Young children who experience toxic stress such as maltreatment, neglect, poverty, or a depressed parent are at increased risk for later life health problems such as asthma, heart disease, cancer, and depression. During the prenatal and early childhood years, the neuroendocrine-immune network creates end-organ setpoints that lead to these disorders. Because well-timed adjustments to the child’s environment can reduce the risk for later disease, the clinician should attempt to uncover toxic stressors at each preventive health visit.
Watching a newborn develop from a dependent being into a communicative child with a unique personality is an amazing process that caregivers and clinicians can actively promote. Early identification of developmental disorders is critical for the well-being of children and their families. Unfortunately, primary care physicians fail to identify and appropriately refer many developmental problems, even though screening tools are available. Because the period of most active development occurs during the first 3 years, clinicians must assess and document developmental surveillance for every preventive care visit and preferably at every other office visit as well regardless of purpose. Table 1-2 lists some developmental “red flags.”
Table 1–2.Developmental “red flags.”a ||Download (.pdf) Table 1–2.Developmental “red flags.”a
|Age (months) ||Clinical Observation |
|2 ||Not turning toward sights or sounds |
|4–5 ||No social smiling or cooing |
|6–7 ||Not reaching for objects |
|8–9 ||No reciprocating emotions or expressions |
|9–12 ||No imitative sound exchange with caregivers |
|18 ||No signs of complex problem-solving interactions (following 2-step directions) |
|18–24 ||Not using words to get needs met |
|36–48 || |
No signs of using logic with caregivers
No pretend play with toys
Surveillance includes asking parents if they have any concerns about their child’s development, taking a developmental history, observing the child, identifying any risk factors for developmental delay, and accurately tracking the findings and progress. If the family shows concerns, reassurance and reexamination is appropriate if the child is at low risk.
As a result of concerns identified during surveillance and specifically at the 9-, 18-, and 30-month visits, a formal developmental screening tool should be administered to uncover problems such as those listed in Table 1-3. These visits occur when parents and clinicians can readily observe strides in the different developmental domains: fine and gross motor skills, language and communication, problem solving/adaptive behavior, and personal-social skills. Developmental tests screen children who are apparently normal, confirm or refute any concerns, and serve to monitor children at high risk for developmental delay. Each test approaches the task of identifying children in a different way; no screening tool is universally deemed appropriate for all populations and all ages. A report in the United States during 2006–2008 found that about one in six children had a developmental disability.
Table 1–3.Prevalence of developmental disorders. ||Download (.pdf) Table 1–3.Prevalence of developmental disorders.
|Disorder ||Cases per 1000 |
|Attention deficit/hyperactivity disorder ||75–150 |
|Learning disabilities ||75 |
|Behavioral disorders ||60–130 |
|Mental retardation ||25 |
|Autism spectrum disorders ||2–11 |
|Cerebral palsy ||2–3 |
|Hearing impairment ||0.8–2 |
|Visual impairment ||0.3–0.6 |
Table 1-4 lists several useful developmental screening tests. The historical gold standard Denver Developmental Screening Test–revised requires trained personnel about 20–30 minutes of office time to administer. Proper use is not widespread in practice. The Parents’ Evaluation of Developmental Status, the Ages and Stages Questionnaire, and the Child Development Review-Parent Questionnaire are all parent-completed tools that take less than 15 minutes to complete and are easily used in a busy clinical practice but are unfortunately proprietary. Shortened, customized lists of developmental milestones should not replace the use of validated developmental assessment tools, a list of which is available from the National Early Childhood Technical Assistance Center (NECTAC).
Table 1–4.Developmental screening tools.
If the screening tool results are concerning, the physician should inform the parents and schedule the child for further developmental or medical evaluation or referral to subspecialists such as neurodevelopmental pediatricians, pediatric psychiatrists, speech-language pathologists, and physical and occupational therapists. In approximately one-fourth of all cases, an etiology is identified through medical testing, such as genetic evaluation, serum metabolite studies, and brain imaging.
If screening results are within normal limits, the physician has an opportunity to focus on optimizing the child’s potential. Parents can be encouraged to read to their children on a regular basis, sing and play music, limit television and other media device use altogether in toddlers and to no more than 2 hours daily for older children, and directly engage in age-appropriate stimulating activities such as exercise or game playing. Clinicians should encourage the parents and patients to report on positive behaviors and activities at every visit.
At both the 18- and 24-month visits, clinicians should formally screen for autism spectrum disorders (ASDs). Increasing public awareness and concern about ASD has made this recommendation key. The Modified Checklist for Autism in Toddlers (M-ChAT) is a widely used, validated autism-specific screening tool. Autistic disorder is a pervasive developmental disorder resulting in various social, language, and/or sensorimotor deficits with an incidence as high as 1 in 88 children. Early diagnosis and intervention may help many autistic persons achieve some degree of independent living. The differential diagnosis includes other psychiatric and developmental disorders; profound hearing loss; metabolic disorders, such as lead poisoning; and genetic disorders, such as fragile X syndrome and tuberous sclerosis. MMR (measles-mumps-rubella) vaccine does not cause autism, but failure to take folic acid during pregnancy is linked to an increased risk.
The school years offer an excellent opportunity to evaluate the child’s development through grades, standardized test results, and athletic or extracurricular activities. Participation in activities outside the home and school also help gauge the child’s development. For example, a critical event during adolescence is learning to drive a motor vehicle.
A general principle for well-child examinations (newborn to 4 years old) is to perform maneuvers from least to most invasive. Clinicians should first make observations about the child-parent(s) interaction, obtain an interval history, and then perform a direct examination of the child. Some parts of the examination are best accomplished when the infant is quiet so they may be performed “out of order.” Although most communication about the child’s health is between the physician and the parent(s), clinicians should attempt to communicate directly with the patient to gauge whether he or she is developmentally appropriate and to develop familiarity directly with that patient.
A physical examination of the newborn should include the following:
General observation: evidence of birth trauma, dysmorphic features, respiratory rate, skin discolorations, or rashes
Head, ears, eyes, nose, and throat (HEENT) examination: mobile sutures, open fontanelles, head shape, ears, bilateral retinal red reflexes, clarity of lens, nasal patency, absence of cleft palate or lip, and palpation of clavicles to rule out fracture
Cardiovascular examination: cardiac murmurs, peripheral pulses, capillary refill, and cyanosis
Pulmonary examination: use of accessory muscles and auscultation of breath sounds
Abdominal examination: masses, distention, and the presence of bowel sounds
Extremity examination: number and abnormalities of digits, and screening for congenital dislocation of the hips using Ortolani and Barlow maneuvers
Genitourinary examination: genitalia and anus
Neurologic examination: presence of newborn reflexes (eg, rooting, grasping, sucking, stepping, and Moro reflex), resting muscle tone
To track the child’s physical and developmental progress, a comprehensive interval history and physical examination is important at each encounter, even if the parents do not report concerns. The child’s weight (without clothes or shoes), height, and head circumference (until 3 years of age) are measured and plotted on standard CDC growth charts at each visit. A child’s rate of growth will usually follow one percentile (25th, 50th, etc) from birth through school age. A child can appropriately cross percentiles upward (eg, a premature infant who then “catches up”) or inappropriately (eg, a child who becomes obese). Any child who drops more than two percentiles over any period of time should be evaluated for failure to thrive (see Chapter 2).
By 15 months of age, children experience stranger anxiety and are much less likely to be cooperative. Clinicians can minimize the child’s adverse reactions by approaching the child slowly and performing the examination while the child is in the parent’s arms, progressing from least to most invasive tasks. Touching the child’s shoe or accompanying stuffed animal first and then gradually moving up to the chest while distracting the child with a toy or otoscope light is often helpful. After the first year of life, the pace of the infant’s growth begins to plateau. At the 15- to 18-month visit, the infant most likely will be mobile and may want to stand during the examination. To engage the child, the clinician can ask where to do the examination or which body part to examine first.
Beginning at 2 years of age, the body mass index (BMI) is plotted; at age 3 years the child’s blood pressure is measured. Eye examination for strabismus (also known as “cross-eye”; measured by the cover/uncover test) allows early treatment to prevent amblyopia. By age 3 or 4 years, documentation of visual acuity should be attempted. Hearing, now tested at birth, is informally evaluated until the age of 4 years, when audiometry should be attempted. At least 75% of speech in 3-year-olds should be intelligible. Speech delay should trigger referral. Physicians need to assess gait, spinal alignment, and injuries, looking particularly for signs of child abuse or neglect. Table 1-5 highlights the important components of the physical examination at each age. The examiner should comment on the child’s psychological and intellectual development, particularly during adolescence, when mood and affect evaluations should be recorded.
Table 1–5.Highlights of physical examination by age. ||Download (.pdf) Table 1–5.Highlights of physical examination by age.
|Age of Child ||Essential Components of Examination |
|2 weeks || |
Presence of bilateral red reflex
Auscultation of heart for murmurs
Palpation of abdomen for masses
Ortolani/Barlow maneuvers for hip dislocation
Assessment of overall muscle tone
Reattainment of birth weight
|2 months || |
Observation of anatomic abnormalities or congenital malformations (effects of birth trauma resolved by this point)
Auscultation of heart for murmurs
|4–6 months || |
Complete musculoskeletal examination (neck control, evidence of torticollis)
Extremity evaluation (eg, metatarsus adductus)
Vision assessment (conjugate gaze, symmetric light reflex, visual tracking of an object to 180°)
Bilateral descent of testes
Assessment for labial adhesions
|9 months || |
Pattern and degree of tooth eruption
Assessment of muscle tone
Presence of bilateral pincer grasp
Observation of crawling behavior
|12 months || |
Range of motion of the hips, rotation, and leg alignment
Bilateral descent of testes
|15–18 months || |
Cover test for strabismus
Signs of dental caries
Any evidence of injuries
Screening Laboratory Tests
Every state requires newborns to undergo serologic screening for inborn errors of metabolism (Table 1-6), preferably at age 2–3 days. Funded by the Department of Health and Human Services (DHSS), Baby’s First Test (www.babysfirsttest.org) is an unbiased website that provides information for providers about the mandated screening requirements in each state. Examples of commonly screened conditions are hypothyroidism, phenylketonuria, maple syrup urine disease, congenital adrenal hyperplasia, and cystic fibrosis. Most institutions routinely screen newborns for hearing loss [US Preventive Services Task Force (USPSTF) recommendation for universal screening level B]. The USPSTF assigned a level I (insufficient evidence) to universal screening of newborns for risk of chronic bilirubin encephalopathy with a transcutaneous bilirubin.
Table 1–6.Commonly screened components of newborn screening panels.a ||Download (.pdf) Table 1–6.Commonly screened components of newborn screening panels.a
|Diseases Screened ||Incidence of Disease in Live Births |
|Congenital hypothyroidism ||1:4000 |
|Duchenne muscular dystrophy ||1:4500 |
|Congenital adrenal hyperplasia ||1:10,000–1:18,000 |
|Phenylketonuria ||1:14,000 |
|Galactosemia ||1:30,000 |
|Cystic fibrosis ||1:44,000–1:80,000 (depending on population) |
|Biotinidase deficiency ||1:60,000 |
The American Academy of Pediatrics (AAP) recommends screening for anemia with fingerstick hemoglobin or hematocrit at age 12 months. Although the USPSTF assigned a level I to screening for iron deficiency, it did recommend iron dietary supplementation for age 6–12 months. Because of the high prevalence of iron deficiency anemia in toddlers (about 9%), repeat screenings may be necessary in high-risk situations. Measurement of hemoglobin or hematocrit alone detects only those patients with iron levels low enough to become anemic, so dietary intake of iron should be assessed. Pregnant adolescents should be screened for anemia. A positive screening test at any age is an indication for a therapeutic trial of iron. Thalassemia minor is the major differential consideration. A sickle cell screen is indicated in all African American children.
The AAP recommends universal lead screening at ages 12 and 24 months. If the child is considered to be at high risk, annual lead screening begins at age 6 months. Risk factors include exposure to chipping or peeling paint in buildings built before 1950, frequent contact with an adult with significant lead exposure, having a sibling under treatment for a high lead level, and location of the home near an industrial setting likely to release lead fumes. Although many agencies require a one-time universal lead screening at 1 year of age because high-risk factors are often absent in children with lead poisoning, the USPSTF recommends against screening children at average risk and assigns a level I to screening for high-risk children.
Tuberculosis (TB) screening using a purified protein derivative (PPD) is offered on recognition of high-risk factors at any age. Routine testing of children without risk factors is not indicated. Children require testing if they have had contact with persons with confirmed or suspected cases of infectious TB, have emigrated from endemic countries (Asia or the Middle East), or have any clinical or radiographic findings suggestive of TB. Human immunodeficiency virus (HIV)-infected children require annual PPD tests. Children at risk for HIV due to exposure to high-risk adults (HIV-positive, homeless, institutionalized, etc) are retested every 2–3 years. Children without specific risk factors for TB but who live in high-prevalence communities may be tested at ages 1 year, 4–6 years, and 11–12 years.
The AAP recommends universal dyslipidemia screening at ages 10 and 20 years. A cholesterol level may be obtained after age 2 years if the child has a notable family history. The National Cholesterol Education Program (NCEP) recommends screening in a child with a parent who has a total cholesterol of ≥240 mg/dL or a parent or grandparent with the onset of cardiovascular disease before age 55 years. Clinical evaluation and management of the child are to be initiated if the low-density lipoprotein (LDL) cholesterol level is ≥130 mg/dL. The USPSTF assigns a level I to cholesterol screening during childhood.
The AAP recommends an HIV test for all 20-year-olds.
All mothers should be strongly encouraged to breastfeed their infants. A widely accepted goal is exclusive breastfeeding for at least the first 6 months of life. Vitamin D supplement (400 U/d) is indicated for breastfed children. Parents who choose to bottle-feed their newborn have several choices in formulas, but should avoid cow’s milk, because of risks like anemia. Commercial formulas are typically fortified with iron and vitamin D, and some contain fatty acids such as docosahexaenoic acid (DHA) and arachidonic acid (ARA) which are not as yet proven to promote nervous system development. Soy-based or lactose-free formulas can be used for infants intolerant of cow’s milk formulas.
An appropriate weight gain is 1 oz/d during the first 6 months of life and 0.5 oz/d during the next 6 months. This weight gain requires a daily caloric intake of ~120 kcal/kg during the first 6 months and 100 kcal/kg thereafter. Breast milk and most formulas contain 20 cal/oz. Initially, newborns should be fed on demand or in some cases as for twins on a partial schedule. Caregivers need to be questioned about the amount and duration of the child’s feedings and vitamin D and fluoride intake at every visit.
Healthy snacks and regular family mealtimes may help reduce the risk of obesity. Fruit juice is best avoided altogether; water is preferred for hydration. Ideal calorie intake is somewhat independent of weight but does change according to activity level. Children age 1 year should take in about 900 kcal/d; age 2–3 years, 1000; age 4–8 years, 1200 for girls and 1400 for boys; age 9–13 years, 1600 for girls and 1800 for boys; and age 14–18, 1800 for girls and 2200 for boys.
Solid foods such as cereals or pureed baby foods are introduced at 4–6 months of age when the infant can support her or his head and the tongue extrusion reflex has extinguished. Delaying introduction of solid foods until this time appears to limit the incidence of food sensitivities. The child can also continue breast- or bottle-feeding, limited to 30 oz/d, because the solids now provide additional calories. Around 1 year of age, when the infant can drink from a cup, bottle-feeding should be discontinued to protect teeth from caries. No specified optimum age exists for weaning a child from breastfeeding. After weaning, ingestion of whole or 2% cow’s milk may promote nervous system development.
Older infants can tolerate soft adult foods such as yogurt and mashed potatoes. A well-developed pincer grasp allows children to self-feed finger foods. With the eruption of primary teeth at 8–12 months of age, children may try foods such as soft rice or pastas.
With toddlers, mealtimes can be a source of both pleasure and anxiety as children become “finicky.” The normal child may exhibit specific food preferences or be disinterested in eating. An appropriate growth rate and normal developmental milestones should reassure frustrated parents. Coping strategies include offering small portions of preferred items first and offering limited food choices. Eating as a family gives toddlers a role model for healthy eating and appropriate social behaviors during mealtimes.
Regular patterns for voiding and defecation provide reassurance that the child is developing normally. Newborn infants should void within 24 hours of birth. An infant urinates approximately 6–8 times a day. Parents may count diapers in the first few weeks to confirm adequate feeding. The older child usually voids 4–6 times daily. Changes in voiding frequency reflect the child’s hydration status, especially when the child is ill.
Routine circumcision of male infants is not currently recommended, so parents who are considering circumcision require additional guidance. Although a circumcised boy has a decreased incidence of urinary tract infections [odds ratio (OR) 3–5] and a decreased risk of phimosis and squamous cell carcinoma of the penis, some clinicians raise concerns about bleeding, infection, pain of the procedure, or damage to the genitalia (incidence of 0.2–0.6%). Therefore, the decision about circumcision is based on the parents’ personal preferences and cultural influences. When done, the procedure is usually performed after the second day of life, on a physiologically stable infant. Contraindications include ambiguous genitalia, hypospadias, HIV, and any overriding medical conditions. The denuded mucosa of the phallus appears raw for the first week postprocedure, exuding a small amount of serosanguineous drainage on the diaper. Infection occurs in <1% of cases. Mild soap and water washes are the best method of cleansing the area. By the 2-week checkup, the phallus should be completely healed with a scar below the corona radiata. The parents should note whether the infant’s urinary stream is straight and forceful.
Newborns are expected to pass black, tarry meconium stools within the first 24 hours of life. Failure to pass stool in that period necessitates a workup for Hirschsprung disease (aganglionic colon) or imperforate anus. Later the consistency of the stool is usually semisolid and soft, with a yellow-green seedy appearance. Breastfed infants typically defecate after each feeding or at least 2 times a day. Bottle-fed infants generally have a lower frequency of stooling. Occasionally, some infants may have only one stool every 2 or 3 days without discomfort. If the child seems to be grunting forcefully with defecation or is passing extremely hard stools, treatment with lubricants such as, glycerin is recommended. Any appearance of blood in the stools is abnormal and warrants investigation. Anal fissure is common.
With the introduction of solid foods and maturation of intestinal function, stool becomes more solid and malodorous. Treatment of mild to moderate constipation may include the use of Karo syrup mixed in with feedings (1–2 tsp in 2 oz of milk) or psyllium seed or mineral oil (15–30 mL) for older children. Older children and adolescents should ingest high-fiber foods such as fruits and vegetables and drink water to reduce the risk of constipation. Children who are severely constipated may require referral.
An important issue for new parents is the development of proper sleeping habits for their child. Newborns and children experience different stages of sleep/wakefulness cycles, including deep, light, or rapid-eye-movement (REM) sleep; indeterminate state; wide-awake, alert state; fussy; and crying. On average, a baby experiences a cycle every 3–4 hours, and the new parents’ first job is to learn their baby’s unique style. Newborns sleep an average of 18–20 hours in each 24-hour period.
At first, feeding the baby whenever he or she wakes up is the most appropriate response. Because babies often have their days and nights “reversed,” tiring nighttime awakenings are commonplace because of frequent feedings. When the baby is 3 or 4 weeks old, feedings can be delayed for a bit of play and interaction. The goal is to space out the baby’s awake time to 3 or more hours between feedings and a long sleep at night.
By 2–3 months, the baby’s pattern of sleeping and feeding should be more predictable and parents can institute some routines that allow the child to self-comfort. After feeding, rocking, and soothing, parents should be encouraged to lay the baby down in the crib when she or he is quiet but not asleep. A soothing, consistent bedtime ritual allows babies to learn to settle down by themselves and lays the foundation for other independent behaviors in the future.
All newborn infants should be placed on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Risk factors include prone and side positions for infant sleep, smoke exposure, soft bedding and sleep surfaces, and overheating. Cosleeping (bed sharing) slightly increases the overall risk of SIDS, especially for infants less than 11 weeks old. The issue of cosleeping is often difficult to address as it is viewed as a common and necessary practice in some cultures. Evidence also suggests that pacifier use and room sharing (without bed sharing) are associated with decreased risk of SIDS. Although the cause of SIDS is unknown, immature cardiorespiratory autonomic control and failure of arousal responsiveness from sleep are important factors. With the “back to sleep” campaign, prone sleeping among all US infants has decreased to less than 20%, and the incidence of SIDS has decreased to 40%.
An unintended consequence of the supine sleep position has been increased incidence of positional head deformity or plagiocephaly. Providers need to recognize physical examination distinctions between this cosmetic deformity and the more significant concern of craniosynostosis. Parents should be counseled early about strategies to minimize plagiocephaly, including use of supervised prone positioning (“tummy time”) and avoidance of prolonged car seat or rocker use. Early referral and treatment in severe cases typically results in satisfactory outcomes.
Sleep disorders are extremely common in young children and adolescents. Good sleep hygiene offers the best solution to these difficulties.
The poor state of oral health in many children is a continued major concern. Tooth decay remains one of the most common chronic diseases of childhood, even more common than asthma. Medically and developmentally compromised children and children from low-income families are at highest risk. Affected children remain at higher risk for cavities throughout their childhood and adulthood. To minimize early-childhood caries, children should not be put to sleep with a bottle or by breastfeeding. Parents should also be discouraged from inappropriately using the bottle or “sippy cup” as a pacifier. Dietary sugars along with cariogenic bacteria, most often acquired from the mother, who should never clean off a pacifier by inserting it into her own mouth, lead to accelerated decay in the toddler’s primary teeth. Ingestion of water after feeding may help reduce cavities.
Current recommendations encourage establishing regular dental care around 6–9 months of age in high-risk children and at 1 year of age for all others. Children should continue with regular biannual dental appointments thereafter. Primary prevention includes provision of a diet high in calcium and fluoride supplementation for those with an unfluoridated water supply (<0.6 ppm) from age 6 months through age 16 years. Once primary teeth erupt, parents should use a soft-bristled brush or washcloth with water to clean the teeth twice daily. A pea-sized amount of fluoride containing toothpaste is adequate. Infants should drink from a cup and be weaned from the bottle at around 12–14 months of age. Pacifiers and thumb sucking are best limited after teeth have erupted. All children need limits on the intake of high-sugar drinks and juices, especially between meals. Fluoride applications 2–6 times per year on erupted teeth markedly reduce the incidence of caries (http://www.ada.org/goto/fluoride).
Accidental injury and death are the major risks to a healthy child. Safety should be stressed at every well-child visit. Poison avoidance; choking hazards; and water, pet, gun, and automobile safety are critical areas to review. The Injury Prevention Program (TIPP) from the American Academy of Pediatrics provides an excellent framework for accident prevention.
Issues in Normal Development
Anticipatory guidance can be helpful to caregivers in preparation for normal growth and development and when their child exhibits variations from ideal behavior. Bright Futures provides extensive information about anticipatory guidance throughout childhood and adolescence. Important anticipatory guidance topics include safety, school readiness, school refusal, bullying, physical activity, media (TV, smartphones, etc) use, drug addiction, sexuality, and intellectual pursuits. Selected behavioral issues that are commonly encountered in young children include infantile colic, temper tantrums, and reluctant toilet training.
Colic is a term often used to describe an infant who is difficult to manage or fussy despite being otherwise healthy. Colic may be defined as 3 or more hours of uncontrollable crying or fussing at least 3 times a week for at least 3 weeks. Many parents complain of incessant crying well before 3 weeks have passed. Other symptoms include facial expressions of pain or discomfort, pulling up of the legs, passing flatus, fussiness with eating, and difficulty falling or staying asleep. Symptoms classically worsen during the evening hours. Because the diagnosis depends on parental report, the incidence of colic varies from 5% to 20%. It occurs equally in both sexes and peaks around 3–4 weeks of age.
The cause of colic is unknown, but organic pathology is present in <5% of cases. Possible etiologies include an immature digestive system sensitive to certain food proteins, an immature nervous system sensitive to external stimuli, or a mismatch of the infant’s temperament and those of caregivers. Feeding method is probably unrelated. Clinicians can provide reassurance to caregivers by informing them that colicky children continue to eat and gain weight appropriately, despite the prolonged periods of crying, and that the syndrome is self-limited and usually dissipates by 3–4 months of age. Colic has no definite long-term consequences; therefore, the main problem for caregivers is to cope with anxiety over the crying child. A stressed caregiver who is unable to handle the situation is at risk for abusing a child.
No definitive treatment can be offered for colic. Little evidence supports the use of simethicone or acetaminophen drops. Switching to a hypoallergenic (soy) formula is effective when the child has other symptoms suggestive of cow’s milk protein allergy. Breastfeeding mothers can attempt to make changes in their diets (eg, avoidance of cruciferous vegetables such as broccoli and cabbage) to see if the infant improves. Both clinicians and caregivers have proposed many “home remedies.” Both reducing stimulation and movement such as a car ride or walk outdoors are recommended. Frequent burping, swaddling, massage, a crib vibrator, and background noise from household appliances or a white-noise generator are moderately effective. Rigorous study of these techniques is difficult, but clinicians can suggest any or all because the potential harm is minimal.
A normal part of child development, temper tantrums encompass excessive crying, screaming, kicking, thrashing, head banging, breath-holding, breaking or throwing objects, and aggression. Between the ages of 1 and 3 years, a child’s growing sense of independence is in conflict with physical limitations and parental controls and hampered because of limited vocabulary and inability to express feelings or experiences. This power struggle sets the stage for the expression of anger and frustration through a temper tantrum. Tantrums can follow minor frustrations or occur for no obvious reason, but are mostly self-limited. A child’s tendency toward impulsivity or impatience or a delay in the development of motor skills or cognitive deficits and parental inconsistency—excessive restrictiveness, overindulgence, or overreaction—may increase the incidence of tantrums. Tantrums that produce a desired effect have an increased likelihood of recurrence.
As much as possible, parents should provide a predictable home environment. Consistency in routines and rules will help the child know what to expect. Parents should prepare the child for transitions from one activity to another, offer some simple choices to satisfy the child’s growing need for control, acknowledge the child’s wants during a tantrum, and act calmly when handling negative behaviors to avoid reinforcement. Physical (corporeal) punishment is not advised.
Most importantly, ignoring attention-seeking tantrums and not giving in to the demands of the tantrum will, in time, decrease the recurrence. Children who are disruptive enough to hurt themselves or others must be removed to a safe place and given time to calm down in a nonpunitive manner. Most children learn to work out their frustrations with their own set of problem-solving and coping skills, thus terminating tantrums. Persistence of tantrums beyond age 4 or 5 years requires further investigation and usually includes referral or group education and counseling.
Some indicators of readiness for toilet use include an awareness of impending urination or defecation, prolonged involuntary dryness, and the ability to walk easily, to pull clothes on and off easily, to follow instructions, to identify body parts, and to initiate simple tasks. These indicators are not likely to be present until 18–30 months of age. Once the child becomes interested in bathroom activities or watching his or her parents use the toilet, parents should provide a potty chair. Parents can then initiate toilet training by taking the diaper off and seating the child on the potty at a time when she or he is likely to urinate or defecate. Routine sittings on the potty at specified times, such as after meals when the gastrocolic reflex is functional, may be helpful. The child who is straining or bending at the waist may be escorted to the bathroom for a toileting trial. If the child eliminates in the potty or toilet, praise or a small reward may reinforce that behavior. Stickers, storybooks, or added time with the parents can be used for motivation.
With repeated successes, transitional diapers or training pants may be used until full continence is achieved. The training process may take days to months, and caregivers can expect accidents. Accidents need to be dealt with plainly; the child should not be punished or made to feel guilty or forced to sit on the toilet for prolonged periods. Significant constipation can be treated medically, because it may present a barrier to training. About 80% of children achieve success at daytime continence by age 30 months.
As with many child-rearing issues, consistency and a nurturing environment give the child a sense of security. Training should not start too early or during times of family stress. Parents can be asked to describe specific scenarios, so concrete anticipatory guidance may be given to deal with any barriers. Toilet training, as with most behavior modification, has a higher chance of success if positive achievements are rewarded and failures are not emphasized.
Medical Concerns Outside Normal Development
Beyond the normal variations in child development, the family physician may need to identify and treat significant medical problems. Early diagnosis and referral lead to prevention of potentially serious sequelae and improved quality of life. Some of the major abnormalities detected in the young child (Table 1-7) underscore the importance of regular and thorough well-child-care visits with the family physician.
Table 1–7.Medical problems commonly diagnosed in childhood. ||Download (.pdf) Table 1–7.Medical problems commonly diagnosed in childhood.
|Problem ||Definition ||Prevalence ||Risk Factors ||Assessment ||Treatment |
|Developmental dysplasia of hips ||Spectrum of abnormalities that cause hip instability, ranging from dislocation to inadequate development of acetabulum ||8–25 cases per 1000 births || |
Possibly birth weight >4 kg
Screening clinical examination at birth and well-child visits of marginal use
Diagnosis: ultrasound in infants <6 months; radiographs >6 months
|Abduction splints in infants <6 months; open or closed reduction more effective in those >6 months; optimal treatment remains controversial; consider orthopedic referral |
|Congenital heart disease || |
Major—large VSDs, severe valvular stenosis, cyanotic disease, large ASDs
Minor—small VSDs, mild valvular stenosis, small ASDs
|5–8 cases per 1000 newborns, 50% with major disease and 50% with minor disease ||Maternal diabetes or connective tissue disease; congenital infections (CMV, HSV, rubella, etc); drugs taken during pregnancy; family history; Down syndrome || |
Major disease presents shortly after birth
Minor disease can present with murmur, tachycardia, tachypnea, pallor, peripheral pulses; EKG, CXR, echocardiogram
|Cardiology evaluation; medication; surgical treatment options |
|Cryptorchidism ||Testicles are absent (agenesis, vascular compromise) or undescended || |
2–5% of full-term and 30% of premature male infants;
prevalence varies geo-graphically
Disorders of testosterone secretion;
abdominal wall defects; trisomies
|Increased risk of inguinal hernia, testicular torsion, infertility, and testicular cancer ||Hormonal or surgical treatment, or both; can start at age 6 months; complete before age 2 years |
|Pyloric stenosis ||Hypertrophic (elongated, thickened) pylorus, progresses to obstruction of gastric outlet ||3 cases per 1000 live births || |
first-born infants; unconjugated hyperbilirubinemia
|Diagnosis by clinical examination, ultrasound, or upper GI series; electrolyte abnormalities (metabolic alkalosis) ||Surgical repair; fluid, electrolyte resuscitation |
|Hypospadias ||Ventral location of urethral meatus (anywhere from proximal glans to perineum) ||~1 case per 250 male births ||Advanced maternal age; maternal diabetes mellitus; Caucasian ethnicity; delivery before 37 weeks’ gestation ||Check for other abnormalities (cryptorchidism) and intersex conditions (congenital adrenal hyperplasia) ||Circumcision contraindicated; urology referral, usually within 3–6 months |
|Strabismus ||Anomaly of ocular alignment (one or both eyes, any direction) ||~2–4% of population || |
low birth weight;
retinopathy of prematurity; cataract
|Clinical tests: corneal light reflex, red reflex, cover test, and cover/uncover test ||Child should be referred to pediatric ophthalmologist for early treatment to reduce visual loss (amblyopia) |
Children should limit TV and computer use to no more than 2 hours per day. Parents must be aware of the content of viewed programs, videogames, and websites to reduce childhood exposure to violence and socially inappropriate content such as drug use. Safe use of handheld phones and computer devices should be routinely discussed with all parents and older children and adolescents.
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