What Does a Child Need to Do To Be Ready to Go To Kindergarten?

Patient Presentation
A 5-year-old male came to clinic for his health supervision visit. He had attended a preschool for the past year three times per week and had done well. His mother reported that the teachers had no concerns about him entering kindergarten. She however was worried about him taking the bus and also needing help in the lunchroom. The past medical history showed a broken arm from falling off a bike. His immunizations were current.

The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters in the 75-90%. His physical examination was normal. The diagnosis of a healthy male was made. The pediatrician filled out the school health form and recommended that he see a dentist as he hadn’t seen one in more than 1 year. He also recommended for the parent to contact the school to see if there was a new parent orientation to learn more about the school, ask questions and meet other parents. “Even if they don’t have one, you can get your questions answered by the school personnel,” he said and then went on, “I know he knows many colors, letters and numbers, but I recommend he knows his street address and your name so if there is a problem an adult can help him.” “You can also practice the bus route with him and show him ahead of time where he will be going. Find another child who will be taking the bus and see if that child can be his “bus-buddy.” In that way he has someone else he knows will help him.” He reassured the mother by saying, “The teachers know that the kids can’t open all their containers, so they just help the kids. They also get a lot of the older kids to help the younger ones. The older ones remember having that problem too and are usually really happy to help the little ones.”

Discussion
Many parents look forward to but worry about their child starting school. These are normal concerns as the child may not have had a school experience before or has school experience but not for as long a time as a regular school day. The child often will be traveling a different route to school such as taking a bus. Kindergarteners also need to be more responsible for their own self, their belongings and often will be handling other adult items such as notes from school and money.

The most important part of kindergarten though is to instill a love of learning. It isn’t how much the children already knows or will learn, it is about them learning that school can be an enjoyable place to learn about the world.

  • What parents can/should do to help their child be successful in school
    • Relax and enjoy your child’s kindergarten time – its the small things that you will remember
    • Have your child registered and fill out all the other paperwork and forms
    • Have your child vaccinated and receive the health care and dental care they need
    • If you can, attend parent orientation or back to school nights that the school offers to learn more about the school
    • If you can, have your child attend their own orientation
  • Know school is tiring
    • Children can be very tired after school. They have been very busy learning and it takes all their energy.
    • Give them a snack (sometimes you have to pack one in the backpack or bring it for the car ride).
    • Allow them some quiet time. Remember they have been around other noisy kids all day and may need some quiet time. That may also mean that you don’t ask lots of questions right away when they get home from school.
    • Phase out naps over the summer so your child is ready to not have a nap at school. There will be rest time but usually this is not for actual sleep.
  • Parents do not have to be involved in everything but they should be involved
    • Ask your child about what they are doing in school. Sometimes they won’t say much, so ask more specific questions such as “What did you do in math today?” or “Last week you were playing soccer in gym class, are you doing the same thing?” We often ask children what they like about something, so try the opposite like “So what was bad today?” It surprises the child and then they will tell you more about what is happening in their life.
    • Clean out the homework folder every night with your child and send information back to school if needed.
    • If you can afford it, send in extra school supplies or donate items for special days
    • Write a note to the teacher with or without your child to thank them at holidays or end of year. Email or saying a special thank you with a big smile goes a long way for teachers to know that you are involved and see that they are trying to do their best for your child.
    • If you can attend or volunteer for a special event, do so. If you cannot, then don’t beat yourself up over it. Not everyone can do everything or afford everything.
  • Model learning to your child
    • Read to your child. Have an older child read to the younger one.
    • If you don’t read well, then do what you can do. Consider talking with the teachers about help for yourself.
    • You will never know all the answers. Tell your child it is okay to not know or to be wrong. Show them how to find answers and be gracious when they are wrong.
  • Communicate with the teachers and school
    • Read the notes teachers send home. Sign and send the notes back if appropriate.
    • Communicate with the school about issues in your family if it might concern the school. Family stress such as losing a job, changing homes, deaths in the family, financial worries, etc. affect the child and if the teacher is aware can be of help to the child.
      Some schools also have resource centers, social workers or guidance counselors who may be able to help you.

    • Communicate with the teacher if you have any questions or concerns. Understand that they have many more students than you do so respect their time. But they do want to hear from parents if you have concerns. Write a note, email or telephone.
    • Trust the teacher but trust yourself when things don’t seem right.
      • Teachers have worked with lots of kids and lots of parents. They probably have a good sense of how your child is doing in the very broad “normal” area. If the teacher has a concern remember that they are bringing this to your attention because they care about your child. Similarly if the teacher is not concerned about your child, but you truly think differently, talk it out with them and see their point of view. You know your child best so be their advocate but don’t be an adversary to the teacher.
      • If you cannot get the information you need from the teacher or you have a larger concern the teacher cannot address, then contact the principal. If you feel you cannot talk with the principal, then the school guidance counselor can often help or contact the central administration of the school district.
  • Find other parents
    • Find a “parent-buddy” who can also give you information about the school that your child may not bring home or be aware of. They often know the unwritten rules or ways that the school works.

    Learning Point

    Children should know (and it is a lot):

    • Self-care
      • Their own first and last name
      • Street address
      • Phone number
      • Parents/guardians first names
      • Where parents work
    • Safety
      • How to dial 911
      • Who will they go home with
      • How they will get home and by what route
      • What will they do if they get off bus, get home etc. and parent is not there
      • What will happen if school gets out early or starts late
      • What they should do in an emergency
    • Academics
      • Colors – some
      • Letters – some
      • Numbers – some
      • How to wait at least 1 minute
      • How to raise hand to be acknowledged
    • Lunch room
      • How to open food containers – but there will be lots of other personnel and students to help
      • How to pay for school meals with money or if receiving free or discounted meals
      • How to carry a tray
    • Bathroom
      • Bathroom etiquette – close door, use toilet paper, flush toilet, wash hands
    • General
      • Label everything – especially clothing and anything else they take to school
      • Keep it simple – all papers go in the homework folder – clean out the folder every night
      • What should they do if they lose something

    Questions for Further Discussion
    1. What should children know before starting middle school?
    2. What should young adults know before starting college? See case here.

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: School Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Peters T. 8 things I wish I’d known before my child started kindergarten. Today Parents.
    Available from the Internet at http://www.today.com/parents/8-things-i-wish-id-known-my-child-started-kindergarten-1D80005092 (rev. 8/8/14, cited 6/2/15).

    10 Things to Think About Before Your Child Starts Kindergarten. Harvard Homemaker.com.
    Available from the Internet at http://harvardhomemaker.com/10-things-to-think-about-before-your-child-starts-kindergarten/ (rev. 7/25/13, cited 6/2/15).

    Countdown to Kindergarten. Scholastic.com (Collection).
    Available from the Internet at http://www.scholastic.com/parents/resources/collection/what-to-expect-grade/count-down-to-kindergarten (cited 6/2/15).

    Starting School. American Academy of Child and Adolescent Psychiatry.
    Available from the Internet at http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Starting_School_82.aspx (rev. 3/11 cited 6/2/15).

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Common Drug Eruptions in Children?

    Patient Presentation
    A 4-year-old female came to clinic because of a rash for 24 hours. The pruritic rash began the evening before with a few red spots on her trunk. She had slept well, but this morning they were spreading and enlarging in size on her trunk, neck and extremities and did not seem to come and go. She also had a fever and her mother thought that she wasn’t moving as well and seemed to be sore. The patient had been started on cefaclor 9 days earlier for an ear infection and upper respiratory tract infection symptoms. She had previously taken penicillins and cephalosporin antibiotics without any problems. Her mother denied any new soaps/lotions/detergents, exposure to streptococcus, lice, scabies, pets or any travel. Her mother denied any difficulties breathing or eating, abnormal movements or mentation and she was urinating and stooling normally. The past medical history showed a relatively well child who had minor infections.

    The pertinent physical exam showed a mildly ill child who was itching the rash. Her vital signs were normal except for a temperature of 100.9°F. Her growth parameters were 10-25%. HEENT showed no conjunctivitis, mild rhinorrhea, and right serous otitis media. Oral mucosa was normal. Her lungs were clear and she had a normal heart and abdomen examination. Her extremities showed swelling and mild warmth without erythema of both elbows and knees. She had decreased range of motion in those joints because of pain and also of her right ankle but there was no obvious swelling of the ankle. Her skin examination showed mainly macules that were 0.5-2 cm in size that were distributed mainly on her trunk and the proximal parts of her upper and lower extremities. It also extended up to her hairline on the back of her neck. Her palms and soles were spared. The many lesions were coalesced and they had a dusky/purplish color but blanched. None were pustular or vesicular. There were no petechiae and she had some regular bruising on her shins that was distinctly different than the rash.

    The pediatrician considered the diagnoses of a general viral exantham, streptococcal skin rash and/or rheumatic fever, Henoch-Schonlein purpura, and a drug reaction such as urticaria multiforme, and serum sickness like reaction (SSLR). The first 3 seemed unlikely given the history and the patient also did not meet criteria for Kawasaki Disease and did not appear to have a sepsis-like presentation of meningococcemia. It was felt that this was most likely a drug reaction with SSLR being the most likely cause especially as the patient was taking cefaclor. The pediatrician discussed the patient by telephone with an infectious disease expert who agreed that it sounded most like SSLR. The laboratory evaluation showed a normal complete blood count, rapid strep testing was negative, and compliments and anti-streptolysin O titres were negative. Her erythrocyte sedimentation rate was 21 mm/hr (normal < 20) and C-reactive protein was 5.5 (upper limit of normal). The patient’s clinical course had her stopping the medication, using antihistamines for pruritis, acetaminophen for fever and starting her on prednisone for the SSLR to be tapered over the next 10 days. At 2 day follow up her arthritis and fever had resolved as had some of the rash. At phone followup 1 week later the patient had complete resolution of her symptoms.

    Discussion
    Drug reactions unfortunately are common in children and adults. These reactions have different but often overlapping appearances. Viral exanthams also often cloud the picture as these rashes can be because of the drug, the virus or both.

    Patients with urticaria multiforme present with an acute rash that appears as urticaria plaques that have a hemorrhagic or dusky discoloration. It occurs 1-3 days after viral symptoms (including cough, rhinorrhea, diarrhea) and may also present with fever.

    Morbilliform drug eruptions one of the most common drug reactions in children and usually occur 7-14 days after the onset of the medication, often amoxicillin. The rash is small, pink or red macules and papules that are diffuse and may coalesce. The rash can get worse with viral syndrome and can be mistaken for a viral exanthams, allergic exanthams or contact dermatitis. The rash usually improves in a few days.

    Fixed drug eruptions occur 7-14 days after exposure to a drug including sulfa, acetaminophen, and common antihistamines. The rash may come and go but is in the same “fixed” spot usually as opposed to true urticaria which comes and go. The rash is erythematous patches or plaques that are round or oval with a central purple or dusky discoloration. They can last for weeks and may leave temporary hypo- or hyperpigmentation.

    Acute generalized exanthematous pustulosis occurs 1-14 days after drug exposure with pruritis and tiny sterile non-follicular pustules. Fever may also occur. The pustules are sterile and not follicular. It occurs more often in adults but can occur with children. It usually resolves in 1-2 weeks after stopping the medication, often antibiotics, or resolution of a viral illness.

    True serum sickness is a type III hypersensitivity reaction to medications that results in circulating immune complexes that cause complement activation, which then leads to systemic inflammation and immune complex deposition within tissues particularly in the kidneys. Historically the reaction was caused by horse or rabbit antiserum.

    Learning Point
    Serum-sickness like reaction (SSLR) is similar to true serum sickness but is clinically distinct. The cause is unknown but it is hypothesized that medication metabolites may have a direct effect on tissues. SSLR does not cause circulating or deposition of immune complexes. SSLR is known to be caused by many medications particularly cefaclor but also cefuroxime, bupropion, griseofulvin and minocycline. It typically occurs 7-21 days after exposure.

    SSLR has a rash, fever and at least arthritis without evidence of systemic or cutaneous vasculitis. The rash of SSLR is urticarial or morbilliform with annular plaques or patches with a central dusky or purple discoloration. Arthralgia can occur alone or arthritis with mild or significant edema of the joints can be seen. Lymphadenopathy can also be a component of SSLR.

    SSLR treatment is stopping the medication and oral antihistamines for pruritis and antipyretics for fever. Oral corticosteroids are used for severe cases particularly those with arthralgias and/or edema. Improvement after stopping the medication is usually seen within a few days to week but may take longer.

    Questions for Further Discussion
    1. What is the difference between the drug reactions above and drug hypersensitivity reactions?
    2. What are criteria for labeling a patient as drug sensitive or drug allergic?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Drug Reactions

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Newell BD, Horii KA. Cutaneous drug reactions in children. Pediatr Ann. 2010 Oct;39(10):618-25.

    Tolpinrud WL, Bunick CG, King BA. Serum sickness-like reaction: histopathology and case report. J Am Acad Dermatol. 2011 Sep;65(3):e83-5.

    Mathur AN, Mathes EF. Urticaria mimickers in children. Dermatol Ther. 2013 Nov-Dec;26(6):467-75.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    What Health Problems are Caused by Inadequate Sleep?

    Patient Presentation
    A 16-year-old male came to clinic for his health supervision visit. He said he was a good student receiving A’s and B’s in accelerated classes. He also played basketball and baseball and participated in other outside activities. He reported no health problems but said that he often went to sleep between midnight and 1 AM because of needing to finish his homework. He got up at 6:30 AM to be able to start school at 8 AM. He said on the weekends he would try to sleep later but even then it was difficult because of weekend activities. The past medical history showed a sprained ankle and overuse shoulder injury in the past two years. The family history was negative for any sleep disorders including obstructive sleep apnea.

    The pertinent physical exam showed a healthy male with growth parameters in the 50 to 75th percentile. The rest of his physical examination was normal. The diagnosis of a healthy male with sleep deprivation was made. The pediatrician discussed with the patient and his father some of the difficulties of not having enough sleep and provided more information about sleep hygiene. The pediatrician emphasized that inadequate sleep had negative effects on academic achievement and had increased accident risks especially when operating an automobile.

    Discussion
    In humans, sleep is regulated by two systems. The first is the homeostatic sleep drive which assumes that the longer the person is awake the more pressure there is to fall asleep. The second process is the circadian system which controls periods of activity and inactivity throughout the day. The circadian rhythm is slightly longer than 24 hours in humans and is controlled by the hypothalmic suprachiasmatic nucleus. When the circadian system and the external environment are misaligned, such that sleep occurs outside of normal times, a circadian rhythm sleep disorder can occur.

    During adolescence, there is a normal physiologic change of the homeostatic and circadian systems such that there is a shift to a later sleep phase for adolescents. Adolescents also commonly have inadequate sleep that occurs on an ongoing basis because of societal norms. These adolescents normally have sleep onset later but need to get up in the morning for school and other activities resulting in inadequate sleep amount. Adolescents, if left alone without external influences, will sleep slightly more than 9 hours. However, 45% of adolescents sleep < 8 hours and 31% sleep between 8-9 hours on school nights. Adolescents may "catch-up" their sleep on the weekends, but the problems of inadequate sleep during the school week may not be mitigated with the additional weekend sleep.

    Adolescents in addition to the normal physiologic change can have circadian rhythm sleep disorders. Delayed sleep phase disorder (DSPD) is the most common in this group a the prevalence of 7-16%. DSPD delays sleep onset by 3 to 4 hours compared to usual normative evening time (i.e. 10-11 PM). If left alone, the sleep is normal in quality and duration. Sleep wakening is then necessarily delayed causing problems with social needs (e.g. not getting up in time to go to school). The adolescent then has inadequate sleep which then leads to poor sleep hygiene which helps to change the intrinsic circadian rhythm which continues to cause the delayed sleep onset. Overtime, DSPD develops. DSPD is treated using good sleep hygiene but other interventions may be necessary.

    • Chronotherapy delays sleep onset progressively over several days until the normal sleep onset time is achieved and then anchors that new time with post-sleep morning light.
      Light therapy especially in the morning can be helpful.

    • Light in the evening delays sleep onset and light in the morning advances it (i.e. makes it earlier in the evening the next night). Light intensity between 2500-10000 lux will advance circadian rhythms.
    • Melatonin is a chronobiotic that can be used to help sleep onset. Melatonin is given ~5 hours before desired sleep onset. Once consistent sleep onset is achieved, a smaller dose given 2 hours before desired sleep onset helps to establish the circadian pattern.

    The opposite of DSPD can occur called advanced sleep phase disorder. It is not common in adolescence. The sleep onset occurs early in the evening despite trying to stay awake until normal times with typical wakening in the early AM (e.g. between 2 and 5 AM).

    Good sleep hygiene includes:

    • Consistent sleep onset and waking times
    • Limited caffeine and food in the evenings before bedtime
    • Limited exercise before bedtime
    • Limited computer, television and other screen time to limit evening light exposure
    • Bed and bedroom with comfortable temperature, no or low level lighting. Bed not used for activities associated with mental alertness such as homework, electronic screens, etc.

    Psychophysiologic insomnia is a sleep-onset disorder and is not a circadian rhythm sleep disorder.

    Learning Point
    Overall, good sleep amounts and patterns have positive health benefits while poor sleep amounts and patterns have negative health benefits. Many of these problems are dose response related and can be reciprocal. For example inadequate sleep can lead to depressive symptoms and depressive symptoms can lead to poor sleep.
    Problems associated with inadequate sleep include:

    • Mental health
      • Anxiety
      • Attention problems
      • Depression (strongly associated with poor sleep)
      • Suicidal ideation
      • Poor perceived mental health
      • Poor perceived physical health
      • Low self esteem
      • Poor psychosocial functioning
      • Fatigue and tiredness
    • Physical health
      • Pain (in females only)
      • Cardiovascular problems
      • Cardiometabolic problems
      • Overweight and obesity
    • Health risks
      • Accidents and injuries particularly automobile accidents
      • Aggression (being in fights, weapons carrying, etc.)
      • Use of cigarettes, alcohol and drugs
      • Unprotected sexual activity
    • Occupational
      • Poor academic achievement (especially in older adolescents)

    Questions for Further Discussion
    1. How is psychophysiological insomnia diagnosed and treated?
    2. What are indications for referral to a sleep medicine specialist?
    3. What are other sleep disorders and how are they defined?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Sleep Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Bartlett DJ, Biggs SN, Armstrong SM. Circadian rhythm disorders among adolescents: assessment and treatment options. Med J Aust. 2013 Oct 21;199(8):S16-20.

    Reiter J, Rosen D. The diagnosis and management of common sleep disorders in adolescents. Curr Opin Pediatr. 2014 Aug;26(4):407-12.

    Shochat T, Cohen-Zion M, Tzischinsky O. Functional consequences of inadequate sleep in adolescents: a systematic review. Sleep Med Rev. 2014 Feb;18(1):75-87.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Are These Abscesses?

    Patient Presentation
    A 35-day-old female came to clinic with a one-day history of two new lesions in her diaper area. The first lesion located near her right labia began 4 days ago and had not changed according to the mother. Last night a second lesion appeared in her left inguinal crease. Initially it was red and swollen but became bluish overtime. The lesions did not appear to cause pain, nor had spreading redness or warmth in this area. Her mother stated that she was otherwise well with no fever orrash and she was feeding, urinating, and stooling well. The mother denied her being around other people that were sick including herself. Her mother denied any open skin lesions nor herpetic ulcers. The past medical history showed a full term infant born by NSVD who went home from the hospital on time. She had been gaining weight well and had been examined for her 1 month check 1 week earlier. The family history was not contributory. The review of systems was negative.

    The pertinent physical exam showed of a smiling infant in no distress. Her vital signs were normal including being afebrile. Her growth parameters were 75th to 90th percentile for age. HEENT examination was normal including a flat fontanelle. Her heart, lungs, abdomen, and musculoskeletal examinations were normal. Her genitourinary examination revealed two masses. The first was in the left inguinal crease that was 13 x 7 mm in size. It was purple red in color with no surrounding erythema or edema of the surrounding skin or structures. It was firm but mobile. The second lesion was at the confluence of the right external labia, perineum and leg crease. It was 10 mm x 5 mm with the longitudinal axis oriented parallel with the spine. An area of approximately 5 mm was able to be seen on the perineum that was also purple red in color and there was no surrounding erythema or edema or warmth. From the caudal end, a thread-like structure was possibly palpated. Because of the location and the unusual coloring, the pediatrician considered that these could be abscesses with or without a fistula in the perineal mass or lymph node abscesses. Much less likely was aberrant testes in a phenotypic female or an unusual presentation of a metastatic cancer.

    The radiologic evaluation of an ultrasound was performed and confirmed that these masseswere abscesses. The patient was referred to surgery who drained the abscesses of a small amount of purulent material. The patient was placed on amoxicillin-clavulanic acid oral antibiotic. The patient’s clinical course over the next two days showed that the patient remained afebrile and had no obvious discomfort. The abscesses were markedly decreased in size. Laboratory testing at that time showed methicillin-resistant Staphylococcus aureus (MRSA). She was to follow up again in one more week.

    Discussion
    Staphylococcus aureus is a gram-positive, catalase-positive coccal bacterium that is found on the skin and respiratory tract. It is the most common cause of skin and soft tissue abscesses. Staphylococcus can also cause enteritis, pneumonia, and toxic shock syndrome. In addition to abscesses, Staphylococcus can cause pustulosis, cellulitis, necrotizing fascitis and other exfoliative skin disease such as bullous impetigo.

    Staphylococcus is well-known to colonize the human skin, nail and nares. It is spread by physical contact and aerosolization. Skin breaches allow Staphylococcus to enter the body and to disseminate by hematogenous spread in as little as 1-3 hours. The host immune defenses may clear the bacteremia or Staphylococcus may provoke disseminated disease including sepsis, multiorgan system failure or distant abscesses. Local skin disruption may also cause localized skin disease without bacteremia or dissemination.

    To review stages of Staphylococcus abscess formation see To Learn More below.

    Learning Point
    In the study of afebrile neonates presenting to two emergency rooms with skin and soft tissue infections, 104 infants were evaluated out of > 120,000 emergency department visits. Pustulosis was most common in the genitourinary areas and abscesses were commonly found on the buttocks. All of these patients did not have bacteremia or other serious bacterial infection. When looking at the types of evaluations and treatments the patients received, neonates with abscesses were treated with antibiotics 59% of the time and were admitted to the hospital 55% of the time. Compared to pustulosis and cellulitis, neonates with abscesses had the most variation in evaluation and treatment, as patients with pustolosis generally were less aggressively evaluated and treated and patients with cellulitis were more aggressively evaluated and treated. All patients did well upon discharge.

    In another study evaluating methicillin-resistant Staphylococcus in children with superficial genitourinary abscesses, found that MRSA was more common in the groin and external genitalia similar to the patient presented. Their patients ranged in age from 29 days to 17 years with the median age of three years. Young infants were not characterized more specifically. All patients were treated with routine incision and drainage of the abscesses and did well.

    There are case reports of neonatal cold abscesses of the large folds of the body caused by Staphylococcus. In 2006, three patients were described that had multiple cold abscesses due to Staphylococcus. The locations were the axillary folds, inguinal folds, supraclavicular fossa, submandibular area, and umbilicus. All of these patients were well, without fever, and had none or very slight surrounding inflammation. All grew MSSA (methicillin sensitive Staphylococcus aureus). All were treated with incision and drainage and antibiotics and did well. The mode of dissemination was unclear but could have been direct invasion of the skin in that location or transitory bacteremia that was controlled by the neonate’s immune system. The patient presented above is similar in that she was a full term infant without any systemic findings and without a specific source of infection. She however had MRSA instead of MSSA.

    Questions for Further Discussion
    1. What organisms commonly cause cold abscesses?
    2. What are indications for an immune evaluation? Click here for more information.
    3. What are risk factors for methicillin-resistent Staphylococcal aureus (MRSA)?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Staphylococcal Infections and Abscess.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Huber F, Leaute-Labreze C, Lina G, Sarlangue J, Taieb A, Boralevi F. Multiple neonatal staphylococcal cold abscesses of the large folds. J Eur Acad Dermatol Venereol. 2006 Nov;20(10):1197-200.

    Alt AL, Routh JC, Ashley RA, Boyce TG, Kramer SA. Superficial genitourinary abscesses in children: emergence of methicillin resistant Staphylococcus aureus. J Urol. 2008 Oct;180(4):1472-5.

    Cheng AG, DeDent AC, Schneewind O, Missiakas D. A play in four acts: Staphylococcus aureus abscess formation. Trends Microbiol. 2011 May;19(5):225-32.

    Kharazmi SA, Hirsh DA, Simon HK, Jain S. Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department. Pediatr Emerg Care. 2012 Oct;28(10):1013-6.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital