strongly encouraged in all athletes. Participation in a game. not be allowed to return to play that day. At this step and the next. irritability. regardless of severity. and progress should be monitored by clinicians who have the appropriate level of training. These same principles should be relevant to nonathletic activity. Complete rest. The primary care physician and the experienced athletic trainer make a good team in determining the appropriate course of action in most cases. Extensive neuropsychological testing is indicated for the minority of patients in whom there is a question about the cumulative effects of concussion or in whom there may be permanent academic impairment and questions about further participation in contact sports. SIS is associated with a mortality rate of 70% to 80% but is completely preventable through the prompt recognition of concussive and postconcussive symptoms. Therefore. Prevention One final note on concussion involves the screening of athletes. The result is rapid mental deterioration. Return to play is allowed only when the player’s signs and symptoms have resolved and when he or she has demonstrated the ability to progress stepwise through several levels of activity without any recurring symptoms. 2. and often fatal uncal herniation. therefore. athletes who have had one concussive episode are nearly six times more likely to have a second episode of concussion compared with their unaffected peers. All of this advice and surveillance can be accomplished during the preparticipation evaluation and can ensure greater safety by targeting athletes who are at greater risk and creating both an educational and health supervisory framework on their behalf. it is important to stress the importance to athletes.3 March 2008 77 . the athlete should rest for 24 to office management of sports injuries 48 hours and try to progress again. Light (low-intensity) aerobic exercise. 3. dizziness. The appearance and persistence of postconcussive symptoms is more likely with more severe concussion. such as walking. although bed rest is not indicated. Postconcussive Syndrome Whenever an athlete suffers a concussion. 4. dropping back if symptoms recur. 5. Full-contact training after clearance by medical personnel. resistance training may be added. Training drills without contact. of reporting postconcussive symptoms during the season. If symptoms recur.29 No. Postconcussive syndrome involves residual symptoms from a concussion. with advancement only if there are no symptoms. effective preseason counseling about the symptoms of concussion involves asking about the history of previous concussive events. particularly those who have had previous concussive events. Mouthguard use in high-contact sports. Activity specific to the sport. A less common but much more severe consequence of concussion is the development of second impact syndrome (SIS). Making the Important Decisions Current concepts of managing concussions related to sports dictate that an athlete manifesting any signs or symptoms of concussion be removed from the practice or game immediately. a much greater period of time away from sports participation. In addition. in addition to reducing oral and dental injuries. Unlike professional athletes who are paid to put their Pediatrics in Review Vol. Such a regimen must be individualized to each athlete. and the trainer can serve as a liaison with the coach to make sure the plan is executed properly. such as running or skating.sports medicine letes who sustain head injuries become totally symptomfree and do not need major intervention.

2) Discussion with a certified athletic trainer who is most likely to be on the sideline regarding responsibility in the case of a cervical spine injury. If the athlete is found in the prone position. including airway control. 78 Pediatrics in Review Vol. After the initial shock. as described in Case 2. to ensure that the athlete has recovered completely before he or she returns to sports participation.and medium-contact sports.gov/ncipc/tbi/Facts_for_Physicians_ booklet. and clinicians that provides guidance in the management of head injuries at http://www. . parents. particularly diving.sports medicine office management of sports injuries bodies at risk for money. As you approach the athlete.pdf. The essential elements in preseason event preparation for a cervical spine injury include: 1) On-site emergency personnel or the ability to access emergency medical services through the use of a charged cell phone that is fully accessible during the sporting event. When approaching the athlete who is suspected of having a cervical spine injury. In the United States.3 March 2008 3) Immobilization equipment. breathing. the athletic trainer rushes onto the field and immediately calls for your assistance. special care should be given to protect against closed-head injury and. He is prone. Preparation The appropriate sideline management of the acute cervical spine injury starts with effective preparation. When trying to tackle a running back. for use in the event of a cervical spine injury. more importantly. however. and plan for transporting injured athletes to the emergency department. Approximately 60% of all acute pediatric spinal injuries occur in the cervical spine. If the airway is obstructed. Rather than waiting for an injury to occur before devising a algorithm for treating a cervical spine injury on the field. pediatric and adolescent athletes are volunteer athletes.cdc. and falls to the ground. treatment protocols are implemented best before the start of the sports season. similar to the spear tackle in football. 4) An understanding of the steps required in the event of an acute cervical spine injury. It is essential to keep the head turning at the same speed as the body to lessen any chance of additional injury to a potentially unstable cervical spine. and circulation (ABCs). typically occurring through a head-first injury mechanism. American football poses the greatest risk for cervical spine injury and accounts for approximately 50% of such injuries in youth sports. which should be practiced before any injury occurs. lying motionless. suffers an axial load with a flexion injury. Treating the prone athlete involves initial assessment of the airway. begins with assessment of the ABCs while attempting to keep the head and neck in a stable position. Current Management of Cervical Spine Injury Case 2: Cervical Spine Injury You are on the sideline of a football game when a 17-yearold player suffers an injury while tackling another player. This technique. On-field Management Appropriate on-field management of a suspected cervical spine injury follows a similar protocol to basic life support. In this scenario. which begins with a focus on airway management. it is imperative to establish the airway first. The football helmet never is removed on the field. If the athlete is unconscious and not breathing. an appropriate initial step includes listening for breathing or putting a hand beneath the jersey and shoulder pads to check for thoracic expansion.gov/ConcussionInYouthSports/ and http://www. If the injury occurs in football. which includes assuring that the tongue is not obstructing the airway. the airway is established in the supine position. Therefore. he lies motionless in a prone position on the field. establishing airway control can be difficult. an initial desire to assess and treat the neck directly is common. The Centers for Disease Control and Prevention supply information for patients. but the helmet and shoulder pads should remain in place to ensure neutral alignment of the cervical spine. the log roll technique (Fig. he uses his head as the initial contact device (spear tackling). including a back board. Cervical spine injuries also can occur during water sports. cervical spine immobilization. Epidemiology of the Cervical Spine Injury Cervical spine injury represents a rare but potentially life-threatening event in youth sports. Appropriate management of the injured cervical spine. involves rolling the injured player by two assistants controlling the body and the team leader controlling the head. Cervical spine injury occurs most frequently in high.cdc. If the athlete is unconscious.29 No. when an athlete hits the water at a high velocity with the neck flexed. the face mask should be removed. 1) is used to move the patient to the supine position.

which suggests paracervical muscular spasm. Five radiographic views should be obtained in all patients in whom cervical spine injury is suspected (Figs. Normal flexion view of the cervical spine. and strengthening programs that involve sport-specific exercises for the prevention of cervical spine injury. Pediatrics in Review Vol. with the exception of the lack of the normal lordosis on the lateral view in Figure 6. 2 through 6). Note that all of these radiographs show a normal cervical spine. Prevention Figure 2. Effective prevention includes the use of proper-size equipment during practice and games. Log roll technique for stabilization of pediatric cervical spine injury. as is the case with the patient in Figure 7. with the person in charge at the head giving commands and keeping the cervical spine in line with the rotating torso. It is always important for the helmet to stay on unless airway problems are present.3 March 2008 79 . Prevention of cervical spine injury is an important consideration for the pediatrician. This technique requires two or three people to complete. Normal anteroposterior view of the cervical spine. Figure 3.29 No. Flexion and extension views never should be obtained when cervical instability is suspected.sports medicine office management of sports injuries Figure 1. proper coaching and refereeing that discourages risky tackling.

Inequality of space suggests instability between the first two vertebrae.sports medicine office management of sports injuries Figure 5. “rolling” of the ankle. the eversion injury. the face mask should be removed quickly by the athletic trainer while the physician keeps his knees around the player’s helmet to minimize motion. and the athlete is transported to the emergency department. obtaining a history is an essential first step in the diagnostic approach to injury (Table 2). The most common mechanism. accounts for approximately 80% of ankle injuries and is the result of a twisting or rolling of the ankle when stepping into a hole or running on an uneven portion of the field. 2) There is no pain with palpation of the cervical spine. 3) There is no report of radicular symptoms emanating from the cervical spine.” When asked. Once the player is supine. 4) Results of all neurologic examinations and associated tests are normal. she describes a rolling episode that occurred during soccer practice yesterday when she stepped in a hole on the field. the mechanism of injury.29 No.3 March 2008 A 12-year-old soccer player limps into your office one day after “rolling her ankle. History As with all medical problems. In this case. so named because of its resemblance to a tooth. Normal extension view of the cervical spine. One helpful method of assessment is to ask the patient to demonstrate the mechanism of injury in the uninjured extremity. extends from the second vertebrae into the first vertebrae for stability. Odontoid view showing the relationship between the first and second cervical vertebrae. Returning to Activity Athletes who are suspected of having a cervical spine injury but have normal radiographic findings can be returned safely to activity when: 1) There is no pain with motion of the cervical spine. The dens. Figure 4. In contrast. involving a player who is unconscious and not breathing. The space around the dens should be equal on both sides. The airway subsequently is secured quickly with appropriate jaw positioning. a less common and more . She sits on the examination table and asks when she can return to play. the inversion injury. needs proper clarification. 80 Pediatrics in Review Vol. the physician should use the athletic trainer and a coach to assist in the log roll technique. Current Management of Ankle Injury Case #3: Ankle Injury In Case 2.

Finally. swelling often is noted in the area of injury in many foot and ankle injuries. forceful injury pattern. The most common reason for an ankle injury in an athlete is the presence of a previous injury that has been rehabilitated incompletely. the presence of previous injury provides important clues in terms of present injury patterns and likely diagnoses. The examiner also should ask about the patient’s activity after the injury occurred. including ability to bear weight and return to activity. Figure 7. the less likely is the ability to continue playing and to bear weight comfortably during running or walking. Observation of how a patient is walking is essential and can assist greatly in differentiating the more serious fracture from the less serious ligament injury. This patient requires complete immobilization and immediate referral to a trauma center for consultation with an orthopedic spine specialist or neurosurgeon. is associated with more severe injuries. Inspection for swelling and ecchymosis also is important. The more serious the injury. Therefore. The more common inversion mechanism produces injury to the lateral portion of the foot and ankle. the examiner can use the hands-on portion of the ankle examination to look for specific injuries. specifically the anterior and posterior talofibular ligaments and the calcaneofibular ligament as well as the proximal fifth metatarsal (Figs.29 No. Lateral view of the cervical spine showing straightening of the normal cervical lordosis but otherwise no evidence of bony abnormality. including the distal fibula and the ligaments around the distal fibula. often involving both the medial and lateral ankle. Lateral view of the cervical spine showing a cervical fracture with cervical instability. With the information gleaned from the history. In addition.3 March 2008 81 . Physical Examination The physical examination begins with observation and inspection. 8 and 9). a fracture of the fibular physis (growth plate) is the most likely injury in the Pediatrics in Review Vol. assessing the past history of ankle injury is essential.sports medicine office management of sports injuries Figure 6.

In the case of a suspected lateral foot injury to the fifth metatarsal. Pain and swelling at this site are suggestive of an injury to the ATFL. The line across the distal fibula in the photo is that of the distal fibular physis. The following exercises can enhance strength and can be learned easily in the pediatric office. If the ankle injury persists for more than a few weeks and if radiographs are negative . How did this injury happen? Examiner should gain appreciation of the mechanism of injury. What happened after the injury? Examiner should gain appreciation for the severity of injury. An elastic band is used to strengthen the muscles gradually as they flex against resistance (Figs. This is the most common site of pain in the athlete who has had closure of the distal fibular physis. 12 and 13). and experiences pain on palpation of the lateral ankle. This closure generally occurs by age 13 years in girls and 15 years in boys. The process of ankle mobilization can proceed after that time. If pain and swelling are present. Pain on palpation of this location is diagnostic for a distal fibular physeal fracture. Ankle views should include anteroposterior (AP). direct loading. Palpation of the lateral ankle at the area of the anterior talofibular ligament (ATFL). Have you injured this ankle before? Examiner should gain insight into previous injuries and underlying predisposing injury patterns. athlete who has inverted the ankle. Ice. but depends on sexual and skeletal development rather than chronologic age. Figure 9. often with the aid of patient demonstrating the uninjured ankle. has open growth plates. Palpation of the proximal fifth metatarsal. radiographs of the foot should be obtained to rule out a fifth metatarsal fracture. These exercises are done in three sets of 15 repetitions daily for a 6-week period. which provide a complete assessment of the bony architecture (Figs. eversion. After 6 weeks. and mortise views of the ankle.sports medicine office management of sports injuries Important Questions to Ask of an Athlete Who Has an Ankle Injury Table 2. after which progressive strengthening can proceed. lateral. Further Studies Radiographs of the ankle and possibly of the foot are indicated in any suspected bony injury. AP. 10 and 11).29 No. 3.3 March 2008 If there is no bone-specific tenderness and the athlete can walk without much of a limp. Elevation) is helpful for the first 48 hours after injury. 1. The premise is that the initial regimen of RICE (Rest. lateral. the pediatrician can suggest exercises as a precursor or possible alternative to physical therapy. The initial step is to start the ankle moving (tracing the alphabet with the first toe is a good start). inversion. the exercises usually can be discontinued. 82 Pediatrics in Review Vol. otherwise known as a “sprain. Bony injury usually is accompanied by swelling and pain. Prevention Figure 8. and oblique views of the foot are indicated. Compression. This site can be injured during an inversion injury. depending on severity. The ability to continue playing denotes a less serious injury than an injury that required assistance from the field and cessation of playing. The examiner must palpate the proximal fifth metatarsal in any inversion injury.” Such injuries are graded on a scale of 1 to 3. 2.

knee. such as the safe return after a concussion or acute asthma attack. as shown in this radiograph. Mortise view of the ankle in a skeletally immature patient who suffered an eversion injury. including the peroneus muscle groups on the lateral aspect of the lower leg and the tibialis posterior muscle on the medial aspect of the leg. This patient should be referred for additional treatment. there is subtle widening and pain at the medial ankle in the area of the distal tibial physis. and there is no bone-specific tenderness.3 March 2008 83 . referral to a physical therapist is indicated. and orthopedic issues. thus exposing the spatial relationship around the talotibial and talofibular joints in the ankle. Normal mortise view of skeletally immature ankle. Safe Return to Sports The safe return to sports following an injury is a complicated and important decision made by thousands of pediatricians daily. is there an inhaler on the sideline for an athlete who has asthma)? Pediatrics in Review Vol. which should be equal. consistent with a growth plate fracture of the medial malleolus. The decision can include medical issues. The arrow points to the site of subtle widening on the radiograph. Multiple studies have demonstrated that the most common cause of an ankle injury is the existence of a previous ankle injury. The prevention of ankle injuries is especially important in any young athlete who has suffered a previous ankle injury. The same exercises used to strengthen the injured ankle are useful in preventive strengthening. The prevention of an ankle injury involves the implementation of programs designed to strengthen the muscles around the ankle.29 No. suggests ligamentous instability in the ankle. In this case. Have all medical considerations been addressed (eg. Alteration of these spaces. In all cases. which also correlates to the site of the patient’s pain. such as the safe return after an ankle. the question must be asked: “Does the return of this athlete to sports put him or her at greater risk for additional complication?” The answer always should be “no. Figure 10. This view is taken with the ankle plantar flexed and the foot rotated inwards.sports medicine office management of sports injuries Figure 11. or shoulder injury.” Important questions to ask in the case of nonorthopedic conditions are: 1.

2002. An excellent resource for the office that is orthopedicfocused and covers most adolescent sports injuries. reducing the risk of additional injury. Philadelphia.3 March 2008 Figure 13. Pa: Saunders. and back strengthening for back injuries. June and August. 3. Elastic band strengthening exercises with the band positioned along the lateral ankle and the foot flexed to 90 degrees is a good approach to starting the process of increasing lateral strength in the ankle. Both editions are dedicated to pediatric sports medicine and are very helpful. has the athlete learned preventive strengthening. As with lateral strengthening of the peroneal muscles.sports medicine office management of sports injuries Figure 12. Sports Medicine: The School-aged Athlete. concussion). .29 No. Is there a system in place to report symptoms if they recur? 3. Clin J Sport Med. shoulder strengthening for shoulder injuries. Is there any ongoing swelling or loss of motion in an affected joint? If so. 2000. medial strengthening of the tibialis posterior muscles aids greatly in the prevention of additional injury. Are the athlete and his or her family aware of the importance of reporting early symptoms (eg. dizziness with an injury can mean a concussion)? Helpful questions for orthopedic injuries and safe return to sports include: 1. this injury may require additional evaluation before clearance. 2. 1997. the athlete should be held until this limitation resolves (eg. The first number is orthopedic-focused and the second is focused on medical sports issues (ie. Ill: American Academy of Pediatrics. Pediatric Annals. In each 84 Pediatrics in Review Vol. Has the proper preventive strategy been employed? Prevention can include ankle strengthening for ankle injuries. this type of lateral strengthening can increase the baseline strength in the ankle. McCrory P. Is there any limitation of normal athletic function with the injury? If so. often through the assistance of a certified athletic trainer or physical therapist. 2. Elk Grove Village. Johnston K. For moderate-to-severe injuries. 2007.31(1). Prague 2004. Over a 4-week period. it is best to refer the patient to physical therapy for an individualized program. 2002. Meeuwisse W. This book is very helpful and comprehensive. This comprehensive book uses both written material and DVD/video technology to teach musculoskeletal skill examination technique. Ill: American Academy of Pediatrics. Such exercises also can be helpful with acute injury.15:48 –55 Recommended Reading The Pediatric Clinics of North America. Medial strengthening of the ankle. et al. to reduce the likelihood of reinjury? Reference 1. case. American Academy of Pediatrics. the soccer player who has shin pain that limits his or her ability to run or the gymnast who has back pain that limits his or her ability to bend backwards). Sports Medicine in the Pediatric Office: Multimedia Text with DVD Companion. Elk Grove. Care of the Young Athlete. Summary and agreement statement of the 2nd International Conference on Concussion in Sport.29(3) and 2002. 2005. 2008 (in press).

the most common reason for an ankle injury in an athlete is: A. Lacrosse. functional progression of activity is a critical aspect of the management of concussion. B. E. C. Grade of concussion is the most significant factor in planning management. C. Pediatrics in Review Vol.sports medicine office management of sports injuries PIR Quiz Quiz also available online at www. Presence of a previous ankle injury. B. D. Which of the following statements about current understanding and management of head injury is true? A. Removal of the face mask. Assessment of circulation. E.pedsinreview. Flat feet. C. Use of the log roll to bring the athlete to a supine position.org. The management of a suspected cervical spine injury in an athlete who is lying prone on the field can include all of the following except: A. A sequential. Improper shoes. C. E. E. D. D.29 No. D. 4. A history of previous concussion is irrelevant to the management of a present concussion. Football. In the United States. Wrestling. Removal of the helmet. The role of the athletic trainer ceases when a concussion victim consults a physician.3 March 2008 85 . symptoms that recur with exercise can be ignored. 1. 2. B. B. Incorrect training methods. Assessment of breathing. Of the following. 3. Participation in a contact sport. Soccer. a cervical spine injury is most likely to occur in which of the following sports? A. Basketball. In the recovery from concussion.

The Importance of Surveillance Diagnosing ASD is very difficult because there are no pathognomonic clinical signs or confirming laboratory tests.Article cognition Recognition of Autism Before Age 2 Years Chris Plauche´ Johnson. PDD-NOS. An increased awareness of early signs of autism can facilitate surveillance and enable PCPs to play a key role in early recognition that. autism is diagnosed infrequently in children younger than 3 years of age. (1) The impact of this prevalence is illustrated by a 2004 survey of PCPs revealing that 44% cared for 10 or more patients who had an ASD.000 children in a general practice should expect approximately six of their patients to meet the diagnosis of an autism spectrum disorder (ASD). they are not discussed.3 March 2008 . 3. when coupled with earlier access to appropriate interventions.” one study reported that approximately 50% of affected children could be diagnosed reliably by 14 months of age. particularly when it is initiated prior to 3 years of age. the DSM (American Psychiatric *Editorial Board. MEd. However. could improve outcomes markedly. (2) The ASDs include: autistic disorder (AD). Because the signs of Asperger disorder usually appear later. 2. Such signs are subtle and may not be noticed by parents. 86 Pediatrics in Review Vol. The term “autism” is used in this review to represent both AD and its milder form. Introduction Primary care physicians (PCPs) caring for 1. these guidelines recommend ongoing surveillance for autism (and general development) at every health supervision visit in all children and “heightened surveillance” in high-risk younger siblings. The diagnostic process is prompted most often by parental concern about absent or delayed speech. Asperger disorder. The purpose of this review is to help the clinician recognize signs of ASDs that occur before age 2 years. MD* Author Disclosure Dr Plauche´ Johnson did not disclose any Objectives After completing this article. Implement a strategy for surveillance and screening of young children. especially deficits in social skills and in preverbal gestural language.29 No.” (7) In an effort to lower the average age of diagnosis and promote earlier access to intervention services. and pervasive developmental disorder—not otherwise specified (PDD-NOS). 4. New information regarding very early signs of autism is emerging through prospective studies of high-risk infant siblings. Over the past 3 decades. Currently. financial relationships relevant to this article. Discuss the management of autism. Characterize the deficits of a child who has autism. Describe the role of observing linguistic and social development in children who have autism. (3) Early recognition of ASDs also is important for timely genetic counseling because younger siblings of children diagnosed as having ASDs have a 10 times increased risk of also having an ASD. signs of autism. (5) To facilitate earlier recognition through surveillance and screening strategies. (4) Using these early “red flags. a threshold term used when a child meets some but not all criteria necessary for a diagnosis of either AD or Asperger disorder. including the use of medication. are present in most children by 18 months of age. Research has documented the positive benefit of developmental and behavioral intervention for children who have ASDs. readers should be able to: 1. the American Academy of Pediatrics (AAP) has published two guidelines: “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening” (6) and “Identification and Evaluation of Children with ASDs.

Social development also parallels general functioning in children who have global developmental delays (GDD).” Such children have little or no inherent drive to connect with others and share feelings. recognition of autism “Clinical probes” are provided in most sections of this article to assist the PCP during the surveillance process. Because referring young children for diagnosis depends on the PCP’s ability to recognize behaviors illustrating these criteria. For example. The delay in social development often is manifested by a lack of or decreased need for social and emotional reciprocity or “social relatedness. surveillance. sounds. Stone and associates (9) have suggested applying only the following four of the possible DSM-IV criteria to children younger than 3 years of age: ● ● ● ● Lack of spontaneous seeking to share enjoyment. and actions. Currently. Additionally. newer standardized tools that operationalize the DSM-IV criteria (eg. attempts to compensate and relate socially to others. but they become more obvious by 18 to 24 months of age in children later diagnosed with autism. Discrepancies may be recognized late in the first year after birth. For example. “failure to form age-appropriate peer relationships” is not applicable to children younger than 2 years of age. some of the DSM-IV criteria address developmental skills that do not apply to children younger than 2 years of age. Realizing this diagnostic dilemma. For children who have autism (with or without coexisting GDD). The PCP may choose to use one or several of these procedures at each visit to monitor for autism. is very important and should lead to earlier diagnosis and intervention. re-evaluation using the full DSM-IV-TR (10) criteria. preverbal child. ritualistic behaviors and a need for routines appear in children who have autism after the third birthday. body postures. making diagnosis even more challenging. In addition. and visual deficits. facial expression. and standardized tools have not yet been validated in this age group. such as eye-to-eye gaze. although some are in development. if any. Rather. is recommended after the third birthday. These researchers propose that all four criteria be present to make the “provisional diagnosis” of autism in the very young child. they are only one part of the total package of developmental screening. and cognitive functioning. especially in the face of widespread media promotion of early diagnosis and intervention. hearing. adaptive. The discrepancy between the development of social skills and general development is one of the most important defining criteria. combined with a standardized tool. Early Social Skill Deficits Social development usually parallels overall general functioning (motor⫹adaptive⫹language⫹cognitive domains) in children developing typically. Autism Diagnostic Observation Schedule [ADOS] (8)) optimize diagnosis.29 No. thoughts. the development of social skills and language is more delayed and characteristically is “out of sync” with motor. affection. Infants who have hearing loss often are visually hypervigilant and use eye contact and gestures to connect with others. or connectedness. an autism screening tool (6)(7)(11) should be used at the 18. or pointing out objects of interest) Lack of social and emotional reciprocity Marked impairment in the use of multiple nonverbal behaviors. Children who have autism may seek comfort and affection when injured or anxious. they often are content being alone and usually ignore other’s bids for attention. by lack of showing. and conversations. facial expressions. However.and 24-month visits and at any time there is concern about ASD. bringing. or achievements with other people (eg. even children who have severe AD may not meet full criteria at very young ages.cognition Association Diagnostic and Statistical Manual of Mental Disorders) criteria have served as the gold standard for making a clinical diagnosis. Deficits in social relatedness are manifested by several behaviors that can be observed spontaneously or prompted during an encounter. infants who have cerebral palsy establish social relatedness through eye contact.3 March 2008 87 . no standardized autismspecific screening tests for children younger than 18 months of age are available. Often. Children who have autism can and frequently do form attachments with family members. but they should not be used as a screening test. illustrating their relative importance in defining autism in very young children. but the inherent drive to connect promotes compensatory strategies. sometimes these may become unusually strong and problematic. and gestures to regulate social interaction Delay in or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) Three of these criteria address social skills. it is impossible to apply criteria relating to abnormal conversational skills and stereotypic language in a young. coupled with a high degree of suspicion. interests. Thus. Thus. the following discussion targets early social and prelanguage deficits. Children who have autism make few. Infants who have other disabilities may have difficulties connecting with others due to their respective motor. Pediatrics in Review Vol. but such self-initiated bids solely when in need should not be interpreted as sufficient indicators for “normal” social relatedness.

3 March 2008 Later emerging JA skills are characterized by the child rather than the adult initiating the connection. ritualistic labeling. However. The gesture is triadic (child. At about 10 to 12 months of age. he or she may look back quizzically at the parent. Such JA pointing should be distinguished from pointing simply to label objects with little eye contact or sharing of affect. children point to comment or to draw another’s attention to an event or object (eg. 88 Pediatrics in Review Vol.” The “requesting” point normally appears first. the child alternates attention between an object/event and another person by looking back and forth between the two and “connecting. they often are unable to point to the same objects on request. object. at approximately 12 to 14 months. The same triad exists (child. may make no attempt to elicit help and just cry.” and point to an interesting object or picture on the wall or ceiling. the typically developing infant. caregiver). there is no eye contact or connection with the parent. and says. caregiver). and the labels rarely are used in social conversation. Most children who have autism do not master this skill at age-expected times. especially younger children. At 14 to 16 months of age. a child looks back and forth between the object and the caregiver to be reassured that the caregiver understands his or her need. “Look at this!” This JA act is qualitatively . As a social function. the typically developing child looks in the direction that the parent is pointing. but the goal is reversed. Clinical Probe for the 12. This action leads to sharing in a mutual experience. while socially engaged with his or her mother. depending on the child’s language level. On seeing the object of interest. some. he or she may use words when pointing. “Look! See the. object. . but to look back at the caregiver and “connect” socially. As a communicative function.to 24-monthold child is a strong indicator of autism. Absence of this type of pointing in the 18. JA may be classified as: 1) “spontaneous” when the child looks back and forth between an interesting object/event and the caregiver to share interest. and 3) “initiating” when the child points to an object/event to establish a connection with another person. so this gesture does not represent true JA. “Oh look!”. Again. no degree of intensity is successful in getting the child who has autism to look. the adult’s attention. Some may engage in primitive pointing involving an outstretched arm in the direction of the desired object and opening and closing the hand in a repetitive grasping motion. if a parent sees something of interest. spontaneously developing behavior that demonstrates the child’s joy in sharing an object or event with another person. Others may lead their parents by the hand to the desired object and simply wait or cry. Often. While pointing to the desired object (eg. .cognition recognition of autism Joint Attention The single most distinguishing characteristic of very young children who have autism is a deficit in “joint attention” (JA) that is discrepant from overall functioning. Such pointing serves a purely social purpose and represents fully developed JA. A child who has autism often is oblivious to the parent’s bid or may look briefly at the object with little interest but does not look back at the parent to connect. JA is a normal. at self-initiated. but it is not purely social because the cookie is the goal and the caregiver is simply a means by which the child can obtain it.” It is a core feature of the DSM-IV-TR criteria and a critical component of current autism screening and evaluation tools. typically developing children point to “comment” or call attention to and share an interesting object/event. The object now is the means by which the child obtains his or her goal. points in its direction. .and 15-month Health Supervision Visits: The clinician might demonstrate the child’s ability to follow a point by saying. At 8 to 10 months of age. the moon) out of mere interest and simply to “share. a cookie). As with all developmental skills. JA appears to develop in graduated stages. the child looks back at the parent and may smile (or frown if the object is frightening). Children who have autism often take no notice of the shift in gaze. even advanced. children point to “request” an item that is out of reach. If there is no response. typically developing children also begin to “show” or bring an object to the parent. Around 14 to 16 months of age.” For example. 2) “responding” when the child looks in the direction indicated by the pointing of a caregiver and connects.29 No. Pointing can serve both communicative and social functions for children. Words later may accompany the pointing as language develops. Although children who have autism can be adept. The child looks alternatively between the object and the caregiver for reassurance that the object has been observed and appreciated. If the object is unfamiliar or the infant does not see the object. as if to say. will follow the mother’s gaze if she shifts her eyes away from the infant to look at an object or event across the room. True JA requires the child not only to follow the point. It is triadic. call louder and initiate the bid with the child’s name or a tap on his or her shoulder. a child can “follow a point.

increases in complexity and imagination. sticks. but true pretend play is rare before the age of 2 years. blocks) rather than miniatures to represent food and pretend to feed the doll or pretend that a banana or stick is a phone. they may play with them in unusual ways. Typically developing children usually respond by the second trial. twirl. such as to open a container. dirt. (3) This insight has stimulated the development of curricula that have resulted in successful promotion of both JA and language development. Children who are 8 to 10 months old may throw the blocks. when children begin to use miniature representative items. Once children can grasp and retain objects (approximately 4 months of age). (12)(13) The best distinguishing factor was failure to orient to name because JA pointing skills may not be universally present in typically developing children at 1 year of age. changing clothes. Children who have severe autism and coexisting GDD often remain in the sensory-motor stage throughout their lifespans. Play usually evolves in a highly predictable manner in typically developing children. GDD is more likely. such as a tiny plastic bottle or spoon to feed a doll or a toy telephone to “talk” with parents. using this new understanding as well as evolving imitation skills. most typically developing children consistently turn their heads toward the speaker when their names are called. “Simple pretend play” usually begins at approximately 16 to 18 months of age. the PCP should try again. children begin to engage in “complex pretend play. This dichotomy occurs because children who have autism often attend to environmental sounds extremely well but ignore human voices. If he or she does not. functional language is dependent on its mastery. Oral-motor play evolves into a more functional type of play as children become aware of the intended use of objects. Newer prospective studies of high-risk infant siblings later diagnosed with autism have confirmed this finding. Parents may begin to have concerns that their child cannot hear. blocks). chains. turning to respond to one’s own name being called. and books or videos (simply for carrying. For example. Retrospective evaluations of birthday videos of 1-year-old children later diagnosed as having autism have demonstrated that “blinded” viewers could recognize autism with accuracy at this age. or bang them together. and putting the doll or teddy bear to sleep). JA appears to be a pivotal skill.” They use generic items (eg. When they are interested in typical toys. Lack of or significantly delayed JA skills appear to be specific to autism. they continue to mouth. autism is likely. functional language begins to emerge within 1 year. that is. in particular. Furthermore. it is necessary to know the child’s overall level of functioning as well as his or her progress in JA development to help distinguish autism from GDD. frequently preferring everyday items such as string. Pretend play also becomes more complex as children engage in several successive pretend scenarios (feeding.3 March 2008 89 . children begin to build towers with the blocks. With greater vigilance. rather than typical play with a miniature truck. Thus. but even this latter type of request is infrequent in autism. and bang objects stereotypically. strings of beads. bang them on the table. Some children. a child who has autism might turn it upside down and spin the wheels repeatedly. Pretend play subsequently emerges and. prompting parents to call louder or tap their child’s shoulder in an effort to get a response. (14) recognition of autism Clinical Probe for the 12-month Health Supervision Visit: The PCP can evaluate the child’s ability to orient socially by calling out his or her name and noting whether the child turns and connects. Some progress to functional play. They mouth and manipulate objects (eg. Children who have autism usually do not. throw. At 12 to 14 months of age. rocks. sensory-motor play begins. Children who have GDD without coexisting autism develop JA skills at rates similar to those of the development of other skills and begin pointing to comment when they attain a mental age of 14 to 16 months. This accomplishment underscores the urgency of an early diagnosis and prompt access to intervention.cognition different from bringing an object to the parent to request help. Pretend (Symbolic) Play Lack of or delayed symbolic play (using pretend actions with objects) appears to be a relatively reliable distinguishing feature of autism. If there is a discrepancy between the two domains in which JA skills are significantly more delayed than general skills. At 18 to 20 months of age. particularly those who have normal Pediatrics in Review Vol. Social Orienting Social orienting is the ability to orient to verbal stimuli. with time. not for reading or viewing). they realize that the child seems to hear well in other situations. If the delays in all domains are similar. At about 8 to 10 months of age. they often have little interest in toys. Studies have shown that once JA is mastered.29 No.

Clinical Probes for the 12. Parents may not be able to verbalize such subtle deficits. cry for long periods of time. thus. may be proficient in constructive play (eg. and be difficult to console. nesting cups. smiles and stops babbling at the sound of her voice. Later. making such concerns less helpful in reaching an early diagnosis. At 10 to 12 months of age.” (4) Some infants later diagnosed with autism are unusually quiet and make few vocalizations.” extend their arms to be picked up. For example. Many children who have autism appear to enjoy “roughhouse play” (being tickled or tossed in the air) and show fleeting moments of social relatedness. Other deficits are more difficult to assess in a clinical setting and impractical for use in surveillance. When the mother approaches the bedside to say “good morning. such as stacking blocks. that is. Although additional social deficits are associated with ASDs. delays and deviancies in language development have been the most common presenting signs in children later diagnosed with autism. squeal stereotypically. parents may state that their child is unusually good. To reassure the parents or to suggest appropriate referrals. the infant may resume babbling but stop again when mother speaks. Normal babbling usually begins by 6 months of age.” the infant. (12) Recent prospective studies of high-risk infant siblings have confirmed video findings and revealed new “red flags. instead of cooing and babbling. they often become very vigilant. on seeing the mother. especially in children who have Asperger disorder. .and 18-month Health Supervision Visits: The PCP should ask the parents about the child’s favorite toys and manner of play. the PCP should be familiar with the more subtle and earlier appearing prelinguistic language deficits associated with autism. and the mother may feel that her child does not recognize her voice or notice when she enters or leaves the room. with repetition of the same phoneme (“ba ba”) in a monotone voice. the enjoyment simply may reflect sensory-motor pleasure rather than social engagement. Early Language Skills Deficits Historically. causing his or her speech to sound like animated gibberish. requiring little attention or intervention from the parent. When the mother turns away to get diaper supplies and pauses in her speech. Children who have autism often do not add inflection at this age. putting puzzles together) and in computer games because mastery of such play depends on independent trial and error problem-solving rather than on observation and imitation of others.29 No. Often. Occasionally. The PCP also might ask the parents to describe a “typical day” to ascertain the amount of time spent in solitary play. Children who have autism excel in tasks learned through trial and error. more parents are aware of the condition and may ask about it regardless of the nature of their child’s symptoms. many infants babble to themselves playfully on awakening. or laugh inappropriately. he or she is content to play alone for hours. they often are not recognized until later. Such solitary play usually is sensory-motor and ritualistic or constructive. the babbling advances in complexity. using objects in combination to create a product. they may hum or grunt for extended periods. Typically developing infants develop a to-and-fro pattern of babbling and silence (or apparent listening) that is coordinated with the caregiver’s speech and is similar to true turntaking conversation seen in older children. In such cases. with utterances becoming longer and including several phonemes (“ba da pa pa da da”). or engage in interactive hand movements associated with children’s songs and nursery rhymes. there is less eye contact. Parents may be unable to answer some questions decisively at the time of questioning. However. probe further. Prelinguistic Language Abnormalities Prelinguistic abnormalities characterizing autism during the first postnatal year became apparent when investigators began retrospective evaluation of infant videos of children later diagnosed with autism. the typical infant adds inflection to utterances in an attempt to tell a story (jargoning). Infants later diagnosed with autism demonstrate fewer gestures. parents usually did not raise such concerns until after their child’s second birthday. but once the subtle 90 Pediatrics in Review Vol. vocalizations overlap and do not resemble the “protoconversations” described previously. Others may be very irritable. High-risk siblings who are later diagnosed with autism often continue to vocalize as if they are not aware of their mother’s speech. the PCP should encourage the parents to report back once they have had the opportunity to observe their child systematically. requiring the PCP to probe with specific questions. If parents report that their child enjoys playing with other children. Other infants make atypical vocalizations. They may not wave “bye. Because autism has been spotlighted frequently in the lay media.3 March 2008 characteristics are brought to their attention.cognition recognition of autism nonverbal intelligence. If play consists solely of chasing and roughhousing.

Although most parents sense something is wrong by the time their child is 18 months of age. it occurs in Rett syndrome and other neurodegenerative disorders. a “wait and see” approach may be appropriate. and 24 or 30 months of age using standardized tools that include social and language milestones. and referrals were delayed. attendance at a preschool with verbal peers. Because parents sometimes overestimate their child’s receptive language abilities and think that their child “understands everything. . but as noted previously. These tools also can provide useful probes for the 12and 15-month visits. children who have hearing impairments fail to orient to both social and environmental sounds. Although children appear to develop normally until the regression. a definitive diagnosis is not necessary to begin intervention. Pediatrics in Review Vol.and 15-month Health Supervision Visits: The AAP has recommended formal screening for developmental skills at 9. Clinical Probes for the 9. Developmental tools are described in both the AAP Developmental Surveillance and Screening (6) and ASD (7) guidelines. the PCP should recommend strategies (by means of developmental handouts. Such “autism regression” usually occurs between 15 and 24 months of age. waving bye) and made less eye contact. the PCP should refer the child immediately to a developmental or autism specialist (or a team of specialists) and to an early intervention program. 18. also ask . when they realize that the child has little or no speech. recent prospective studies have revealed that some children have subtle social and language deficits prior to regression. the strategies can be revised after a diagnosis becomes evident. but recent studies of infants later diagnosed with autism have revealed that the deficit is linked more closely to the infant’s lack of social relatedness than to a deficit in receptive language or auditory comprehension. . . (13) (15) Loss of language skills is not pathognomonic for autism. Selected tools are included in the AAP ASD Toolkit (11). Sometimes they may rationalize that the delays are due to the child’s temperament (shy) or to a lack of opportunity to interact with peers if the child is an only child. Parents may report that children stopped talking and gesturing (eg. Sleep electroencephalographic tracings in affected children often are characteristic.and 12-month Health Supervision Visits: Does your baby . parents of children who have autism sometimes complain that they received inappropriate reassurance regarding their concerns. with most occurring between 18 and 21 months.” referrals to audiology to evaluate hearing status and to a speech and language pathologist to evaluate both expressive and receptive language are indicated. the PCP must consider the possibility of autism or GDD. a “wait and see” approach is not appropriate. Loss of speech associated with seizures is characteristic of Landau-Kleffner syndrome. Language Regression Approximately 25% to 30% of children later diagnosed with autism seem to develop normally and then regress. Absent or Delayed Speech Absent or delayed speech has been the most common presenting sign in children who have autism. Does he or she take turns vocalizing back and forth with you? Are vocalizations becoming more varied in terms of types of sounds and length of sequences? Are these associated with a growing repertoire of gestures? • Wave “bye bye”? Raise his or her arms to be lifted? • Hear your voice as well as he or she hears environmental sounds? • Make any unusual vocalizations or laugh inappropriately? recognition of autism If hearing is normal but receptive language is delayed. they often do not share such concerns with the clinician until much later. Clinical Probes for the 12. • Look at you when you are speaking? • Babble? If yes. (14) The possibility of a hearing loss also must be considered.3 March 2008 91 .cognition Other prelinguistic language deficits overlap with social skills. and if necessary. For example. However. receptive language is normal. (7) The clinician should not delay.29 No. . but regression is later (usually older than 3 years) and not associated with loss of eye contact or social skills. etc) to stimulate speech. If hearing and receptive language are normal. not responding to one’s name being called (previously discussed in the section on social orienting) traditionally has been considered a receptive language deficit. the clinician counseled a “wait and see” approach. Although these and other environmental factors may cause delayed speech. pointing. In such a case. Staff can begin an intervention program that is tailored to the child’s deficits. Unfortunately.

they may insist on holding the object most of the day. For example. children who have severe GDD or visual impairment also may demonstrate stereotypies. Unless this discrepancy between echolalic and functional language is recognized. a piece of rope. Unlike typically developing toddlers. Because they may not raise a concern spontaneously. the attachment is much more robust. They are not specific for autism. or particular action character). pop-up words. move to a new house.3 March 2008 Downloaded from or sentences spoken as a single “giant word” (eg.” but the speech is echolalic.18. Some children engage in repetitive behaviors (eg. licking.. Clinical Probes for the 15. and Repetitive Behaviors Although many typically developing children form attachments to a stuffed animal.and 24-month visits. The next time mother wears the same pink blouse. Echolalia is classified as immediate (parroting that occurs immediately after the partner’s vocalization) or delayed (parroting that occurs at a later time). They may use overlearned gestalt pseudophrases 92 Pediatrics in Review Vol. especially those who are of normal intelligence. As suddenly as these words pop up for no apparent reason. they also disappear. and exceptional labeling skills. they demonstrate less interest in common everyday objects or pictures in books and rarely point to them to request new words.cognition recognition of autism Clinical Probe for the 15-. flashlights.. a toddler who has little if any functional speech exclaims “elephant. death of a family member) caused the loss of skills. Atypical Language In addition to delays. Autistic echolalia also is much more pervasive and enduring and includes larger “chunks” of verbal material. or a “blankee. They repeat the last one or two words of the sentence they have just heard. or the ABCs at much younger ages. and numbers. a special pillow. and not functional. may become obsessed with labeling colors.” No elephants (real or stuffed) or pictures of elephants are within sight. Such atypicalities sometimes can give the false impression of “advanced speech. he again begins saying “elephant” repeatedly. yet they are unable to use the terms in conversation or point to them on request.” children who have autism often prefer hard items (ballpoint pens. For example. Stereotypies. He repeats this several times that day but not the next. head nodding. sniffing). shapes.29 No. The mother may recall that she wore the blouse the day they went to the zoo and he saw his first elephant. Children who have autism may demonstrate exceptional verbal memory linked to echolalia and recite nursery rhymes. Many children develop stereotypies (hand flapping. Some children who have autism. children who have autism may demonstrate atypical language during their second year. twirling. Most typically developing children pass through a stage where they imitate or echo another’s speech (echolalia). they usually appear later than 2 years of age. Occasionally. Whatisit? Idontknow. the parent might discover the stimulus for the verbalizations. Moreover. advertisement jingles. Even typically developing children can flap their hands briefly when excited. others may rationalize that some event in the child’s life (birth of a sibling. Some children who have autism say “pop-up” words that seem to be out of context and have no communicative intent to the listener. yet they lack the ability to combine words in novel phrases that convey meaning. even during meals. a child may be able to recite the ABCs or sing a television advertisement jingle but be unable to ask the parents for a drink or follow a command. a probe might be needed to highlight the importance of skill loss. Formal screening is recommended at the 18.and 24-month Health Supervision Visits: The clinician may ask the parent about echolalia. lining objects up) and may protest violently when they are directed to a new activity. a speech deficit may be overlooked. toe walking. Echolalia usually is a temporary phenomenon and occurs when toddlers are rapidly gaining new words. 18.). ritualistic.and 24-month Health Supervision Visits: Although most parents are keenly aware when regression occurs and are likely to raise a concern. on seeing his mother dressed in a pink striped blouse. Whereas typically developing children demonstrate the immediate variety. The complexity of such speech utterances can mask true deficits in both functional speech and receptive language skills.. children who have autism demonstrate both types. finger movements. The anger and protest may escalate quickly to a prolonged temper tantrum and aggression or self-injurious behaviors. Restrictive Interests. Although stereotypies are distinctive and obvious. rocking. .

Others may be hypoactive or withdrawn. transition. the head size often normalizes in late childhood. Screening tools for younger children are in development and should be available soon. Some may appear to be hyperactive and motor driven. (16) Clinical Strategy for All Health Supervision Visits: Generally. Although the PCP should consider the possibility of hydrocephalus.and 15-month Health Supervision Visits: Note gait and whether the child carries a comfort item into the office. A neurologic examination or gross and fine motor screening tools can be helpful in evaluating coordination and motor skills. phenylketonuria) and manifest the physical signs that are characteristic of that syndrome. sometimes to the point of macrocephaly. although this may be linked more closely to social rather than pure motor deficits.and 24-month visits and whenever a concern is raised. or certain textures.. For example. and two collections of fact sheets (one set for physicians and one for parents) that address major health. children who have autism may demonstrate abnormal amounts of activity.or hypersensitivities. parent concern. other caregiver concern. Clinical Probes at the 12. Additionally. surveillance and screening algorithms and tools. if any. meaning that the cause currently is unknown and that there is no known associated syndrome.12. In addition to abnormal quality of motor actions. Others may have oral aversions and intolerance to certain food textures that contribute to self-imposed restricted diets. and seem to have an interior focus of attention.. and most target children 18 months and older. However. The motor skills of children who have autism may seem advanced. computed tomography scan or magnetic resonance imaging often is not indicated unless there are associated neurologic signs or other indicators for neuroimaging studies. (11) Although the toolkit contains several screening tools. educational. The AAP tool kit also can serve as a resource guide for both clinicians and parents because it contains related policy statements.cognition Clinical Probes for 9. the AAP has recommended formal screening of all children with a standardized ASDtargeted tool at the 18.. The dichotomy is puzzling. holding objects very close to their eyes. and family support issues associated with ASDs. Some of these children demonstrate accelerated head growth beginning at about 6 months of age and continuing for the next few months. no screening tool is ideal. and jumping skills. developmental. More than 90% of children who have ASDs have “idiopathic” ASD. garment labels. Affected children may explore toys visually in unusual ways. self-injurious behaviors.18. most dysmorphic features are recognized at birth. older sibling having an ASD. yet the child may seem oblivious to his mother calling his name loudly. Screening and Evaluation In addition to conducting surveillance at every health supervision visit. fragile X syndrome. the slightest sound of water dripping may irritate the child. they may be indifferent to noxious stimuli and injuries that typically are painful to others. and motor planning and sequencing of movements. or demonstrating an unusual head tilt. but it is believed to be due to an abnormal arousal level or sensory gating system. The ASDs surveillance and screening algorithm published in the AAP ASD clinical report (7) states that if a child has two or more risk factors (eg.29 No.and 24-month Health Supervision Visits: The clinician should ask the parents about diet. children may demonstrate “tactile defensiveness” and not tolerate soft touch. move little. clinical reports. Additional Early Autism Characteristics Not Included in the DSM-IV-TR Criteria Children who have autism may demonstrate simultaneous hyposensitivities and hypersensitivities for different stimuli within the same sensory modality. recognition of autism Autism is not associated with a classic physical phenotype. Most affected children exhibit fewer imitative motor patterns. especially running. coordination. The PCP should measure the head circumference and plot head growth to monitor for growth acceleration. climbing. looking at objects out of the corners of the eyes. tuberous sclerosis. with an exterior focus of attention. Pediatrics in Review Vol.. hypo. Probe for unusual attachments. Such children look normal and have few. unusual visual behaviors. stereotypic movements. and unusually severe temper tantrums with transitions or for no apparent reason. The remaining 5% to 10% have an associated syndrome (eg. and activity level. some children may have subtle deficits in fine motor skills.15. dysmorphic features (eg. However.3 March 2008 93 . the AAP has developed an ASD toolkit. (7) To operationalize this recommendation.. posteriorly rotated ears). some may be subtle and require ongoing surveillance as they become more prominent. On the other hand.

and intense and should address development. and help them enroll in appropriate early intervention programs benefit the chil- . 2) a detailed physical examination focusing on neurologic signs and dysmorphic features. This process is described in much greater detail in the AAP ASD clinical report. the PCP should use an appropriate screening tool based on the age of the child. to an ASD specialist or team of specialists for a comprehensive evaluation. 3) thorough developmental or psychometric evaluations. the PCP should be familiar with some of the most popular local options and provide the family with evidence-based information. obsessions. the clinician should “start low and go slow. and academic issues.3 March 2008 need to counsel parents regarding the 10 times increased risk of ASDs in subsequent siblings if this information was not conveyed by the specialist making the diagnosis.medicalhomeinfo. depending on the available local resources and his or her level of comfort. There is no medical “cure” for autism. 4) Children may have ongoing pica and continue to need lead screening. Such evaluations usually include the following components: 1) a thorough history. and to audiology (if this has not already been done). self-injurious behaviors. When prescribing the medication. 4) assessment with a standardized ASD tool (eg. teachers. This can be more challenging for several reasons: 1) Many children who have ASD are unable to describe their symptoms or localize their pain. educators. therapeutic. not all require medication. and behavioral (aggression. sleep disorders) problems. PCPs now have the opportunity to play a pivotal role in early recognition. When the child puts him.” Children should be monitored for adverse effects. assessment of the criteria themselves using clinical judgment. ear infection. Medications should be considered when behaviors (eg. 5) Children may have coexisting medical (seizures. therapists. Parents of children who have ASDs often seek complementary and alternative medicine (CAM).29 No. refer them for comprehensive evaluations. When choosing a medication. the child should be screened with an ASD-specific tool at 18 and 24 months. (18) Conclusion A growing body of evidence is revealing that many children who have autism can be recognized before age 2 years. and behavioral interventions. pediatric subspecialists. anxieties. Early intervention programs and schools should provide services that are individualized. therapists.or herself or others in danger. Management of autism generally is the province of early intervention specialists. aggression. medications never should be started without first performing a physical examination to rule out a medical cause (eg. 2) Care coordination can be complex due to a variety of practitioners (developmental and behavioral specialists. 3) Parents may be stressed and require more family supports. psychiatric (anxiety. However. an additional appointment should be made within 1 month to monitor progress and address any residual concerns the parent or PCP might have in spite of a negative screen. and only one medication (risperidone) has been approved by the United States Food and Drug Administration for use in children who have ASDs. the clinician should target the most challenging behavior. abdominal discomfort) for a newonset behavior. and behavior management specialists. or if not available. (7) Whereas surveillance and screening are the responsibility of the PCP. The AAP clinical report provides a detailed review of the management of children who have ASD. depending on the child’s mental age and level of cooperation. If the results of the screening are negative. vocational staff). the comprehensive evaluation may be accomplished best by a specialist or team of specialists who have expertise in autism. (17) Although it is difficult to be familiar with the myriad CAM possibilities. ADOS) that operationalizes the DSM-IV-TR criteria. Management The PCP’s most important role is to provide a medical home. behavior. and educational services. Medication is an adjunctive treatment that often is used to address challenging behaviors after behavioral and environmental interventions have failed. social workers. medication may become a “front-line” intervention. If the child has only one risk factor. the PCP should make the same three referrals. therapeutic. Although all children should receive appropriate developmental. If the result is positive. nutritional). The PCP may be involved in this process to varying degrees. and 6) Infant siblings need heightened surveillance. sleep disorders) negatively affect or prevent the progress of educational. the PCP should make three simultaneous referrals: to an early intervention or school program (depending on the child’s age). including a three-generation pedigree. tooth abscess. stereotypies. If there are no risk factors. especially when they are unable to verbalize symptoms.org). social skills. as with all children (www.cognition recognition of autism or physician concern). and 6) an etiologic search based on results of the first five components. 5) an assessment of the family’s strengths and needs. appropriate. PCPs who recognize autism in children younger than 2 years of age. The PCP also may 94 Pediatrics in Review Vol. if available. obsessive compulsive disorder).

Johnson CP.org. DC: American Psychiatric Publishing.27: S88 –S94 3. Pediatrics. Can autism be diagnosed accurately in children under 3 years? J Child Psychol Psychiatry. www. 2007.29 No. Zwaigenbaum L. Autism Spectrum Disorders in Children. and society. especially if there are no coexisting cognitive deficits. Committee on Interventions for Children With Autism. Myers SM. Arch Pediatr Adolesc Med. and http:// firstwords. 2001 4. their families. available free of charge at www. Dev Psychopathol. contains more than 100 video clips that illustrate both typical and atypical development. Sigman M. United States. DC: National Academies Press. 2000:109 –141 Autism Speaks. A prospective study of response to name in infants at risk for autism. et al. 2007. Munson J. NJ: John Wiley & Sons. Johnson CP. J Dev Behav Pediatr. decrease the need for special education services in later years. 1999. Ment Retard Dev Disabil Res Rev. Educating Children With Autism. Weiner CL. Dijamco A. empower families. their future schools. American Psychiatric Association. Osterling JA. Pediatrics. Washington. Fourth Edition.30:205–223 9. Stone WL.13: 16 –25 6. 2004.56(SS-1):12–28 2. Lord C. Arch Gen Psychiatry. Arch Gen Psychiatry. Klin A. Council on Children With Disabilities. 2006. Cesari A. Council on Children with Disabilities. Early language and communication development of infants later diagnosed with autism spectrum disorder. Autism spectrum disorder screening and management practices among general pediatric providers. Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Bryson S. Washington. 2007 12.120:1162–1182 Suggested Reading Chawarska K. Hoboken. Elk Grove Village. Diagnostic and Statistical Manual of Mental Disorders.161:378 –383 15. Myers SM. 2007. Werner E. Is early development really normal? Acta Psychiatr Scand. Dawson G. In: Wetherby AM. 2004:85–123 Landa RJ. Early clinical characteristics of children with autism. 2000 11. 2007. Pediatrics. together with First Signs. Text Revision (DSMIV-TR).62:889 – 895 16. Rapin I. eds. Pediatrics.3 March 2008 95 . 2007.14:239 –251 13. The glossary. Gratier M. Autism Spectrum Disorders. Young GS. 2005:223–246 Johnson CP. Johnson L. Ozonoff S. have developed a first-of-itskind web-based video glossary to help professionals learn more about the early warning signs of ASDs. Section on Developmental and Behavioral Pediatrics. Prizant BM. eds. 2004.64: 853– 864 Mitchell S. 3rd ed.113:68 –72 14. Council on Children with Disabilities. Roberts W. Brian J. AAP Autism Expert Panel. The AAP ASD clinical reports and toolkit should help guide and support PCPs in this endeavor. Dawson G.firstsigns. Landa R. 2006. In: Gupta VB. Garrett-Mayer E. Pediatrics.23:143–152 5. Pecini C. 2007. Lee EB. Maestro S. Nadig AS.107:598 – 601 18. 2002. Dosreis S. Ill: American Academy of Pediatrics. American Academy of Pediatrics. 14 Sites. 2001. Handbook of Autism and Pervasive Developmental Disorders. National Research Council. Int J Dev Neurosci. MMWR Surveill Summ. Centers for Disease Control and Prevention. Committee on Children with Disabilities. Risi S. Pediatrics in Review Vol. Baltimore. In: Volkmar FR. 2000. Prizant BM.118:405– 420 7. Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability. Ment Retard Devel Dis Res Rev. Autism in infancy and early childhood. Paul R. J Dev Behav Pediatr. The Autism Diagnostic Observation Schedule— generic: a standard measure of social and communication deficits associated with the spectrum of autism. Behavioral manifestations of autism in the first year of life. Rogers S. Rozga A. Stern D. Validation of the phenomenon of autistic regression using home videotapes. A view to regressive autism through home movies. American Academy of Pediatrics. Ashford L. Zwaigenbaum L. Apicella F.120:1183–1215 8. et al. Rozga A. Early recognition of recognition of autism 1-year-old infants with autism spectrum disorder versus mental retardation. Holman KC. Brookes Publishing Co. et al. Lembrecht L.edu. Prevalence of autism spectrum disorders—Autism and Developmental Disabilities Monitoring Network. ed.40:219 –226 10. Identification and evaluation of children with autism spectrum disorders. the leader in early identification and intervention of children with developmental delays and disorders. 2002.10: 221–233 Wetherby AM.autismspeaks. NY: Marcell Decker. a nonprofit organization dedicated to increasing awareness of autism and raising money to fund autism research. Trentacoste SV.org. Brian J. Understanding the nature of communication and language impairments.fsu. and Florida State University. References 1. Rogers T. 2005.cognition dren. 2006. and increase the child’s chance for independence and gainful employment as an adult. 2005. Muratori F. Autism: Caring for Children With Autism Spectrum Disorders: A Resource Toolkit for Clinicians. Inc. Muhle R. Szatmari P. 2006. Md: Paul H. Early detection of core deficits in autism. New York. Newschaffer CJ. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Inc. Volkmar FR.113:472– 486 17. A high degree of suspicion and a solid understanding of early deficits in social and preverbal skills are critical to early recognition. Management of children with autism spectrum disorders. Social and communication development in toddlers with early and later diagnosis of autism spectrum disorders. Bright Futures Steering Committee. The genetics of autism. Early communication development and intervention for children with autism. Schuler AL. J Autism Dev Disorder.27(2 suppl):S69 –S78 Sigman M. Early diagnosis and intervention improve outcomes.

Label. C. Hearing. C. Differences in pointing behaviors. Receptive language. Auditory processing.org. Impairment in use of nonverbal behaviors. D. Cognition. Children who have autism rarely demonstrate evidence of: A. D. B. E. E. B. Delay in achieving speech and language milestones. Abnormal conversational skills and stereotypic language. Of the following. as an example of “joint attention. Roughhouse play.29 No.3 March 2008 . E. D. Comment. Ritualistic behaviors and need for routine. Social relatedness. D. Distract. The failure of an 18-month-old child who has autism to respond to his or her name when called is believed to be the result of deficits in: A. the best DSM-IV-TR-based criteria to identify children younger than 2 years of age who have autism are: A. Careful observation of typical children at play has been important in better understanding children who have autism.” may be used in descriptions of children believed to have autism. B. Oral motor play. 6. Sensory motor play. E. Failure to form age-appropriate peer relationships. Request. 8.cognition recognition of autism PIR Quiz Quiz also available online at www. B. C. Direct. Constructive play. 96 Pediatrics in Review Vol. Symbolic play. C.pedsinreview. 5. 7. Mature joint attention is demonstrated best with a point whose purpose is to: A.

he awakens every night around midnight and consumes large quantities of food. At that time. Since early childhood. Author Disclosure Drs Peshkovsky. He remembers his eating in the morning but has no remorse or regret. her WBC is 9⫻103/mcL (9⫻109/L). Septer. Now he has lost complete vision in his right eye. and a hyperemic right tympanic membrane. Two days later. Her respiratory rate is 50 breaths/min. Please inquire first by contacting Dr. We invite readers to contribute case presentations and discussions. Nazarian at LFredN@aol. and learning problems. Leggiadro. and her platelet count is 775⫻103/mcL (775⫻109/L). A urine culture is negative. she again developed cough with posttussive vomiting and rhinorrhea.index of suspicion The reader is encouraged to write possible diagnoses for each case before turning to the discussion. cough. psychiatrist. headache. 43% lymphocytes. psychologist. clear rhinorrhea. He recently was exposed to mosquitoes on a camping trip. even those he dislikes. and occasional scattered crackles are present. Kupersmith. with 41% neutrophils. neurologist. Case 3 Presentation A 14-year-old boy is evaluated for excessive nighttime eating. she had a normal CBC and serum electrolyte measurement and was treated with intravenous fluids and discharged. Physical examination reveals a pleasant boy in good spirits. diarrhea. In addition. pulse oximetry saturation is 94%. His visual acuity is 20/20 in the left eye. A chest radiograph shows no acute disease and mild hyperinflation. Intercostal retractions. He still complains of pain in his right eye on lateral movement. and fever. all of which appeared to have resolved. She is admitted to the hospital. His symptoms began 4 days ago with eye pain on lateral movement. the girl is awake and alert but in mild-tomoderate respiratory distress. On day 4. she develops a temperature to 101°F (38. Frequently Used Abbreviations ALT: AST: BUN: CBC: CNS: CSF: CT: ECG: ED: EEG: ESR: GI: GU: Hct: Hgb: MRI: WBC: alanine aminotransferase aspartate aminotransferase blood urea nitrogen complete blood count central nervous system cerebrospinal fluid computed tomography electrocardiography emergency department electroencephalography erythrocyte sedimentation rate gastrointestinal genitourinary hematocrit hemoglobin magnetic resonance imaging white blood cell Case 1 Presentation Case 2 Presentation A 16-month-old girl is evaluated in the ED for increased work of breathing. She has moderate pharyngeal erythema. and heart rate is 161 beats/min. The rest of her physical findings are normal. despite frequent albuterol treatments.4°C) and has no improvement.com. followed by worsening blurriness and vision loss that have progressed upward through his right visual fields over the past 3 days. but no fever or diarrhea. Initial laboratory studies include negative results for respiratory syncytial virus (RSV) and influenza A and B antigens. and punishment have not stopped this habit. He has been evaluated by a pediatrician. She had been seen 4 days ago for rhinorrhea. he eats a small breakfast and a lunch and dinner normal for his age. She is afebrile. He denies fever.29 No. A 10-year-old boy is admitted to the hospital after 4 days of progressive vision loss in his right eye. 2% bands. An external examination of the eye gives normal results. or trauma to the eye. with no periorbital swelling or conjunctivitis. and 7% monocytes. locks. On physical examination. mild wheezing. but all extraocular motions appear intact. but he denies getting tick bites or having any recent illnesses. but a blood culture is reported positive for gram-negative diplococci. He has gained 50 lb in the last year. has been diagnosed as having mild autism. obsessive-compulsive disorder (OCD). vomiting. and educational specialist. and he has only light perception in the right. She is given three treatments of albuterol and prednisolone and responds with a lower respiratory rate of 40 breaths/min but a pulse oximetry saturation of 92% in room air. and Zapata did not disclose any financial relationships relevant to these cases.3 March 2008 97 . A more extensive eye examination reveals the diagnosis. Fernandez. Over the next 3 days. and has been treated with Pediatrics in Review Vol. Alarms.

additional evaluation for that state was not undertaken. sickle cell disease. Other antibiotics active against this organism include macrolides. Bronchiolitis is predominantly a viral illness (RSV. major management and social implications are associated with the differentiation between N gonorrhoeae and M catarrhalis when gramnegative diplococci are identified in the smear of an eye discharge from a baby who has neonatal conjunctivitis. Tachycardia and tachypnea also may reflect sepsis. which proved to be indicative of a bacterial infection. sinusitis. Subtle presentations can occur in young infants and immunocompromised children. a clinician should suspect sepsis whenever a patient has fever associated with behavioral changes such as irritability. poor feeding. The management and infection control differences between Neisseria sp and M catarrhalis are important. localized infection such as otitis media. thus.index of suspicion methylphenidate. conjunctivitis. gramnegative diplococcus in the family Neisseriaceae that commonly inhabits the upper respiratory tract (nasopharynx). His vital signs are normal. He has mild hypotonia and mild weakness of the legs. and pneumonia in children. and fluoroquinolones. weight is 171 lb (above the 95th percentile). and chest wall retractions were consistent with a diagnosis of bronchiolitis. lethargy. and other immunodeficient states. conversational boy who answers questions appropriately. and altered mental status. bronchiolitis may be complicated by bacterial infection (about 2% to 10% of cases). she was treated for presumptive viral lower respiratory tract disease. with the clinical picture influenced by the patient’s level of immunity. M catarrhalis generally is not thought of as causing invasive. The blood culture grew Moraxella catarrhalis. The Clinical Clue Typically. and no family medical history is available. Notwithstanding negative antigen tests for RSV and influenza A and B. divalproex. this association has not been seen in pediatric patients. especially meningococcemia. Although uncommon. The presentation of sepsis depends on the competency of the patient’s immune system. systemic disease (such as meningitis and endocarditis) except in immunocompromised conditions. Confirmation of N meningitidis also warrants antimicrobial prophylaxis for appropriate contacts. identification of gram-negative diplococci in a patient’s blood culture warrants droplet precautions for suspected meningococcemia for 24 hours while the patient receives appropriate antimicrobial therapy. pneumonia) are oral amoxicillin-clavulanate or oral second. It is possible that her hyperemic tympanic membrane was caused by an M catarrhalis infection. Case 1 Discussion The patient’s age of 16 months in conjunction with cough. as well as associated urinary tract infection. A weak cry and jaundice may indicate sepsis in neonates. but the finding also could result from underlying viral infection. acquired immunodeficiency syndrome. Therapy More than 85% of M catarrhalis isolates are ampicillin-resistant because of beta-lactamase production. isolates of M catarrhalis must be differentiated from Neisseria sp. trimethoprim-sulfamethoxazole. This patient’s course was atypical because she developed her initial fever after 3 days of cough and wheezing. parainfluenza 3 virus. malignancy. M catarrhalis can cause acute. He was adopted at 6 days of age.29 No. Risk factors for bacteremia include viral infection. Petechiae and purpura are well-known cutaneous indicators of possible sepsis. As in this case. sinusitis. wheezing. Bacterial otitis media and pulmonary 98 Pediatrics in Review Vol. height is 69 in (90th percentile). Other than obesity. The Agent M catarrhalis is an aerobic. First-line antibiotics for focal infections (otitis media. and body mass index is 25. adenovirus. Also. In general. and she was treated for 7 days with parenteral ceftriaxone followed by 7 days of oral cefuroxime axetil.3 March 2008 bacterial coinfection. Physical examination reveals an interactive. Gonococcal neonatal conjunctivitis requires systemic antimicrobial therapy for the baby as well as evaluation and management of the mother and her partner. with increased seasonal colonization in fall and winter.2 (95th percentile). She was discharged without complications. fussiness. all other physical findings are normal. Although it causes a large proportion of cases of lower respiratory tract infection in elderly patients who have chronic obstructive pulmonary disease and chronic bronchitis. influenza virus) but also can be caused by Mycoplasma. rhinorrhea. This child did not have any other evidence of immunodeficiency. A final diagnosis of M catarrhalis does not raise any of these issues. but documentation of bacteremia occurs in children in rare instances.and third-generation cephalosporins. and clonidine. Sepsis generally is treated paren- . In the clinical laboratory. are examples from recent literature. bronchiolitis reaches its most critical stage during the first 48 to 72 hours after the onset of cough.

Because as many as 85% of cases are associated with a viral infection or recent immunization (most commonly. New York.index of suspicion Case 2 Discussion circumstances. infectious mononucleosis. to dilate again. Optic neuritis also has been associated with other infectious entities. it is important to inquire about a recent viral prodrome.29 No. depending on the clinical course and antimicrobial susceptibility results. and some do not even have that ability. although it is more common in adults than in children and is more common in females.” A flashlight is moved back and forth between the eyes. but it is not always possible to determine the specific cause for each patient. varicella. M catarrhalis has the potential to cause a serious bacterial infection. the left optic nerve appeared normal. paradoxically. Generally. Lincoln Medical and Mental Health Center. An APD. An APD is identified by examining the eyes with a bright light. Some of these infectious causes are associated with distinct historic or Pediatrics in Review Vol. and the boy was admitted for additional evaluation as well as to receive a course of high-dose corticosteroids. when the light is shone in one eye. the pupil of the affected eye paradoxically dilates rather than constricts. The boy also had an afferent pupillary defect (APD) in his right eye. when the light is shone in the affected eye of a patient who has an APD. When receiving an initial report of “gramnegative diplococci” growing in a blood culture. On physical examination. On funduscopic examination. The pediatric generalist should perform frequent funduscopic examinations in the course of practice and be able to discern abnormalities of the optic disc that require referral for additional study. with both pupils constricting. occurs when there is a problem transmitting an afferent signal through the optic nerve to the brain. when treatment may be changed to oral therapy to complete a 7. This abnormal response signifies that the afferent pathway to the brain is not functioning normally and the brain is not receiving the message properly. and tuberculosis as well as with toxocariasis and helminthic infestations. and an APD is seen in more than 50% of patients. it is appropriate to consider the possibility of multiple diseases occurring simultaneously. Differential Diagnosis Many underlying conditions have been associated with optic neuritis. he continued to have the diagnosis of optic neuritis of unknown cause. when the light is shone in the unaffected eye. catscratch disease (Bartonella henselae infection). NY. it is prudent to administer parenteral third-generation cephalosporins (to cover Neisseria sp and M catarrhalis) until the isolate is identified. it is most common to see visual acuity in the affected eye of 20/400 or worse. However. measles-mumpsrubella). and a viral prodrome. Lessons for the Clinician When the course of a patient’s illness does not follow the usual expectations. Other common presenting symptoms in children include pain with ocular movements.to 14-day course. Generally. an APD in combination with papilledema confirms the diagnosis of acute-onset optic neuritis. If the light is moved back to the affected eye. the afferent pathway in the unaffected eye as well as the efferent pathway in the affected eye function normally. also referred to as a MarcusGunn pupil. disc edema is visible in the affected eye on funduscopic examination. and the pain had resolved completely. the pupil appears. NY) The Condition neuritis experienced bilateral visual loss. but new data have shown that unilateral visual loss is the most common presentation in children and adults. but the presence of an APD points toward the diagnosis of optic neuritis. edema of the right optic disc with blurring of the disc margin was noted in this patient. This edema can resemble the swelling seen with papilledema. Bronx. Visual fields and color vision are abnormal in more than 80% of patients. toxoplasmosis. In normal Optic neuritis refers to inflammation of the optic nerve. Some children can perceive light only. The identification of gram-negative diplococcus in the blood of a patient who has fever and respiratory disease or otitis media should alert the physician to the possibility of the uncommon M catarrhalis as well as the more dangerous N meningitidis. depending on the organism. MD. such as Lyme disease. (Courtney Peshkovsky. Although rare.3 March 2008 99 . One week later. headache. Robert J. and Weill Medical College of Cornell University. MD. the pupils of both eyes constrict equally. Then. This diagnosis was confirmed by an ophthalmologist. the acuity in his right eye had improved to 20/ 100. This condition can occur at any age. It previously was believed that most children who acquired optic terally until the patient becomes asymptomatic and has a negative repeat blood culture. At the time of discharge and at follow-up with the ophthalmologist. brucella. syphilis. However. pertussis. therapy can be individualized. who comprise 60% to 75% of affected patients. known as the “swinging flashlight test. Leggiadro.

The pathogenesis of the other viral causes is a cell-mediated attack on optic nerve myelin. Treatment The current treatment of optic neuritis is administration of corticosteroids. The prognosis for optic neuritis is worse for children who have bilateral presentation. is especially important because varicella-zoster virus infection can progress from direct infiltration of the optic nerve to retinal necrosis if not treated appropriately. including stellate macular exudates and splinter hemorrhages. but not in the brain. with blood cultures and antibody tests. such as B henselae. Any preceding history of varicella or herpes zoster. Another possible cause of optic neuritis is neuromyelitis optica or Devic syndrome. MS is a more likely cause if the child presents with bilateral involvement or has recurring episodes. (2) Long-term follow-up of patients diagnosed as having Devic syndrome shows a poorer outcome and relapses. In the case of cat-scratch disease. These findings also can be seen in toxoplasmosis. With syphilis. MRI changes. histologic changes demonstrating noncaseating granulomas are diagnostic of sarcoidosis. CSF studies may indicate an acute infectious process. it has been shown that steroid treatment has no effect on long-term outcome. patients who have Lyme disease may have a positive travel history or a history of a rash consistent with erythema migrans. the spirochete invades the eye. of the patients they reviewed. and varicella-zoster infection by culture or polymerase chain reaction. Performing a lumbar puncture for the collection of CSF is another important part of the evaluation of optic neuritis. gramnegative organisms tend to invade endothelial cells. suggesting an autoimmune etiology for optic neuritis in those patients. especially in an immunocompromised patient. (1) It also is important to treat any infection that may be present. Of those patients experiencing multiple relapses. most likely due to a direct infection of the optic nerve.index of suspicion physical findings. the prognosis for visual recovery is excellent regardless of therapy. This lesion should be biopsied. Devic syndrome may be the first presentation of SLE. and recurring episodes because these features are associated with a higher risk for developing MS. In one prospective study. leading to an inflammatory response. demyelinating lesions are found in the optic nerve or 100 Pediatrics in Review Vol.3 March 2008 the spinal cord. only that patients recover visual acuity more quickly when steroid therapy is initiated. in which there have been reports of choroidal and retinal masses representing granulomas. Conversely. However. Such areas of retinal damage are consistent with funduscopic signs of neuroretinitis. A similar response within the retina can lead to both generalized inflammation and focal areas of endothelial cell damage and proliferation. none who had normal MRI findings developed MS after 2-year followup. the pathogenesis of disease following bacterial infection is less clear. this association is not as substantial. in children. and B burgdorferi. An MRI of the spinal cord also should be performed in any patient in whom Devic syndrome is a consideration.29 No. Epstein-Barr virus. For example. causing direct inflammation of the optic nerve. The Optic Neuritis Treatment Trial recommends a 3-day course of highdose steroids followed by an 11-day course of oral prednisone. In fact. and of systemic lupus erythematosus (SLE). The MRI also can show changes in the white matter that may represent demyelination and signify the possibility of developing MS. but there are various protocols. acid-fast bacteria. In general. Prognosis No extensive data address the prognosis of childhood optic neuritis. fungal infection. It also is possible to test for other infections. Lessons for the Clinician Optic neuritis offers a wide differential diagnosis. CSF analysis can include antinuclear antibodies to screen for SLE as well as lymphocyte analysis for sarcoidosis. Optic neuritis in adults classically is associated with the development of multiple sclerosis (MS). but history and physical examination (including a comprehensive ophthalmologic assessment) may help to focus and guide diagnos- . Making the Diagnosis MRI of the brain and orbits with contrast showing enhancement of the optic nerve is essential to confirm the diagnosis. Optic neuritis also may be due to systemic conditions such as sarcoidosis. The evaluation also can include testing the CSF for markers of syphilis. Analysis of CSF for oligoclonal banding can help determine if MS is likely. bilateral optic neuritis in combination with MRI white matter lesions was associated most strongly with development of MS. Sarcoidosis should be considered if a mass is seen at the head of the optic nerve on MRI. In the case of Borrelia burgdorferi infection. and their clinical pictures are suggestive of a demyelinating disease. In these patients. a vitreous cellular reaction typically is present. Syphilis associated with optic neuritis also is seen more commonly in immunocompromised patients. Lyme titers.

Ophthalmology. Sacramento. Other problems associated with NES include psychological disorders such as depression.index of suspicion tic testing. and pediatric diagnostic criteria still are being developed. but purging is not reported typically in NES. Although the criteria for inclusion have changed over the years. MD. The long-term effects on his health from the gain of 50 lb in 1 year are significant and could include metabolic syndrome. which may indicate a predisposition for the development of MS. whereas SRED sufferers often are not aware of their eating and do not remember the event. Buncic J. including sleep-related eating disorder (SRED).67:258 –262 Case 3 Discussion This boy had an eating disorder characterized by overeating at night in conjunction with associated psychological problems. Anorexia was present each morning.417 kcal from 10:00 PM to 6:00 AM and consumption of 1. but eating greater than 50% of total calories at night and awakening from sleep to eat are not normal eating behaviors. and he was fully aware of his eating. Nighttime eating was reported during 7 of 7 nights. although patients who have NES can eat enough to gain excessive weight. MRI findings. which was ruled out via genetic testing. and the recurrence of optic neuritis.3 March 2008 101 . Most research has been performed in adults. Shroff M. and the circadian timing of food intake is delayed. although they may not lead to discovery of a cause. His nighttime eating was causing numerous problems. Differential Diagnosis Nighttime eating can have many causes. awakening at least once per night. and behavioral disorders that have nonconventional eating patterns. Patients who have SRED often consume unusual foods and nonfood items. Birkvedt and associates (1) include additional criteria: consuming greater than 50% of total daily calories at night. What we have learned from the Optic Neuritis Treatment Trial. Circadian oscillators may signal food intake at a different phase than is signaled normally. SRED is associated with other sleep-related disorders. 2006. the central feature is a delay in the circadian pattern of eating. The Condition As part of his evaluation. Intake of massive quantities of food is more characteristic of bulimia. for the Optic Neuritis Study Group. (Lauren Kupersmith. insomnia with waking to eat at night. Trobe JD. An MRI and lumbar puncture for CSF analysis are essential.29 No. The major characteristics are evening or night hyperphagia. Polysomnography can aid in differentiating the conditions because the only abnormality usually reported in NES is low sleep efficiency. et al. This patient. binge eating disor- der with binges at night. This boy’s learning problems Pediatrics in Review Vol. having symptoms for at least 3 months. SRED and NES are similar conditions. therefore. and outcome of optic neuritis in children. The clinical features. and not meeting the criteria for bulimia or binge-eating syndrome. syphilis. but the history can elicit differences. Neurology. Another consideration in this patient who has an associated learning disability is PraderWilli syndrome. including OCD and learning disability. especially in teenagers. It is important to seek all underlying causes that can be treated (Lyme disease. that are not seen in NES. anxiety. diabetes. Bulimia nervosa also can present with nighttime eating binges. hypercholesterolemia. the patient completed a diet log that revealed an average consumption of 1. Beck RW. His eating pattern is troubling socially and has been disruptive to the family. The abnormal feature seen in NES is more the timing of food intake than the actual amounts. often with purging. and morning anorexia.) References 1. Affected patients should be followed to monitor the recovery of visual function. and the disorder still is in the early stages of investigation.102:1504 –1508 2. It should be noted that some nighttime snacking is normal. Wilejto M. 1995. NES was not studied extensively until the recent societal increase in obesity. Calif. such as sleep apnea and restless legs syndrome. Discerning the cause of nighttime eating requires clinical judgment aided by a thorough history. consuming a snack during awakenings. and coronary artery disease. and low selfesteem. varicella) in the initial diagnostic testing. The diagnosis of NES is difficult in pediatrics because criteria are established only for adults. night eating syndrome (NES). seemed to fit closely a diagnosis of NES. Another variance between the two disorders is that patients who have NES are aware of their eating (and show no remorse). in contrast to the consistent food choices in NES. including dietary “logs” and eating questionnaires. University of California at Davis Medical Center. including a loss of sleep that might be affecting his school performance.388 kcal during the other 16 hours of the day (more than 50% of calories after the evening meal). The boy also met criteria for depression (by use of a standard depression scale). Although first described in 1955. the occurrence of neurologic complaints.

and prognosis still are being explored and require more study.39: 224 –232 3. org and click on Index of Suspicion. This diagnosis should be considered in patients who demonstrate excessive nighttime eating or in those who are obese without clear cause. Treatment with SSRIs offers some promise based on a recent study. 5. JAMA. Int J Eating Dis. The use of selective serotonin reuptake inhibitors (SSRIs). As additional research is completed in children. Birkvedt GS. Nighttime eating: a descriptive study. Clinical trial of sertraline in the treatment of night eating syndrome. et al.pedsinreview. treatment. (Seth Septer. In one study. Sundsfjord J. Cristina Fernandez. A history that involves detailed documentation of eating and sleeping habits is the most important diagnostic tool. O’Reardon JP. has been studied in treating NES. Mitchell JE. Kraz S.) References 1. Outpatient psychiatric clinics report an incidence of NES as high as 16%. DO. especially in children. a more concrete set of criteria may be developed for diagnosis in pediatric patients.282:657 2.8 lb).6% of the general population and 6% to 14% of patients who attend obesity clinics. and tryptophan is a precursor to serotonin synthesis. 2006. Patients who have NES can be of normal weight as well as obese. . Neb. Florholmen J. The nighttime food preferences primarily seeming to be carbohydrates may signify an attempt to promote sleep or improve mood.35:16 –26 To view Suggested Reading lists for these cases. visit www.8. Approximately 25% of the patients in this study experienced remission and had an average weight loss of 4. therefore. de Zwaan M.3 March 2008 NES is an unusual form of eating disorder whose pathophysiology.29 No. Roerig DB. episodes of nocturnal ingestion. and percent of calories eaten after supper after 12 weeks of treatment with sertraline. MD. Fernando Zapata. Sunnkard AJ.6% of patients who had NES had OCD as well. (2) rotonin. University of Nebraska/ Creighton University School of Medicine. 1999. 2004.index of suspicion and OCD are consistent with such observations about NES. Int J Eating Dis. Allison KC. The prevalence of NES is estimated to be 0. Behavioral and neuroendocrine characteristics of the night-eating syndrome. MD. Circadian rhythms of eating and sleep are controlled by a part of the hypothalamus that is affected by se- 102 Pediatrics in Review Vol. Crosby RD. Tryptophan uptake is promoted by insulin release after carbohydrate ingestion. Lessons for the Clinician Treatment Optimal treatment of NES still is subject to research. A study by O’Reardon and colleagues (3) showed a decreased number of awakenings.5% to 1. especially if they have sleep disturbances or other psychological disorders. Omaha. The mean body mass index in a study of 106 patients was 30.8 kg (10.

Leggiadro RJ. Influenza complicated by Moraxella catarrhalis bacteremia.52: 1047–1057 Case 3 Suggested Reading O’Reardon JP. Bronchiolitis: in-patient focus. Moraxella catarrhalis bacteremia: a 10-year experience. 1999.19:997–1008 .92:1071–1074 Coffin S. Pediatr Clin North Am. Allison KC. Peshek A. 2005. Asmar BI. Night eating syndrome: diagnosis. epidemiology and management. Dajani AS. South Med J.The following Suggested Reading lists are included online only for the “Index of Suspicion.” Case 1 Suggested Reading Abbasi S. 2005. Pediatr Infect Dis J. CNS Drugs.13:937–938 Abuhammour WM. Abdel-Haq NM. Pendergrass LB. 1994.

Regressive behaviors. three or more emotional numbing/ avoidance symptoms. and duration of exposure to the stressor as well as the child’s age. New York. 1998 According to the National Child Traumatic Stress Network. and Comorbidity: Results from the National Survey of Adolescents. 2003. Violence and Risk of PTSD. Burgess AW. rape. violence (eg. DC: American Psychiatric Press.org. and have difficulty expressing feelings. PTSD sufferers may experience intense emotional distress and physiologic reactions when exposed to cues or situations that remind them of the experience.3 March 2008 103 . PhD. Available at http://www. A subset of youth exposed to a traumatic event develop posttraumatic stress disorder (PTSD). it is common to have difficulty remembering aspects of the event. coping strategies. Author Disclosure Drs Copeland-Linder and Serwint did not disclose any financial relationships relevant to this In Brief. Criteria for diagnosing PTSD are the presence of at least one symptom related to re-experiencing. Kilpatrick DG. Int Rev Psychiatry. which is characterized by intense fear and the occurrence of three categories of symptoms following exposure. feelings. Handbook of Preschool Mental Health: Development. Best CL. nctsnet. poor concentration.13:194 –200 Posttraumatic Stress Disorder: Clinical Guidelines and Research Findings. Factors that influence the development of severe stress reactions include the proximity. Rothbaum BO. people. Youths’ reactions to catastrophic events or major stressors can vary from temporary distress to severe forms of psychopathology. 2006:165–185 Substance Abuse and Mental Health Services Administration Model Programs: Trauma-focused Cognitive Behavioral Therapy. In addition. or activities that are reminders of the trauma. hyperalertness. irritability. and quality of family support. combat or warrelated events. The trauma may be re-experienced in a number of ways. witnessing violence). The third category of symptoms involves increased arousal. In: Luby JL. Am J Psychiatry./nctsn_assets/pdfs/ reports/NCTSNProgressReport 2004. Substance Abuse/ Dependence. Foa EB. Scheeringa MS. Children and Trauma in America: A Progress Report of the National Child Traumatic Stress Network. Holmstrom LL. The second category of symptoms relates to emotional numbing and avoidance of stimuli associated with the event. memories.modelprograms. this category of symptoms may be manifested by repetitive play and drawings that involve themes related to the event as well as by reenactments of aspects of the experience.131:981–986 Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. Available at www. This category of symptoms also includes avoidance of thoughts. Accessed December 2006. 2001. which may encompass sleep disturbances. including intrusive thoughts. recurring dreams. and two symptoms of hyperarousal. Md. The first category involves re-experiencing the event. National Child Traumatic Stress Network 2004. and traumatic events related to illness or injury. ed. intensity.pdf. J Consult Clin Psychology. American Psychiatric Association. hurricanes). NY: The Guilford Press. children’s sense of fear and helplessness may be manifested by agitated or disorganized behavior. Major Depression.29 No. Accessed November 2006 Diagnostic and Statistical Manual of Mental Disorders. with symptoms being present for more than 1 month. Additional symptoms associated with children’s stress reactions include an increase in tantrums and aggressive behavior as well as new fears that are thematically unrelated to the traumatic event. or nightmares.pdf. Resnick HS. Saunders BE. places. physical assault. Disorders. and easy startling. In young children. NY: Guildford Press. such as Pediatrics in Review Vol. Text Revision. flashbacks. In addition. lose interest in participating in activities. and Treatment.in brief In Brief Posttraumatic Stress Disorder Nikeea Copeland-Linder. samhsa. Yule W. prior mental health. 25% of youth experience a traumatic event by the time they are 16 years old.gov/pdfs/model/TFCNT. In addition. Individuals may feel hopeless about the future. Sufferers of PTSD may feel disconnected or estranged from others. including natural disasters (eg.71:692–700 Rape Trauma Syndrome. Washington. Acierno R. 2000: 463– 468 Posttraumatic Stress Disorder in Children and Adolescents. 4th ed. 1974. New York. Ruggiero KJ. MPH Johns Hopkins School of Medicine and the Bloomberg School of Public Health Baltimore.

gradual exposure to feared stimuli (ie. Children and adolescents may experience separation difficulties. Comment: PTSD has been acknowledged more in the media since September 11. and risky behavior. Serwint. with some studies reporting rates as high as 90% among witnesses of domestic violence and rape survivors. Recognition and treatment of PTSD is imperative for the ultimate optimal function of children and families. The lifetime prevalence of PTSD among adults has been estimated to be 8%. such as motor vehicle crashes. with special attention to the youth’s age. and stress management. but health-care practitioners must be vigilant for a suggestive history and symptoms of PTSD and should present therapy in a socially acceptable manner to help break the cycle and facilitate healing. often increase among young children. stomachaches) also may occur. homicides. individuals who have been exposed to trauma warrant concern because they often are highly symptomatic and functionally impaired. Societal barriers to mental health counseling exist. intimate partner violence. Most forms of CBT involve education about the nature of the trauma and symptoms. Combined parentchild sessions as well as separate parent sessions are used. PTSD may have more pronounced effects on younger children because of the vulnerability of a rapidly developing central nervous system. Youth who have been raped or otherwise physically and mentally assaulted may feel permanently damaged. Youth who have been exposed to trauma and are symptomatic should be referred to a mental health professional. and some urban families may find the inciting events to be commonplace in their environments. TF-CBT consists of 12 to 16 sessions. which may compromise their identity development. and as acts of terrorism have become more common. Janet R. based on the type of event. tolerating and expressing feelings. recount memories. PTSD sufferers may feel guilty about surviving when others died or they may feel guilty about what they had to do to survive. Trauma symptoms are so common among rape survivors that prior to the introduction of PTSD in the Diagnostic and Statistical Manual of Mental Disorders. Rates of PTSD vary considerably among individuals who have been exposed to trauma. family history of psychopathology. PTSD can interfere with children’s emotional. Parent sessions help parents process their feelings and distress related to their child’s traumatic exposure and assist them with effective parenting skills. Regardless of whether diagnostic criteria for PTSD are met. MD Consulting Editor . and substance abuse. with the war in Iraq. Validated symptom checklists and structured clinical interviews can aid in assessment. difficulty trusting others. needing to remain in close proximity to their parents. prior history of trauma exposure. or even invasive medical procedures also must be recognized and considered. researchers described a constellation of trauma symptoms that they labeled rape trauma syndrome. most researchers and practitioners agree that rape trauma syndrome is characterized best as PTSD. and trusting others. with higher rates reported among girls. Although the diagnosis can be more challenging in younger children because symptoms of distress may not be as obvious. Although this term sometimes is used. cognitive reframing. Youth components focus on factors such as identification of feelings. The appropriateness of applying some PTSD diagnostic criteria to young children continues to be debated. It has been recognized as a model program by the Substance Abuse & Mental Health Services Administration and the United States Department of Health and Human Services and has been classified as “Selective and Indicated” by the Institute of Medicine. and cognitive development.29 No. symptoms of PTSD are associated with high rates of depression. social. The intervention addresses issues such as low self-esteem. Information from all modes of assessment should be examined. gradual expo- sure. CBT aims to modify maladaptive thoughts and behaviors that have developed in response to the traumatic event. this category of symptoms may be underreported in young children. Traumafocused CBT (TF-CBT) is an evidencebased intervention designed to help youth ages 3 to 18 years and their parents who have been affected by trauma. support network. However. confront situations). and duration of the symptoms. The 104 Pediatrics in Review Vol.3 March 2008 numbing/avoidance symptoms are very difficult to detect among preverbal children because endorsement of such symptoms depends greatly on verbal abilities. and cognitive restructuring to address maladaptive thoughts. developmental stage. Cognitive behavioral therapy (CBT) has received the most empiric support as an effective treatment for PTSD. A multi-informant approach is preferred and involves gathering information from the youth and the parents about the nature and frequency of the event and the severity. Thus. suicidal ideation. Traumatized youth often have difficulties managing their behavior. Direct observations of play may be incorporated into assessments of young children. Such difficulties can have a negative impact on their ability to develop and sustain healthy relationships. although an increase in physical complaints (headaches. the estimated prevalence is 3% to 6%. Among adolescents.in brief bedwetting and clinginess. events that occur in everyday life. intensity. and protective factors. Among adolescents.

and disease state. short bowel syndrome). neurologic disease or impairment. MD Barry K. NY Author Disclosure Drs Weissman. Most patients tolerate bolus feeding. Weissman. Abad-Sinden A. In: Walker WA. 2004:750 –753 Nutrition Support. safer. Enteral feeding stimulates gastrointestinal (GI) motility. The Osler Medical Handbook. MD The Children’s Hospital at Montefiore Bronx. Tiberio E. large gastric residuals. Surkhang D. eds. and Adam did not disclose any financial relationships relevant to this In Brief. formula variables to consider include digestibility and availability of the nutrients.29 No. Md: Johns Hopkins University. Schneider BL. painful abdominal distention. continuous infusion pump feedings are indicated. 2006 Nutrition in Gastrointestinal Diseases. Gastric administration of feedings is preferred because of the ease of management. ability to use a bolus feeding regimen. nutritional adequacy. Enteral feeding also may be indicated for children at high risk for aspiration. Special attention should be paid to osmolality and carbohydrate content when patients exhibit signs of intolerance. and associated with fewer adverse effects than parenteral nutrition. Vanderhoof J. trauma/ head trauma). Friedman LS. Sherman PM. Baltimore. liver failure. Sanderson IR. as in critically ill patients. tube enterostomy is the preferred access route and includes percutaneous tubes (eg. Kleinman RE.in brief In Brief Enteral Feeding Taryn E. A formula that has an osmolality greater than that of normal body fluids can produce an osPediatrics in Review Vol. carbohydrates. Malnourished children unable to maintain adequate nutrition can benefit from enteral feeding. and conditions of hypermetabolism (burn injury. and potential benefits of gastric acid as a bactericidal agent. For longer-term needs or for patients who have chronic esophageal abnormalities. In: Walker WA. requires minimal supplies. 4th ed. Sanderson IR. Wershil. Pediatric Gastrointestinal Disease. Goulet O. and may facilitate the transition to home care. cancer. inflammatory bowel disease. severe protein-energy malnutrition. Ontario. Sutphen I. Hamilton. decreases the risk of bacterial overgrowth. Enteral feeding provides calories and fluid to the GI tract by means other than the oral route and requires some type of tube delivery system. Enteral Nutrition. eds. 2006:365–378 Nutrition support is essential for patients unable to meet daily caloric or fluid requirements orally and can be provided either by an enteral or parenteral route. In: Piccini JP. Wershil. nasoduodenal. Pa: Saunders. DeLegge M. eds. and electrolytes. Pediatric Gastrointestinal Disease. When selecting an enteral preparation. Bolus feedings deliver formula as rapidly as an oral feeding. in which the tube supplies a portion of the nutrients. Enteral nutrition avoids the need for central venous access. Ontario. and renal disease. However. Canada: BC Decker. or diarrhea may be evidence of intolerance. thus diminishing infections and eliminating the thrombotic and hepatic complications of parenteral nutrition. critical illness. minimizes atrophy of the GI mucosa. to primary therapy. Kleinman RE. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. Continuous administration also is preferred for patients fed through the small intestine or at high risk of aspirating and appears to be particularly beneficial for patients suffering impaired absorption (chronic diarrhea. Parenteral nutrition ranges from supportive therapy. open gastrostomy).3 March 2008 105 . Sleisenger MH. Brusco T. prolonged anorexia. This technique is simple. and osmolality. Canada: BC Decker. endoscopic gastros- tomy and jejunostomy) and surgically placed feeding tubes (eg. Schneider BL. 8th ed. 4th ed. Philadelphia. Nilsson KR. Sherman PM. The osmolality of a formula is affected by the concentration of amino acids. Patient variables include nutritional status and requirements. Feldman. but vomiting. Enteral feedings can be delivered by bolus or continuously. either temporary for acute conditions or permanent for chronic disabilities. Hamilton. short gut syndrome. in which the tube delivers all nutrients. When intolerance of bolus feedings is suspected. 2004:1981–1991 Short-Bowel Syndrome and Intestinal Adaptation. human immunodeficiency virus infection/acquired immune deficiency syndrome. A temporary nasoenteric tube (nasogastric. and prevents translocation of bacteria or bacterial products into the circulation. 2nd ed. cardiopulmonary disease. Conditions warranting enteral nutrition include feeding of preterm infants.” less expensive. Goulet O. eds. or nasojejunal) is recommended when the anticipated duration of nutrition support is limited (1 to 3 mo). digestive and absorptive capacity. jejunal placement should be considered for patients who have significant upper tract disease or when there is a high risk of aspiration. In: Feldman M. Enteral support is preferred because it is more “physiologic.

approximately 300 mOsm/L. drawing water into the gut and diluting the formula. respiratory failure. or excessive build-up of granulation tissue with intermittent bleeding. parenteral nutrition is necessary. Aspiration. impaired gastric emptying.” characterized by the development of hypokalemia. reducing its absorption.and protein-dense preparations for fluidrestricted patients and fiber-enriched formulas for patients who have severe constipation. and magnesium-containing antacids. Special considerations should be given to the patient who is transitioning from parenteral to enteral feedings after bowel resection. large gastric residuals. or migration of the tube tip into the upper stomach or esophagus. liver dysfunction. The timing of this transition depends on the activity of the underlying disease and whether GI function is sufficient for enteral nutrition. Patients who have severe GI disease or protein allergies may require semi-elemental or elemental formulas. More commonly. Other specialized formulas include calorie. or a decrease in dietary fiber.3 March 2008 complication of enteral feeding. and dilute formulas commonly are used. an incompetent lower esophageal sphincter. or enterally administered medications. continuous enteral infusion may be started. GI complications include nausea. The initial rate should be slow. is most likely to occur in patients who have neurologic injury. Specialized formulas have been tailored to a wide variety of physiologic circumstances while attempting to minimize specific types of intolerance. but examples are worth mentioning. heart failure. nausea. obstruction. tube obstruction (ie. with fear of misplacement into the airway instead of the GI tract. or GI tract obstruction. but this approach has limitations. constipation. Once full-strength feedings are tolerated. improper tube placement. over which the gastrostomy tube is guided into place. the concentration can be increased rapidly to full-strength. and diarrhea. Adam. and distention. Often when enteral feeding is initiated. Complications of enteral feeding include GI. Constipation may result from dehydration. bacterial overgrowth. This procedure involves insufflation of the stomach to bring it into apposition with the abdominal wall. In addition to formula intolerance. A complete discussion of the many formulations is beyond the scope of this review. Ingenious! Henry M. When the oral route is restricted. and hypomagnesemia. MD Editor. which avoids laparotomy and usually can be accomplished with sedation rather than anesthesia. vomiting. including antibiotics. if tolerated. patients may experience chronic drainage. erythema. Surgically placed gastrostomy tubes and inconspicuous “buttons” made G-tubes more cosmetically acceptable.29 No. medications are administered by tube. Immediately following resection. and death. and mucosal damage (ie. and the volume of parenteral nutrition can be decreased simultaneously. potentially the most serious 106 Pediatrics in Review Vol. When fluid and electrolyte losses have resolved. Initially. Isotonic formulas are designed to alleviate these problems. enteral tube feeding meant placement and repeated replacement of nasogastric tubes. significant gastroesophageal reflux. The osmolality of full-strength isotonic formulas is similar to that of normal body fluids. mechanical. skin breakdown) are examples of mechanical complications. Diarrhea can be caused by diminished absorptive capacity. However. large volumes of fluid and electrolytes may be secreted and gastric fluid lost from nasogastric suctioning. Metabolic complications are less common with enteral than with parenteral feeding. This disorder can result in cardiac arrhythmias. An ostomy may produce additional significant losses. followed by the percutaneous passage of a cannula and subsequently a wire into the stomach. taking into account the extent and specific portions of resected bowel. Ciprofloxacin has been shown to bind with tube feedings. primarily because of bowel ileus. to optimize tolerance. Excessive traction may cause gastric wall necrosis and perforation of the stomach. This excess water can cause diarrhea. Dehydration and fluid shifts may occur with formulas of high osmolarity. phenytoin concentrations can be affected because phenytoinformula complexes adhere to the wall of the tube. cramping. and each choice should be individualized for the specific needs and circumstances of the patient. which also are free of lactose and fructose. Percutaneous feeding tubes also are associated with a risk of infection or erosion at the insertion site. delayed gastric emptying. Some formulas address the special nutrient requirements of preterm infants while diminishing osmolality and improving digestibility. and metabolic problems. the volume of enteral feedings can be increased gradually until caloric goals are reached. nausea and vomiting can be caused by too rapid an infusion rate. enteral feeding often is the safest. decreased bowel motility. formulations containing sorbitol. coma. In Brief . formula hyperosmolality. dislodged or occluded feeding tube). hypophosphatemia. Now we have percutaneous endoscopic gastrostomy. most cost effective.in brief motic effect in the stomach and small intestine. Overly aggressive caloric administration to severely malnourished patients can lead to “refeeding syndrome. Aspiration. Several approaches and multiple formulas are available. Comment: Within the memory of some of us. For example. and most physiologic approach to providing adequate nutrition to both acute and chronically ill patients.

and Silber did not disclose any financial relationships relevant to this article. PhD. Each of the summaries presented here. the references for each policy are provided with each individual summary and commentary.3 March 2008 e15 . Do-Not-Resuscitate Orders for Pediatric Patients Who Require Anesthesia and Surgery 9. and Assent in Pediatric Practice 2. 16 policies published by the AAP are summarized. it can be assumed that the quote is taken directly from the policy being summarized. Sterilization of Minors With Developmental Disabilities 5. The policies referenced in this article represent the efforts of various committees and committee members over the years. Guidelines on Forgoing Life-sustaining Medical Treatment 7. Friedman Ross. MD.* Lainie Friedman Ross. Forgoing Life-sustaining Medical Treatment in Abused Children 8. Religious Objections to Medical Care 3. Introduction MA. Maxwell. 1994. Do-Not-Resuscitate Orders in Schools 10. Informed Consent. Ethical Issues With Genetic Testing in Pediatrics 11. Guidelines on forgoing life-sustaining medical treatment. MD.* Marilyn A. each followed by a brief commentary. The subjects addressed cover a wide range of topics. Policies Reviewed Part 1 of this series reviews: 1. For ease of use. Pediatrics in Review Vol.org/cgi/ *On behalf of the American Academy of Pediatrics Section on Bioethics. Infants With Anencephaly as Organ Sources: Ethical Considerations 15. as indicated at the beginning of each summary. The American Academy of Pediatrics (AAP) has a strong and longstanding interest in the field of bioethics and periodically publishes policy statements pertaining to specific ethical questions relevant to pediatrics. When quotations are used within a summary and not referenced. Silber. Responding to Parental Refusals of Immunization of Children 4. Understandably. Human Embryo Research Part 2 of this series reviews: 6. MAAS* Author Disclosure Drs Mercurio.* Brenda Jean Mears. represents the work of an individual serving on the Executive Committee of the Section on Bioethics. at least on a cursory level. Mercurio.aappublications. MS. Ethics and Care of Critically Ill Infants and Children Part 3 of this series reviews: 12. Palliative Care for Children 16. some of the wording of these summaries is taken directly from the published policies. Available at: http://aappolicy. Some briefly point out possible alternative viewpoints. MD. from parental refusal of immunization to the care of critically ill children. MD. In this series.* Tomas J. Mears. Maxwell. This article is the second in a series of three intended to familiarize readers with many of the AAP policies currently in place that address issues in bioethics. Parental Permission. some of the ethical principles underlying the policies. The commentaries are intended to address. Female Genital Mutilation 13. Pediatrics.29 No. Institutional Ethics Committees Guidelines on Forgoing Life-sustaining Medical Treatment Committee on Bioethics. MD.Article policy statements American Academy of Pediatrics Policy Statements on Bioethics: Summaries and Commentaries: Part 2 Mark R. as well as the commentaries that follow.93:532–536. These policies are authored initially by the AAP’s Committee on Bioethics and undergo extensive internal review by other committees prior to publication. Appropriate Boundaries in the Pediatrician-Family-Patient Relationship 14.

Within the gray zone. Either decision might be acceptable in certain circumstances and should be based primarily on the relative benefits and burdens to the patient. Nevertheless. Physicians have an obligation to provide decisionmakers (generally the parents) with relevant information regarding risks and benefits of available options and to provide a specific recommendation. limiting. In other cases.” 2. All e16 Pediatrics in Review Vol.policy statements bioethics content/abstract/pediatrics. but in this case. in the opinion of the clinicians) are opposed to the child’s best interests.pdf.” The guidelines emphasize the following points: 1.29 No. and the guidelines rightly advise that steps be taken to override parental wishes. many clinicians have observed a psychological difference in that it often is far more difficult for parents to agree to remove LSMT. it is useful to think of it in terms of the child’s best interest. “Forgo” in the context of these guidelines is meant to encompass withholding (failing to initiate) or withdrawing a therapy. The ethical gray zone might be thought of as the area wherein the best interest of the child cannot be discerned easily. with one notable exception: “Medical professionals should seek to override family wishes only when those views clearly conflict with the interests of the child. parental wishes clearly (again. Medical professionals should seek to override family wishes only when those views clearly conflict with the interests of the child. and ‘increased physical pleasure. MA. The Committee describes potential benefits as follows: “The benefits may include prolongation of life (understanding that the continuation of biologic existence without consciousness may not be a benefit). the opinion) of the family generally should prevail. Whether the benefits of ongoing LSMT to the patient outweigh the burdens frequently is a matter of opinion. Hospitals should have policies addressing disagreements that persist after all efforts at communication and collaborative decision-making have failed. which states that decisions should be based on an assessment of the benefits and burdens of the proposed treatment. The guidelines state that the values (and. Those benefits and burdens usually are assessed in light of the values of the patient and the patient’s family. is the most consequential in the guideline. and no conflict exists. the parents’ wishes regarding LSMT clearly (in the opinion of the clinicians) are consistent with the child’s best interests.’ ” (1) Comment It is widely agreed that. rather than the values of the physician. whether life-sustaining or otherwise. including but not limited to mechanical ventilation. A physician cannot be compelled by patients or families to provide any treatment he or she feels is unlikely to benefit the patient. Decisions for infants and young children should be based on the best interest standard. with the outcome of the analysis ultimately being a value judgment. as the policy states. Families should be given adequate time to consider the options because they may reconsider as events gradually unfold or become clearer to them. or discontinuing treatment. improved quality of life after the LSMT has been applied (including reduction of pain or disability). rather than an event. It is acknowledged that individuals may value benefits differently and that families should be given wide latitude: “Our social system generally grants patients and families wide discretion in making their own decisions about health care and continuing. declining. The foundation of this guideline is the patient’s best interest standard.3 March 2008 children should have the opportunity “to participate in decisions about LSMT to whatever extent their abilities allow. 4. that assessment often is subjective. MD. That is. which dictates a choice based on the relative benefits and burdens of the proposed treatment to the child. In some cases.93/3/532. Many pediatric patients. Summary and comment by Mark R.” 3. the physician might be uncomfortable . “Decision-making should be treated as a process. such as mechanical ventilation or intravenous nutrition/ hydration. Summary of Policy Statement “Life-sustaining medical treatment” (LSMT) refers to any intervention that could prolong the life of the patient. An ethical gray zone may have various definitions.” perhaps. Of course. and artificial nutrition and hydration. Mercurio. hence. Reaffirmed January 2004.” The word “clearly. and intellectual satisfaction. it is equally acceptable to try a treatment for a while and then withdraw it and to refrain from initiating that same treatment. The guidelines acknowledge that there is no ethical or legal distinction between not instituting a treatment and withdrawing it. emotional enjoyment. there is no significant ethical difference between withholding and withdrawing an LSMT. dialysis. such as emancipated minors and some “mature minors” (often judged to be ⱖ14 years old) generally should be viewed as having decision-making capacity for their care. than it is to agree not to initiate it.” 5. rather than simply “offer a menu of choices.

despite the misgivings or even the frank opposite recommendation of the physician. or prosecutor of the alleged abuser may have a conflict of interest. and pediatric surgeons should be aware of the legal and ethical issues in caring for children who have been seriously injured as a result of abuse. nature. Therefore. MAAS. 1989:295 2. The location of the borders of the gray zone. in all cases in which a parent or guardian may have a conflict of interest. The physician might be concerned about the pain of the ongoing course or the potential burden of severe disability should the child survive. it also opens the door to other considerations. and extent of a child’s injuries. “given the likelihood of criminal prosecution. it may be prudent to supplement the clinical determination of brain death with an ancillary test. A guardian ad litem for medical decision making should be appointed in all cases of child abuse requiring LSMT in which a parent.policy statements with the parental choice and. 4. NY: Routledge Publishers. communication. Only when it seems to the clinicians that the parental wishes are clearly opposed to the child’s interests should they be overridden. MD.” The document ends with five recommendations: 1. the parent or guardian of an abused child may be considered to have a conflict of interest when a decision to forgo LSMT risks changing the legal charge faced by a parent. Summary and Comment by Tomas J. Pediatrics. Meisel A.29 No. 3. Some have suggested that this is too narrow a view and that it may be legitimate to consider the interests of family members as well. 2. Ongoing patience. In the case of LSMT. 2000 Forgoing Life-sustaining Medical Treatment in Abused Children Committee of Child Abuse and Neglect and Committee on Bioethics. relative. Pediatricians. guardian. NY: Wiley Law Publishers. Hardwig A. (2) How much weight should be accorded to the interests of the family is a central question in decisions regarding LSMT. Local procedures for collecting evidence and performing postmortem examinations should be developed to allow for organ and tissue donation. additional review and consultation should be sought in hopes of resolving the conflict. and compassion provide the best approach in such a case. even recommend against it. Decisions to forgo LSMT for a critically ill child whose injuries are the result of abuse should be made using the same guidelines as those used for any critically ill child. The medical examiner’s office should be involved early and before forgoing LSMT. but does not feel that his or her choice clearly opposes the best interests of the child. as appropriate. for any given physician. suggesting that although brain death is a clinical determination based on established criteria. perhaps. the parent(s) or guardian(s) should be involved.” in decisions about LSMT. where the best interests of the child seem unclear. guardian. Such consultation includes requesting the appointment of a guardian ad litem. The Right to Die. the statement recommends that if a physician suspects that a parent or guardian is not acting in a child’s best interest. the values and judgment of the parents generally should hold sway.org/cgi/ content/full/pediatrics%3b106/5/1151. The patient’s best interest standard is strictly interpreted to require exclusive consideration of the benefits and burdens to the patient.aappublications. at one point stating that physicians and families should include “the interests of others. 2000. essentially is determined by the degree of certainty (or clarity) he or she feels about the child’s best interest. the guidelines do not advocate overriding parental decisions.3 March 2008 e17 . such as family members and loved ones. Summary of Policy Statement In this joint statement. 5. or acquaintance from assault to manslaughter or homicide. Forgoing life-sustaining medical treatment in abused children. but be uncertain whether the burdens outweigh the benefit of possible survival. who represents the child’s interests regarding LSMT. Although the AAP guideline generally seems to endorse the patient’s best interest standard. Silber. adherence to these guidelines might result in a child being kept alive because of parental request. it is affirmed that the decision to forgo LSMT for a critically ill child injured as the result of abuse should be made using the same criteria as those used for any critically ill child. such as a cerebral flow study. References 1. In such a case. Reaffirmed Oc- bioethics tober 2006. Is There a Duty to Die? New York. Within the ethical gray zone. Pediatrics in Review Vol. New York. Available at: http://aappolicy. in all aspects of the child’s care and treated with respect and due consideration for their privacy. In addition. Regardless of the cause. The statement also clearly addresses the issue of the brain-dead child. pediatric subspecialists.106:1151–1153. in cases of abuse.

Committee on Bioethics. Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery. and preferences rather than on individual resuscitation procedures. Goal-directed approaches focus on patient goals. betray. Deshpande JK. Pediatricians need to function as child advocates. and a family may refuse resuscitation attempts. 2004. but a requirement that the order be suspended in the operating room may not be in the best interest of the patient. This consideration of options allows care to be individualized to the needs of the child. Surgical procedures and anesthesia may increase the risk of hemodynamic instability.” At the end. When a DNR order is in place. Reconsideration of the DNR order allows a review of therapeutic interventions that might be used and possible . the thoughtful and systematic approach of the statement comes around to helping us understand that decision-making in the treatment of abused children is no different from the painful dealings with other injured or moribund children— only more so.” However. The responsibility of the physician does not end when a court appoints a guardian ad litem. Do-Not-Resuscitate Orders for Pediatric Patients Who Require Anesthesia and Surgery Fallet ME. (2) Despite the possible risks of an iatrogenic arrest during anesthesia and surgery. and hurt them.policy statements bioethics Comment This is among the most tragic circumstances that a pediatrician may encounter in his or her practice. continuing to provide input so the guardian ad litem makes an informed decision. and the Section on Surgery. An older child is included in the discussions when possible and assent obtained. Policies requiring the suspension of a DNR order force families to balance the benefits of surgery against the risks of unwanted resuscitation. (3) Procedures commonly used in the operating room may be considered resuscitation in other situations (3). MD. The document also is on solid footing when it identifies “the best interest of child” as the primary focus when considering whether to forgo LSMT and appropriately advises that when the pediatrician suspects that the parent is not acting in the best interest of the child. aappublications. Available at: http://aappolicy. values. e18 Pediatrics in Review Vol. it initially is counterintuitive to accept the advice that decisions to forgo LSMT be based on complete and compassionate communication with the family. Documentation of all discussions and communication to all involved in providing care are needed. “even if one or both parents are suspected of causing the injury. there still should be the freedom to request beneficial interventions without fear of prolonged resuscitation or unwanted intensive care. MS. Procedure-directed planning documents decisions on the use of various interventions but lacks flexibility. Comment Parents. Because it is only human to be enraged at the suffering of the most vulnerable at the hands of those who abuse their power.org/cgi/content/full/pediatrics.3 March 2008 Summary of Policy Statement This clinical report from 2004 discusses preexisting donot-resuscitate (DNR) orders for the pediatric patient who undergoes anesthesia and surgery. may refuse treatment without implying a choice to hasten the child’s death. Section on Anesthesia and Pain Medicine. an ethics consult can be very useful in assuring the hospital administration that reasonable steps were taken before proceeding to a court hearing. acting as surrogates for their children. Summary and Comment by Brenda Jean Mears. which includes identifying for them and offering them the possibility of meeting with bereavement counselors. Pediatricians need to be aware that prosecutors may not support a decision to forgo LSMT “out of concern that the case against the alleged abuser may be weakened. DNR orders may be written for a child at the request of the parent when the burdens of resuscitation exceed any expected benefit. Such orders should not preclude the provision of appropriate surgical interventions. If the physician cannot comply with the decisions made by the family. A family may choose to suspend or modify the DNR order intraoperatively. transfer of the patient or involvement of other consultants may be necessary. an ethics “consult” should follow in hopes of resolving the conflict. but arrests in this setting have a higher percentage of successful resuscitation. (1) Several points bear emphasis. The various components of the surgery are reviewed and the implications of the DNR considered.114:1686 –1692. Honoring the DNR order may allow a potentially reversible death to occur. it is not always in the best interest of a child to be resuscitated.114/6/ 1686. additional reflection on who we are as pediatricians and what our role and obligations are clarifies that we have been granted by society the special mission of providing support for the parents of critically ill children.29 No. Indeed. chaplains. or any other professional or group they may need in the midst of this emotional and spiritual crisis. The timing of resuming previous DNR orders should be planned. “Required reconsideration” specifies that DNR orders be reviewed during the informed consent process. Pediatrics.

Public Law 94142. such as a mucous plug in a child who has a tracheostomy. “a DNR order is not synonymous with abandonment of all medical treatment and does not. Such orders possibly could be misinterpreted bioethics by medically untrained staff. along with their child. Pediatrics. Finally. some of which may involve liability for the school. In addition. Challenges involved in the care of these children who have continuing life-threatening health problems can be encountered as they reach school age.org/cgi/reprint/93/3/532 2.29 No.org/publicationsAndServices/standards/09. Reaffirmed JanuPediatrics in Review Vol.” The risk of dying while attending school is a real possibility for some children who have chronic and terminal conditions. 2000. school officials may be worried about a variety of other issues.org/cgi/content/full/pediatrics. Available at: www. such as a child choking on food or being injured. The goal of working together would be to ensure that a child’s participation in the education process continue for as long as reasonably possible. provides that children who have disabilities or handicaps “have access to education in the least restrictive environment appropriate for their needs. Avoiding adversarial struggles between school personnel and parents is important. many children who previously would have died are surviving serious conditions.” More importantly. Available at: http://aappolicy. MD. Suspension or modification of the DNR order can be planned and documented for use during the procedure. Waisel DB. Lancet. Summary of Policy Statement This statement addresses the challenging situation of DNR orders in schools.365:733–735 3. The AAP recommends that pediatricians work with parents of at-risk children as well as with school and nursing personnel. and emergency medical service personnel.” School officials may have concerns about DNR orders in schools. The AAP recommendations in this area are both helpful and practical in attaining common ground for the school and the family. Do-not-resuscitate orders in schools. aappublications. The AAP believes that pediatricians should be involved with these decisions and work with families and school personnel to provide guidance and advice in this area. Reaffirmed June 2003. On the other hand. should the parents desire a DNR order be followed in the school. teachers. such as suction.105:878 – 879. have a right to have the DNR order followed at school. the committees stress. Maxwell. Comment Children who have life-threatening problems are at risk of dying while in school. Guidelines on forgoing life-sustaining medical treatment. as well as parents of other children not wanting their children exposed to death at school. there is a concern about the effect of a death in school on other students. Ethical Issues With Genetic Testing in Pediatrics Committee on Bioethics.105/4/ 878. may decide on DNR orders and may wish for these orders to be followed at school. There also is concern that school personnel may not respond to easily reversible situations. Parents. Parents who have chosen no cardiopulmonary resuscitation for their child also may want this decision carried out while the child is at school. All of these issues raise liability concerns. 1994. “Concerted efforts to accommodate all points of view will help avoid confrontation and possible litigation. Available at: http://pediatrics. From an ethical standpoint. Ethical issues with genetic testing in pediatrics. (2)(3) If a conflict cannot be settled to the satisfaction of the participants. parents could argue that they. finding common ground is in the best interest of children at increased risk of dying in school.html Do-Not-Resuscitate Orders in Schools Committee on School Health and Committee on Bioethics. References 1. Committee on Ethics.org/cgi/ content/full/pediatrics. after appropriate consultation. Do-not-resuscitate orders in the surgical setting.asahq. Burns JP. Summary and Comment by Marilyn A.3 March 2008 e19 . Truog RD. administrators. American Academy of Pediatrics. This last point also could be presented as a rights-based argument. In this statement. the Education for All Handicapped Children Act. oxygen. Pediatrics. 2001. rescind the obligations of the health care team to provide quality care. Ethical Guidelines for the Anesthesia Care of Patients with Do Not Resuscitate Orders or Other Directives that Limit Treatment. Committee on Bioethics. of itself. With the advances of medical knowledge and technology. which could result in harm to a child. Pediatrics. there is a consideration of the effect on other students exposed to a death at school.policy statements responses to expected and unexpected events as well as the risks and benefits of the surgery and anesthesia. American Society of Anesthesiologists. Available at: http://aappolicy. there are concerns that situations not anticipated by a DNR order. could cause confusion among personnel. 2005.107:1451–1455.93:532–536.aappublications. In addition. the preference of the family should prevail. aappublications. and pain medication.107/6/1451.

Reverse cascade screening of newborns for hereditary haemochromatosis: a model for other late onset diseases? J Med Genet.or herself. 2) carrier screening.29 No.95:1889 –1893 2. Compliance factors in Tay-Sachs screening. (1) The Committee on Bioethics is against mandatory screening because it fails to acknowledge the role of parents in making decisions for their children. Barlow-Stewart K. (4)(5) The great expansion of genetic technologies in the past 5 years has not created much of a change in ethical analysis. Ethics and care of critically ill infants and children. (8)(9) Second. Clow CL. 2005. 2005. They also argue against routine carrier screening in adolescents on the grounds that adolescents should decide whether they want this reproductive information as adults. Burnett L. 2003. Fost NC. Newborn screening technology: proceed with caution.106(suppl):386 – 427 4. Pediatrics. although many argue against predictive testing and screening of children and adolescents for carrier detection and late-onset conditions. Serving the family from birth to medical home: a report from the Newborn Screening Task Force convened in Washington DC. Capron D.117:1793–1799 9. Assessing Genetic Risks. However. A genetic screening programme for Tay-Sachs disease and cystic fibrosis for Australian Jewish high school students. during newborn screening for sickle cell disease or cystic fibrosis) or it may be part of a program for providing reproductive information to adolescents and young adults. An international survey of predictive genetic testing in children for adult onset conditions.40:e45 8. Botkin JR. Am J Public Health. The statement is aligned with the traditional position that as a public health program. Principles. Gallet M. National Research Council. 1996. 1977. Progr Clin Biol Res. (4)(5) Carrier detection may occur as an incidental finding (eg. 2006. The two primary ethical issues in newborn screening that the statement addresses are: 1) consideration of how to introduce new tests into newborn screening ethically and 2) examination of the current policy of mandatory screening without parental permission. Warren SF. Again. The latter rarely has been attempted in the United States but has been undertaken internationally. 2005. (10)(11) References 1. The Committee recommends replacing current mandatory screening practices with a program that requires “mandatory offering. . Committee on Genetics. Bailey DB Jr. and the decision to test takes away the child’s right not to know and to make such decisions for him. MD. (4)(5) Finally.98:149 –152.98:473–501 3. (3) and many other ethical analyses of genetic screening programs.116:862– 871 10. Gillam L. and Research.7:390 –396 11. Scriver CR. Summary of Policy Statement In this statement. et al. 2005. et al. Cadet E. PhD. a position that currently is being challenged by some patient advocates. the Committee states that the information should be conveyed to parents. Proos A. Clayton EW.18:379 –380 7. Washington DC: National Academy Press. Pediatrics. Duncan RE.3 March 2008 Comment The position outlined in this statement is mainstream and consistent with many earlier ethics documents about genetic testing and genetic screening. J Med Genet. et al. unclear. (2) the AAP Newborn Screening Task Force.42:390 –395 Ethics and Care of Critically Ill Infants and Children Committee on Bioethics. these positions are similar to other United States statements. Newborn Screening Task Force. Institute of Medicine. Savulescu J. the statement addresses the issue of predictive testing for late-onset disorders. Implications for Health and Social Policy. Genetic Screening: Programs. American Academy of Pediatrics. 2000. American Academy of Pediatrics. and 3) predictive testing for late-onset disorders. newborn screening must provide a clear benefit to the child. 1996. Newborn screening for developmental disabilities: reframing presumptive benefit. although it has influenced genetic practice. supporting the delay of testing until the child “has the capacity to make the choice. Pediatrics. when carrier information is discovered incidentally. Research for newborn screening: developing a national framework.” which is consistent with the position of the AAP Committee on Genetics (although some of those committee members wanted to leave the program as mandatory). First.” This position is based on the premise that whether the psychological benefits outweigh the risks is e20 Pediatrics in Review Vol.policy statements bioethics ary 2005. 1999. Skinner D. (6)(7) The Committee on Bioethics takes the position that newborns should not be screened for the purpose of determining carrier status because the primary use of such information is reproductive and is irrelevant to the child. May 10 –11. Pediatrics. 1975 5. Newborn screening fact sheets. 1994 6. Summary and Comment by Lainie Friedman Ross. Botkin JR. empiric data show that such testing is occurring. Genet Med. Delatycki MB. newborn screening has expanded rapidly without appropriate systems in place to ensure that the policy decisions can be re-evaluated. Williamson R. the Committee on Bioethics seeks to address three areas of genetic testing and screening in children that raise serious ethical issues: 1) newborn screening. Pediatrics. Washington DC: National Academy of Sciences.

(15)(17) and court decisions concerning required treatment have varied.29 No. Informed decisions should be made together by the family and medical personnel.215&catg⫽AMA/HnE&catg⫽AMA/ BnGnC&catg⫽AMA/DIR&&nth⫽1&&st_p⫽0&nth⫽2&.215. These “Baby Doe rules” resulted from a perception in the early 1980s that beneficial treatment was being denied to infants. (1)(2)(3) Physicians should justify treatments to families. Parents are presumed to accept responsibility for providing care for their children and should be informed of available options. The actual language may permit more discretion than frequently realized. American Academy of Pediatrics. and “virtually futile” therapy that imposes excessive burdens on the infant. Summary of Policy Statement Current LSMT can prolong the lives of patients who. Guidelines on forgoing life-sustaining medical treatment. and be responsible for altered standards of care by limiting the ability “to select individualized treatment plans and act in the best interests of infants” (9) and by disregarding parental concerns about pain and suffering. E 2. one AMA policy supports withdrawal when the risks of pain and suffering are greater than “any potential for joy. and physicians should use judicial intervention to override parents only when their decisions “clearly conflict” with the child’s interests.policy statements Available at: http://aappolicy. (2)(3)(4) Withdrawal of LSMT in some settings may be appropriate. appropriate decisions.” (1) Treatment should be individualized and re-evaluated frequently. This policy references the 1984 Child Abuse Amendments. American Academy of Pediatrics. 1995. Available at: http://www.ama-assn. Pediatrics. Misconceptions about these requirements may have hampered attention to concerns about possible overuse of LSMT. (1) References 1. 1994. more recently. Parents may perceive and value these benefits and burdens differently than medical personnel. The AAP supports parental involvement in decisions from the earliest possible moment for all children. (1)(2)(3)(4)(5) Parents need to be fully informed as early as possible (1)(2)(3)(4) because different individuals judge the value of benefits and risks differently. A trial of therapy may be necessary to clarify a clinical situation and the pertinent ethical values in the particular situation. American Medical Association. The primary consideration should be the “best interests” of the child. and legal norms. Reaffirmed June 2003. The value of LSMT may be uncertain.” (3) This policy has created controversy because it may relate to the 1984 Child Abuse Amendments (the Baby Doe rules) and. considering both burdens and benefits. MD. 7/ 10/06 Pediatrics in Review Vol.” (8)(11)(12)(14) This policy has been said to give support to the Baby Doe rules. (6)(8) In brief.96:362–363 3. each case requires careful consideration by the family members and medical and support personnel that possibly involves multiple group meetings prior to the making of acceptable. A Texas case upheld the right of parents to make decisions to withhold treatment except in an emergency. but survival alone is not necessarily in a child’s best interest.org/ apps/pf_new/pf_online?f_n⫽resultLink&doc⫽policyfiles/HnE/ E-2. MS. be inconsistent with other guidelines.3 March 2008 e21 . (6)(16) The definition of child abuse does include failure to provide medically necessary treatment. (6)(9)(18)(19) but a Wisconsin case seemed to require maximal treatment unless there is irreversible coma or dying. Pediatrics. patients. which elicits the moral question: When is it appropriate to apply LSMT to a critically ill infant or child? Although a critically ill infant or child ultimately may have multiple physical or mental limitations.HTM&s_t⫽e⫹2. there has been concern that this definition may “jeopardize the normative ethical practice of offering discretionary palliative care. in the past.215 Treatment Decisions for Seriously Ill Newborns. to the 2002 Born Alive Act. (15) Predictions of outcome are imperfect. Committee on Bioethics. (13) Although the AAP Neonatal Resuscitation Program Steering Committee said that no changes in approach are necessary. Only rarely should the involvement of child protective services be necessary. Committee on the Fetus and Newborn. Exceptions to mandated treatment include “permanent unconsciousness. (6)(7)(8)(9)(10)(11)(12)(13) The “Born Alive Act” defines “human being” to include any infant born alive at any stage of development. might not have been treated vigorously. Comment This policy has much in common with other AAP and American Medical Association (AMA) policies and statements. (1) Parents are granted wide discretion in decision making. bioethics LSMT should be provided “in conformity with current medical.” “futile” treatment.aappublications. it is impossible to predict the outcome accurately for any individual.98/1/149.org/cgi/ content/abstract/pediatrics. and themselves based on possible benefits and burdens. The initiation or withdrawal of treatment for high-risk newborns.93:532–536 2. Summary and Comment by Brenda Jean Mears. ethical.

American Medical Association. J Med Ethics.org/apps/pf_new/pf_online?f_n⫽resultLink&doc⫽ policyfiles/HnE/H-480. Salter R. 55(3):11–22 7. Adam. and Edwin N. It is presented by the AAP Section on Bioethics as part of its mission to foster education in this area among pediatricians. N Engl J Med. Born-Alive Infants Protection Act of 2001. 2175. ACKNOWLEDGMENTS.116:1019 –1021 12. there may not be unanimity about the positions taken. and that is important to recognize. Pediatrics. As the commentaries suggest. Perinatal care at the threshold of viability. McCullough LB. This is the second in a series of three articles. Decisions regarding treatment of seriously ill newborns. J Perinat Neonatal Nurs. American Academy of Pediatrics. for guidance and helpful comments in the preparation of this manuscript. HR.29 No.111:680 – 681 15. MA. Baby Doe rules: in reply. Hurst I. Pediatrics.7/20/06 6. Goldsmith J. Part 1 appeared in the January 2008 online-only issue of Pediatrics in Review.116: 1601–1602 8.org/sections/bioethics. . 2004. Neonatologists judge the “Baby Doe” regulations. Baby Doe redux? The Department of Health and Human Services and the Born-Alive Infants Protection Act of 2002: a cautionary note on normative neonatal practice. Ethics of refusing parental requests to withhold or withdraw treatment from their premature baby. 2005. Forman.34(4):32–39 Conclusion The AAP periodically publishes policy statements and guidelines addressing difficult ethical issues that physi- e22 Pediatrics in Review Vol. 2005. Boyle D. Treatment decisions for critically ill infants: the abrogation of the best interests standard. Pediatrics.110:1024 –1027 5. Born-Alive Infants Protection Act of 2001. MD.318: 677 – 683 11. Pediatrics. This review is intended to provide readers with an overview of some of those guidelines and possibly stimulate additional thought and dialogue within the profession. Pediatrics. Pediatrics. JAMA.281:2041–2043 18. as well as other relevant references and information. and Part 3 will appear in the May issue. Affiliate membership also is available to physicians and other health professionals not eligible for AAP membership. 2005. Juv Family Court J.HTM&s_t⫽withdrawal&catg⫽AMA/ HnE&catg⫽AMA/BnGnC&catg⫽AMA/DIR&&nth⫽1&&st_p⫽ 0&nth⫽8&.3 March 2008 cians caring for children continue to face. Sayeed SA. Irons TG. 107th Cong. 2005. Kopelman AE. The full text of each policy. Arnander MW. et al. 2003. The authors would like to thank Mary B. 2002. can be found on the web site for the Section on Bioethics at http:// www.992 Moral and Ethical Issues in the Use of Health Care Technologies. Robertson JA. 2004. Boyle RJ. Baby Doe rules: in reply.116:1600 –1601 9. The legal landscape at the threshold of viability for extremely premature infants: a nursing perspective. MD.992. and carry out other educational efforts intended primarily for pediatricians. Kopelman LM. They organize educational forums in bioethics at the annual AAP National Conference and Exhibition. Clinical report.ama-assn. Hurst I. Frader JE. 2005. The Section on Bioethics serves primarily an educational role within the AAP and beyond. 107–207. 2005.policy statements bioethics 4. Hastings Center Report.19:155–166 19. part I. 2004.116:1601 16.115:797– 802 10. Clark F. Extreme prematurity and parental rights after Baby Doe. H-480. 1988. In addition. Public Law No. Carlo WA. publish a newsletter that includes original articles in the area of bioethics. Baby Doe rules. Neonatal ethics at the limits of viability. they provide input to the Board of Directors and other committees regarding proposed policy statements and guidelines. their colleagues on the AAP Section on Bioethics Executive Committee. Pediatrics. 2nd Sess (2001) 14. Clark FI. Kopelman LM. 2005. Fost N. Available at: http:// www. Membership in the Section is open to all AAP Fellows who have an interest in bioethics.aap. 1999. Are the 21-year-old Baby Doe rules misunderstood or mistaken? Pediatrics.30:402– 405 17.116:e576 – e585 13.