What Causes Gross Hematuria?

Patient Presentation
A 14-year-old African-american female came to emergency room after having an episode of painless gross hematuria. She had been otherwise well and had bright red urine in the toilet. She had no burning, pruritis, or change in frequency of urination.
She had been drinking, voiding and defecating normally previously.
She was well with no recent illnesses, her last menstrual period was 2 weeks ago and was normal. She denies sexual activity, trauma, and easy bruising or bleeding.
She had no medication or illicit drug use except acetaminophen which she took several days before this episode. She was a cross-country runner and 2 weeks previously began her pre-season training. She had a normal physical examination about 1 month ago.
The past medical history was negative including sickle cell trait or disease or other hemoglobinopathies.
The family history was positive for arthritis and sickle cell trait. There was no kidney disease, hearing problems, urolithiasis, gynecologic or other rheumatologic diseases.
The review of systems was negative.
The pertinent physical exam revealed a healthy female with normal vital signs including a blood pressure of 112/74, and weight and height at 25-50%. She had no edema noted. Skin examination revealed no rashes and a few bruises on her lower legs. There were anterior cervical and inguinal shoddy adenopathy.
Genitourinary examination revealed a Tanner Stage V female with normal genitalia. No evidence of perineal irritation, trauma or blood was seen. Her external rectal examination was also normal. The rest of her examination was normal.
The laboratory evaluation included a complete blood count with a hemoglobin of 13.2 g/dl, hematocrit of 38% , white blood cells of 8.4 1000/mm2 and platelets of 1.75 x 1000/mm2 with a normal smear.
A urinalysis revealed 1.20 specific gravity, 6.5 pH, 4+ blood, 1+ leukocyte esterase and +1 protein on dipstick. Microscopic examination revealed too numerous to count red blood cells, 1-2 white blood cells, and rare fine granular casts.
Her serum calcium, total protein and electrolyes were normal with a blood urea nitrogen of 12 mg/dl and a creatinine of 0.8 mg/dl.
Urine culture and Anti-streptolysin O titre were sent.
The diagnosis of painless gross hematuria of unknown cause was made at that time, but the physician was considering idiopathic, post-infectious glomerulonephritis and exercise as the most likely causes. The patient was to follow-up with her regular physician within the week and sooner if the hematuria returned. She was told that she most likely needed further tests such as a urine collection, additional urinalayses and possibly a renal ultrasound.

Discussion
Hematuria is either gross or microscopic (> 5 red blood cells per high power field on a centrifuged urine sample). It is a common sign and symptom in healthy children and those with underlying renal disease. It is estimated that ~1-2% of school age children have hematuria on at least one urine sample and 0.5% will continue to have it in two of three samples.

Gross hematuria is much less common than microscopic hematuria and most pediatric nephrologists believe it deserves a complete work-up.
What is included in a complete workup varies by the source. Commonly cited laboratory testing includes:

  • Urinalysis
  • Urine culture – infection
  • Blood urea nitrogen and creatinine – renal function
  • Electrolytes – hyperkalemia, acidosis, etc.
  • Complete blood count – hemoglobinopathy, coagulopathy, chronic disease, tumor, hemolytic uremia syndrome, etc.
  • Serum total protein and albumin – nephrotic syndrome
  • C3 and C4 – post infectious glomerulonephritis
  • Anti-streptolysin O titre – post-streptococcal glomerulonephritis
  • Rental ultrasound or CT scan – anatomic abnormalities
  • Timed urine testing – hypercalciuria, proteinuria
  • Antinuclear antibody – immunologic diseases
  • Check other family members – familial hematuria

Learning Point
The most common cause of hematuria (gross or microscopic) is idiopathic.
The differential diagnosis of hematuria can be remembered using the pneumonic SHIRT:

  • S – Stones (Urolithiasis)
  • H – Hematologic abnormalities
    • AV malformations
    • Coagulopathy
    • Sickle cell trait or disease
  • I – Infection, Iatrogenic, Idiopathic, Immunologic
    • Benign familial hematuria, idiopathic
    • Hemorrhagic cystitis, often viral
    • Collagen vascular diseases
    • Epididymitis
    • Exercise
    • Medications
    • Menses
    • Urinary tract infection/Pyelonephritis
    • Vasculitis, i.e. Hemolytic uremic syndrome
  • R – Renal abnormalities
    • Anatomic abnormalities, i.e. Ureteropelvic junction obstruction, renal cysts
    • Alport’s syndrome
    • Nephritis, i.e. Post-streptococcal glomerulonephritis
  • T – Tumor, Trauma
    • Hypercalciuria with or without urolithiasis
    • Foreign body
    • Perineal irritation/meatal irritation
    • Trauma
    • Urinary tract tumor

A recent study reported on 228 patients seen for gross hematuria in a referral pediatric nephrology clinic (see Bergstein, et.al. in To Learn More below). Only one case of urinary tract infection and one tumor was reported. The causes of gross hematuria in this series were:

	No diagnosis                            86
	Hypercalcuria without nephrolithiasis   51
	IgA Nephropathy                         34
	Post-streptococcal glomerulonephritis   21
	Exercise                                 8
	13 other causes with < 3 cases          26

Questions for Further Discussion
1. What is the differential diagnosis for microscopic hematuria?
2. What is the follow-up for a patient with hematuria?
3. What are the indications for a renal biopsy?

Related Cases

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

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

Berkowitz C. Pediatrics A Primary Care Approach. WB Saunders Co. Philadelphia, PA. 1996:265-270.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1663-1665.

Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:262-276, 560-563.

Bergstein J, Leiser J, Andreoli S. The Clinical Significance of Asymptomatic Gross and Microscopic Hematuria in Children. Arch Pediatr Adolesc Med. 2005;159:353-355. Available from the Internet at: http://archpedi.ama-assn.org/cgi/content/full/159/4/353 (cited 06/23/05).

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

Date
August 29, 2005

What Social Services are Available in the Community?

Patient Presentation
A 7-year-old male came to clinic for the first time to establish care and for his health supervision visit.
He moved to the community only 2 weeks ago. Although his mother has already contacted the school district, she needs some help in locating a private speech and language pathologist and other specialists for her son who has autism.
His autism was provisionally diagnosed at ~ 15 months of age and as he has grown older his clinical signs are consistent with this diagnosis.
He has problems making friends, has little social play and has some sterotypical motions/play and language. He is verbal but has problems with production, content and sustaining a conversation. He is very interested in science, but has a restricted range of interests and needs to follow routines.
He has been making progress in a separate special education classroom with integration into a regular classroom for art and music. He has received speech and language services in the classroom and at home. He has a current individualized education plan (IEP) that his mother is happy with.
He has also worked with a behavioral psychologist to improve his interactions with his family members and other children.
The past medical history includes an extensive and appropriate evaluation since his provisional diagnosis. He has not had seizures, or other behavioral problems that have required medication for control. He is otherwise well.
The pertinent physical exam shows a healthy male with normal growth parameters. He has restricted social and verbal interactions. He is able to follow the physician’s instructions and is fairly compliant with the examination.
The diagnosis of autism is confirmed by history, office observation and review of his medical records. The physician offers the mother several options for obtaining speech and language services, behavioral psychology services as well as other options in the community such as specialists in developmental disabilities, developmental play groups and general community family activities.
A social service referral is also offered to the mother.

Discussion
Autism is a social communication disorder of unknown cause that is usually diagnosed in infancy or early childhood. The prevalance is .05 – .15 % with males affected more frequently. The recurrance risk in a family in a subsequent child is 3-5%.
The cause is unknown but underlying brain disease may occasionally be identified including congenital infections, developmemtal brain abnormalities (i.e. microcephaly), metabolic diseases (i.e. phenylketonuria), acquired destructive disorders (i.e. herpes simplex, lead encephalopathy), tumor and some genetic disorders (i.e. tuberous sclerosis).
As most children with these brain diseases are not autistic, it is probably the location of the neuropathology that determines the development of autistic behaviors.

The American Psychiatric Association classifies Autistic Disorder with other similar disorders such as Pervasive Developmental Disorder, Childhood Disintegrative Disorder, Rett’s disorder and others.

The diagnostic criteria for Autistic Disorder are:

A. A total of 6 or more items are needed. At least two items items must be from group 1 and one each from groups 2 and 3:

  • 1. A qualitative impairment in social interaction manifested by:
    • Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
    • Failure to develop peer relationships appropriate to developmental level
    • A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
    • Lack of social or emotional reciprocity
  • 2. Aualitative impairments in communication as manifested by:
    • 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)
    • In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
    • Stereotyped and repetitive use of language or idiosyncratic language
    • Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
  • 3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by:
    • Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
    • Apparently inflexible adherence to specific, nonfunctional routines or rituals
    • Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
    • Persistent preoccupation with parts of objects

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

  • Social interaction
  • Language as used in social communication
  • Symbolic or imaginative play

C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder

As the underlying cause is not known at this time, treatment involves three main areas – educational/behavior management, medications and family support.

Education usually involves special education with a major focus on communication skills. Classrooms are often highly structured with much one-on-one instruction and consistent routines.

Behavior managment is similar with family routines, structured home environment and continued communication skills being emphasized by the family members. Social skills including basic life skills are also taught in the classroom and at home.

Many autistic children have behaviors which are disruptive. Positive reinforcements are used whenever possible and the management plan needs to be consistent between the child’s environments (i.e. school, home, workshop, other, etc.)
Sometimes medications are used for autistic children with other conditions such as seizures or attentional problems. Neuroleptics can be used for severe behavioral upset on a short-term basis.

Family support is very important. Families need to attend to all the members needs and wishes, which is often difficult to balance with the sometimes overwhelming needs of a child with autism. Social workers may provide direct emotional support and/or mental health needs to family members.

Learning Point

Community social services are a key component of helping children and families. Since each community has different social services available, it may be helpful for the family to have a consultation with a social worker or similar community agent.
The goal is to orient the family to the local educational services including the local and intermediate school districts and special educational services provided in the state. The social worker can also orient the family to services such as play groups, child care and parent support groups.
The social worker can also help arrange appointments for medical and ancillary services care such as speech and language therapy or behavioral therapy. Additionally the social worker may help the family with finances, transportation, respite care, legal and other family needs.

Questions for Further Discussion
1. If you are unfamiliar with the local community, how would you locate social services needed for a child with a disability?
2. What are the differences between Autism and Pervasive Developmental Disorder?
3. What are the child’s educational rights under Public Law 94-142, the Education of the Handicapped Act?
4. What should be included in the evaluation of a child for possible Autism?

Related Cases

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

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Asperger’s Syndrome and Autism.

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

Parker S, Zuckerman B. Behavioral and Developmental Pediatrics; a handbook for primary care. Little Brown and Co. Boston, MA. 1995:75-77.

American Psychiatric Association. DSM-IV-TR.
Available from the Internet at http://www.behavenet.com/capsules/disorders/autistic.htm (rev. 2000, cited 6/13/05).

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

Date
August 22, 2005

What are the Clinical Presentations of Intussusception?

Patient Presentation
A 24-month-old male came to the emergency room with a 12 hour history of colicky abdominal pain every 15-20 minutes. He is normal between episodes but has decreased overall intake. He has non-bilious emesis during some of these episodes.
He has had several normal stools which do not contain mucous or blood. The rest of his history is unremarkable.
The pertinent physical exam shows a healthy boy with normal growth parameters. His abdomen shows no distension, nor is tympanetic. He has normal bowel sounds. His abdomen is soft, without pain and with no organomegaly or masses palpable. His genitourinary examination is normal.
At this time the differential diagnosis that was discussed was gastroenteritis versus intussusception.
His radiologic evaluation began with a plain film of his abdomen which showed a non-obstructed gas pattern and a suspicious soft tissue mass in the right lower quadrant.
The ultrasound confirmed the diagnosis of intussusception at the level of the cecum just below the hepatic flexure. During the examination he was noted to draw-up his legs to his abdomen in episodic pain.
The intussusception was easily reduced by air contrast enema. He was admitted for 20 hours of follow-up and was eating and drinking normally at discharge.

Figures

Figure 19 – Supine AP radiograph of the abdomen showing an unremarkable bowel gas pattern and suggests a mass in the right lower quadrant.

Figure 20 – Ultrasound image of the right lower quadrant, obtained transversely through the colon, showing a colonic mass in the ascending colon, the so-called “target sign” representing intussusception.

Figure 21 – Ultrasound image of the right lower quadrant, obtained longitudinally through the colon, showing a colonic mass in the ascending colon, the so-called “pseudo-kidney sign” representing intussusception.

Figure 22 – Fluoroscopic spot film obtained during an air enema showing an intussusception near the hepatic flexure. The “coiled-spring” appearance of the intussusception can be seen.

Discussion
Intussusception happens when one segment of the gastrointestinal tract telescopes into an adjacent segment. The outer receiving segment of bowel is known as the intussuscipiens and the inner inverting segment is known as the intussusceptum.
It occurs most often in children between 2 months to 5 years, with a peak incidence between 4-10 months. Males are more often affected than females by 3:2. It also occurs more often after abdominal operations.
It is the second most common acute abdominal emergency in children after appendicitis.

in adults ~80% have an underlying cause or lead point such as a polyp, tumor, fibrosis, endometriosis, etc.. The cause is usually idiopathic in children (95%) but it is hypothesized that In children is caused by a viral induced edema of the Peyer’s patches in the ileum that serves as a lead point, but this hypothesis has not been confirmed. It commonly occurs near the ileocecal valve.
Unequal longitudinal forces in the bowel then cause the bowel wall to invaginate into the lumen. The intussusceptum is propelled onwards by peristalsis with more bowel becoming involved. Blood vessels and mesentery also become involved with resulting edema, all of which results in intestinal obstruction.
Pressure in the bowel wall increases with impedence of venous outflow and followed by arterial inflow, which again leads to edema and more intestinal obstruction.
Early diagnosis and treatment is necessary to prevent these physiologic changes from progressing to bowel infarction and perforation.
If not treated, intussusception can be fatal in 2-5 days.

In the radiology suite, diagnosis and definitive treatment often occur concurrently.

  • Plain film was first used to diagnose intussusception in 1941. Early on there are few radiological changes seen. With time, soft tissue densities or absence of air in the right upper and lower quadrants can be seen.
    Small bowel dilitation and air fluid levels may also be seen in more advanced cases. If the intussusception has progressed to perforation, then free air may be seen.
    Although plain films are useful, they lack sensitivity and many false negatives can occur.

  • Ultrasound was first used to diagnose intussusception in the 1980s.
    Ultrasound is fast, non-invasive, easy to perform and reproducible, with a high rate of sensitivity and specificity in experienced hands. The classic findings are a doughnut or target sign with concentric rings formed by the intussusceptum.
    The pseudo-kidney sign on longitudinal imaging shows multiple thin parallel stripes of varrying echogenitiy .

  • Barium or air enema is one of the most reliable tests for intussusception in children. It is both diagnositic and therapeutic.
    The pediatrician must work with the radiologist and surgeon, to clinically stabilize the child before the procedure and to plan for treatment of possible problems such as perforation.
    Radiologic reduction should be attempted unless there are signs of peritoneal irritation and is successful in >90% of cases.
    The procedure involves placing a catheter without balloon inflation into the rectum and taping the buttocks together. Barium in introduced via a reservoir suspended ~3 feet over the child.
    Traditionally 3 attempt, each lasting 3 minutes are made to reduce the intussusception.
    Fluoroscopy confirms the intusccusception and monitors the reduction. The intussusception is reduced when there is free flow of barium or air into the terminal ileum.
    Air can be used instead of barium by introducing air up to a pressure of 120 centimeters of water.
    If air is used, the pressure can be maintained for 3 minutes before being released. The air enema reduction is also attempted 3 times before surgery is indicated.
    Some centers will attempt more than 3 times to reduce the intussusception if progress is being made as the patient will be going to the operating room if the enema fails.
    The main risk of the procedure is causing perforation of the bowel or unmasking a pre-existing perforation of bowel and subsequent barium peritonitis or tension pneumoperitoneum. Air has less risk of perforation than barium and is less messy.

  • Computed tomography and magnetic resonance imaging are not often used in children as the diagnosis is often made by ultrasound or enema. These modalities are often used in adults to diagnose the underlying pathology of the intussusception.

After reduction, the children are monitored for several hours for reoccurrance (3-10%) and then are dischaged home. Reoccurence after the peri-reduction period is uncommon.
Children with reoccurence or who are older than the typical age should be evaluated for possible underlying pathology.
Causes in descending order are: Meckel’s diverticulum, polyp, gastrointestinal duplication, hemangioma, suture line, appendix, tumors and ectopic pancreas.

Learning Point
Intussusception has a classic clinical triad of severe, colicky, intermittent abdominal pain, red “currant jelly” stool (because of sloughed intestinal mucosa and blood) and a palpable mass in the right lower quadrant or mid-upper abdomen.
This occurs only in 50% of patients though.
The child will often flex the knees and hips during the pain. The pain often becomes more frequent with time. Stool passage may be normal at first then turn bloody after hours to days. With time, pallor, diaphoresis and apathy in the child ensue.

Presentations of Intussusception include:

  • Abdominal pain – 85%
  • Emesis – 75%
  • Bloody stools – 60%
  • Young infants may present with “intussusception encephalopathy” or lethargy, obtundation, and even coma

Questions for Further Discussion
1. How long after the onset of symptoms should radiologic intervention not be attempted?
2. How much does ultrasound contribute to the management of patients with suspected intussusception?
3. What are teh contraindications to radiologic reduction of intussusception?

Related Cases

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

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Acute Abdominal Pain.

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

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1407-08.

Byrne AT, Geoghegan T, Govender P, Lyburn ID, Colhoun E, Torreggiani WC. The Imaging of Intussusception. Clin Radiol. 2005;60(1):39-46.

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

Date
August 15, 2005

What Kind of Toys Should a Home Have?

Patient Presentation

A 9-month-old male comes to clinic for his health supervision visit. His mother says, “I know that he needs to play but I’m not sure what type of toys to buy him.”The past medical history shows a former 35-week premature infant who is developmentally appropriate for his chronological age.
The pertinent physical exam reveals a healthy infant with normal growth parameters.

The diagnosis of a healthy child is made and appropriate health supervision and anticipatory guidance is given. His mother is told that he will like brightly colored rubber and soft items that he can easily grasp, mouth and throw. Items which make noise or even light up are also appropriate for his age.
She is also told that having him near people will be good for him and that all of his toys should be checked for safety.

Discussion
Play is children’s work. It is the core of their daily existance and is the stimulant for their emotional, social, physical and cognitive growth. Play is children’s scientific approach to acquiring and understanding knowledge. It is one of the most powerful teaching tools for them in the early years.
Learning takes place with every experience. It occurs when the child is ready to understand all by himself just what is happending.
Children play with many kinds of specially produced materials called toys, but toys are only one part of the total environment which also includes people, imagination and real materials.

Play:

  • Uses a child’s energy
  • Creates an environment for imagination
  • Develops physical and mental skills
  • Develops acceptable social traits including individuality
  • Releases emotions
  • Provides pleasure
  • Reaffirms values and attitudes of others in the environment

Remember for child it is the process, not the product that is important. It doesn’t really matter that he used 5 colors of paint that are now all a muddy brown picture. He learned from the painting. Or, it matters that he is matching the colors on the board game, not that he wins the game.
It is the process not the product.

The learning process is simple:

  • The child sees and experiences all sorts of things for the first time
  • He cannot remember or understand them all at once
  • He uses his own time, the people around him, the materials in his reach and his own imagination and creative ability to reproduce and explore the realities he has seen
  • From this comes knowledge – learning through doing and experiencing

    The same principles apply for choosing toys for children with disabilities. The National Lekotek Center has resources for choosing toys for children of all abilities (see To Learn More below).

    Toys by Developmental Stage

    Infants – birth to walking

      Developmentally, the infant:

      • Has a beginning awareness of the world, senses, feelings and other people
      • Believes all things revolve around him – his needs and care
      • Needs to learn to trust in the new environment – his view of the world is built as the child finds security in having his needs met
      • Uses his mouth to explore much of the world
      • Is different from every other child. All children need food, sleep, cuddling, cleaning, talking and interesting stimulation, but each child needs these to different degrees
      Toy types and examples

      • Simple, safe materials
      • Bright colors
      • Moveable or dangly objects – ball, mobile (if out of reach)
      • Rattles and toys which make noise – keys
      • Rubber and soft items – dolls
      • Materials which attract light – unbreakable mirror
      Rationale for the toy types

      • Everything in the surroundings is new and therefore attractive to the child
      • He explores with all his senses
      • He needs to reach out and find what his interactions do to the world – action begets reaction
      • Few purchased toys are needed. The child entertains himself from stimulating forces in the environment
      • Being near and able to see and hear others is important. A crib or seat near people allows the child to have stimulating interactions with people and the simple materials within his limited reach

    Toddler

      Developmentally, the toddler is:

      • Expanding his world through the increased ability to move on his own and get what he wants through actions and speech
      • Still believing often that all things revolve around him
      • Enjoying being around other children but plays mainly by self
      • Finding it difficult to share
      • Easily distracted from one activity to another
      Toy types and examples

      • Push and pull rolling toys
      • Real materials – boxes, spoons, food
      • Bright colors
      • Shapes
      • Climbing and locomotion toys – ride-on wheeled toy
      • Containers – tissue box, bucket, cup
      • Water toys – sprinklers, watering can, funnel
      • Sand toys – funnel, plastic cups, sifters
      • Transportation toys – push truck, fire engine
      • Books
      • Animals and dolls
      • Musical and rhythm toys – rattle, tamborine, whistle
      • Art materials
      • Dramatic play – dress up clothes
      • Sensory objects – shaving cream, pinecone, snow
      Rationale for the toy types

      • Usually he explores the world without fear
      • Still he puts many things in mouth
      • Developing large muscle skills rapidly
      • Materials should be geared to his size because he will try everything
      • He gathers everything so containers and items to collect and carry from one location to another are important
      • Unlimited curiosity
      • Imitates much of what he sees and will reproduce it with materials on hand
      • May need several of the same or similar items available as he has problems sharing

    Preschooler

      Developmentally, the preschooler is

      • Rapidly developing in all areas including physical, social, emotional and cognitive
      • Seeing things in only one way
      • Finding it hard to carry concepts from one experience to another
      • Exploring the world with others than just by himself
      • Molding his individuality
      • Learning differences are important
      • Learning by doing or seeing rather than just hearing
      Toy types and examples

      • Indoor-outdoor physical equipment – swing, ball
      • Building and construction materials – blocks
      • Locomotion and transportation
      • Books
      • Compact discs, tapes, movies
      • Animals and dolls
      • Music and rhythm equipment
      • Simple board games – Candy Land&reg, Uncle Wiggly&reg, HI HO Cherry-O!&reg
      • Manipulative materials – shells, stickers, coins, paperclips
      • Special interest items
      • Sensory materials
      • Materials for conceptual stimulation of math, art, science and language – cards, magnetic letters or numbers
      • Dramatic play
      Rationale for the toy types

      • Continued development of large and small muscles
      • Continued curiosity of the world
      • Can struggle with all the new information, but learns its meaning through “playing it” into reality
      • Experiments with language
      • Familiar objects continue to be familiar play toys
      • Unstructured materials encourage experimentation; structured materials reinforce necessary concepts
      • Future interests are taking form
      • Values and attitudes of adults are important
      • Emotions are developing, toys that help their expression are necessary

    School Ager

      Developmentally, the school ager is:

      • Discovering the causes and mechanisms of the world through fantasy
      • Further defining specific interests
      • Having peers take on new meaning and importance
      • Having rules and social acceptance mark his life
      • Gaining competency through his experiences, abilities and knowledge
      • Having more conflicts arise between peer confirmity and individuality
      Toy types and examples

      • Games
      • Sports equipment
      • Musical instruments
      • Books, magazines, newspapers
      • Radios, compact discs, tapes
      • Arts and crafts
      • Working replicas of real things – play make-up
      • Specific experimental materials for science, math, language
      • Models or materials that can be built – model cars
      Rationale for the toy types

      • Child is developing a strong sense of realism and self-criticism and needs direction and constructive choices
      • Understands concepts and begins to apply their meaning to new materials and skills
      • Group interaction and acceptance of rules to make things ‘work’ captures his interests
      • Wants to be independent and responsible
      • More complex materials that develop and perfect skills are valuable
      • New stimulation may be needed to keep interests alive
      • Many toys are no longer artifical replicas but are real materials signifiying interests and the child’s personality

    Learning Point
    Toys do not have to be expensive. Some of the best items are free because they are packaging or would be discarded from the home.

    Toys should be safe for the child at each age and developmental level, and play should be appropraitely supervised, especially anything with small parts or is sharp. Children can and should learn to take care of their toys and help the family by picking up their toys with supervision and the help of adults and older children.

    Children will be messy when they are playing and need to be allowed to be messy. Putting an inexpensive shower curtain under a work area and using an old shirt as a cover-up over the child’s clothes can keep the mess to a minimum. The shower curtain is also a good place for older children to play on with small toys as the curtain can be easily folded up if a small child comes into the room.

    Suggestions for an Art/Writing Box

    • Paper for writing/drawing- all colors, sizes, textures
    • Paper for cutting up – magazines, cardboard, greeting cards
    • Paper for mimicking – envelopes, forms, checkbook registers
    • Writing instruments – markers, crayons, pencils, pens, window markers
    • Paint – fingerpaint, watercolors, school paint
    • Tape
    • Glue, gluesticks or paste
    • Scissors

    Suggestions for an “Art Center” or the “Big Box of Junk” as many parents call it

    • Blocks – wooden, plastic, boxes
    • Cans – coffee cans, oatmeal boxes, juice cans
    • Foil
    • Foil pie tins
    • Kitchen utensils – egg beaters, measuring spoons, metal cups, wood spoons, cookie cutters
    • Old clothes and hats
    • Keys
    • Plastic bottles and cups
    • Cotton tippped swabs
    • Cotton balls
    • Ribbons
    • Thread spools
    • Wood scraps
    • Buttons
    • Beads
    • Yarn
    • String
    • Fabric scraps
    • Bottle caps
    • Corks
    • Plastic garden containers
    • Cardboard tubes – from toilet paper, paper towels

    Other manipulatives for children to play with

    • Shaving cream
    • Pipe cleaners
    • Pom Poms
    • Stamping – stamp pads, bingo markers
    • Straws
    • Popsicle sticks
    • Napkins
    • Food – gelatin, pudding, macaroni, small marshmallows
    • Nature items – rocks, sticks, pinecones, leaves, flowers, feathers, nut shells, sand, water, seeds
    • Toothpicks
    • Paperclips
    • Coins

    Questions for Further Discussion
    1. Where can parents get information about toy safety recalls?
    2. What should parents consider when allowing children to play with computer games?
    3. What is the American Academy of Pediatrics recommendation for the ages and amount of time children should view television and/or use computers and videogames?

    Related Cases

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

    Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Toy Safety.

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

    Hauser P. Toys a Guide for Selection. Child Care Coordinating Council of Detroit, Michigan (Handout, no date available).

    National Lekotek Center. Top 10 Tips for Choosing Toys.
    Available from the Internet at http://www.lekotek.org/resources/informationontoys/tentips.html (cited 6/7/05).

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

    Date
    August 8, 2005