What Causes Different Colored Urine?

Patient Presentation
A 9-year-old boy is brought to the clinic because of brightly colored orange urine that he noticed this morning when he urinated after sleeping.
He has had one other urination this morning that was also bright orange in color. He had no pain, frequency or urgency. His mother states that he has been drinking well and feeling well.
He was started on Rifampin yesterday by a local public health official after the child seated next to him at school each day was diagnosed with Neisseria meningititis.
The family history and review of systems are negative including no rash, fever, headache or trauma.
The pertinent physical exam shows a normally developed child with normal vital signs and a negative examination.
The laboratory evaluation showed a bright orange colored urine that had a pH of 6.5, specific gravity of 1.015 with 0-1 white blood cells and was otherwise normal.
The diagnosis of rifampin colored urine was made and the patient and family was reassured.
They were also counseled about symptoms to watch for and the need to seek medical care promptly because of the Neisseriaexposure.

Discussion
Neisseria meningitis is highly invasive with an attack rate for household contacts of 500-800 times higher than the general population.
Therefore, close contacts should ideally receive chemoprophylaxis within 24 hours of diagnosis of the primary case.
High risk contacts include:

  • Household contacts especially young children
  • Child care or nursery school contacts within the past 7 days
  • Direct exposure to secretions
  • Mouth to mouth resuscitation
  • Frequently slept or ate in same dwelling
  • Passengers seated directly next to the index case for more than 8 hours on airline flights

Recommendations for expanded immunization coverage for Neisseria meningitis were made in 2005.

Most urine color changes are harmless.
They often are due to eating particular food or drugs.
Usually parents can be reassurred that once the child stops ingesting the offending agent, the urine will return to normal color in a short time.
Sometimes infections or other medical problems cause color changes. Some urine color changes occur over time as the urine sits and is exposed to oxygen.

Learning Point
The causes of urine color changes include:

  • Red/Burgundy Urine
    • Old urine
    • Hemoglobin
    • Red blood cells
    • Urates
    • Phenolphthalein
    • Beets
    • Blackberries
    • Food coloring
    • Serratia marcescens infection
  • Orange Urine
    • Bile
    • Urates
    • Warfarin
    • Rifampin
    • Rifabutin
    • Phenzopyridine
    • Congo red dye
  • Yellow Urine
    • Dehydration
  • Deep Yellow/Yellow Brown Urine
    • Bile
    • Bilirubin
    • Anti-malarial drugs
    • Cascara
    • Metronidazole
    • Nitrofurantoin
    • Sulfasalazine
    • Riboflavin
    • Carotene-containing foods
    • B-complex vitamins
  • Green/Blue Urine
    • Biliverdin
    • Hypercalcemia
    • Blue Diaper Syndrome
    • Amitriptyline
    • Triamterene
    • Prochloperazine
    • Doxorubicin
    • Indomethacin
    • Pseudomonas infection
    • Indigo blue dye
    • Methylene blue dye
    • Copper clasp on diaper holder
  • Black Urine
    • Old blood
    • Hemogentistic urine
    • Melanin
    • Myoglobin
    • Hemosiderin
    • Tyrosinosis
    • Melanosis
    • Quinine
    • Nitrofurantoin
    • Metronidazole
    • Cascara
    • Senna
    • Rhubarb

Questions for Further Discussion
1. When should health care professionals receive chemoprophylaxis for Neisseria meningitis?

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 MedlinePlus for this topic: Kidney Diseases
and at Pediatric Common Questions, Quick Answers for this topic: Stool and Urine Color Changes

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

Illingworth RS. Common Symptoms of Disease in
Children. Blackwell Scientific Publications: Oxford. 1998. pp. 95, 97.

Schiff D, Shelov SP. American
Academy of Pediatrics. The Official, Complete Home Reference:
Guide to Your Child’s Symptoms. Villard: New York. 1997. pp. 587.

Sheldon SH Levy HB. Pediatric
Differential Diagnosis, Second Edition. Raven Press: New
York. 1985. pp. 22, 156.

American Academy of Pediatrics. Meningococcal Infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;452-460.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

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

    Date
    August 28, 2006

  • How Do You Treat A Pilonidal Cyst?

    Patient Presentation
    A 15-year-old female came to the emergency room with a 2 day history of a bump on her back just above her buttocks that 1 day ago became extremely swollen, red and exquisitely painful.
    She complained of a small amount of pus coming from the area on her underwear. She had taken some ibuprofen with no relief and was having difficulty sitting or walking because of the intense pain.
    The past medical history and family history were negative.
    The review of systems was negative for fever, chills, rashes, or bowel or bladder problems.
    The pertinent physical exam showed a teenager in moderate distress secondary to pain. She was afebrile and her other vital signs were normal.
    Midline at the top of the gluteal cleft was a 4×5 centimeter area of swelling with intense redness. There was exquisite tenderness and a fluctuant mass. A small amount of purulent discharge was expressed from a central punctum in the mass.
    There were no other dermatological changes including hair whorls or color variations. The spine was non-tender in other areas. The anus was patent with no abnormalities externally. She had a normal neurological examination in the lower extremities.
    The rest of her examination was normal.
    The laboratory evaluation included a culture of the discharge.
    The diagnosis of a pilonidal cyst with abscess formation was made. Under conscious sedation with nitrous oxide and local pain control, the fluctuant mass was incised, drained, and packed.
    She had some pain relief following the procedure. The patient was placed on oral cephalexin and codeine.
    Although arrangements were made to have her follow-up in the surgery clinic in 2 days, she was told to return to the emergency room or see her regular doctor if she had any fever, spreading of the swelling, or problems with bowel, bladder, her lower extremities or other neurological problems.

    Discussion
    The term pilonidal was coined in 1880 by Hodge. “Pilo” means hair and “nidal” means nest which describes this nest of hair.
    There is a spectrum of pilonidal disease which ranges from asymptomatic hair with cysts and sinuses to large abscess in the sacrococcygeal area.
    The cause is not entirely clear and initially was believed to be congenital remnants of neural crest tissue. Today, it appears that it is an acquired problem where hair/debris enters the skin and hair follicles causing an inflammatory reaction and edema. There is then occlusion of the entry portal and building up of material in the hair follicle and a foreign body reaction.
    This reaction then forms multiple microabscess in the subcutaneous tissue. Trauma causes in more microabscessses with sinus tract and abscess formation.
    This theory is consistent with the findings of pilonidal cyst formation in other places such as hands of barbers’ and sheepsheerers’, and that it can be a repetitive problem (up to 40% of patients).
    During World War II, so many serviceman had pilonidal disease that it was called “jeep driver’s disease” as described by Dr. Louis Buie in 1944.

    Only 50-70% of pilonidal cysts contain hair at surgery. It is more common in adolescent and young males. Other risk factors include hirsute people, hair in the gluteal cleft, sitting occupations, obesity, and caucasian race.

    Presentation includes asymptomatic tracts noticed by the patient or health care provider, episodic or chronic minor pain or irritation, acute pain and irritation with or without drainage or abscess formation.

    The most commonly cultured pathogens from abscesses differ by study and include anaerobic cocci and Staphlococcus aureus.

    The differential diagnosis commonly includes:

    • Congenital abnormalities
    • Inclusion dermoid
    • Presacral sinus or dimple
    • Pyoderma gangrenosum
    • Sacrococcygeal sinus

    Learning Point
    Treatment for pilonidal disease depends on the patient’s presentation.
    Asymptomic cysts and tracts should be referred to a surgeon for evaluation and removing the debris.
    Acute abscess formation requires initial incision and drainage removing all the debris and hair, and packing of the wound. Surgical followup within 1 week should be arranged.
    Hygiene of the area is paramount and weekly shaving of the local area can decrease recurrance.

    The type of definitive surgical therapy for recurrent disease is controversial. Treatments include marsupialization, z-plasty, and various flap procedures.
    One review study of 16-35 year olds including men and women showed showed excision techniques to be evaluated as superior because they had a shorter period to return to work, but no differences in terms of wound infection or recurrance when compared to marsupialization and flap procedures.
    A recent randomized-controlled trial of different excision techniques showed limited excision of the pilonidal sinus to be the best surgical option when compared to two different wide-resection techniques.

    Questions for Further Discussion
    1. What are the complications of pilonidal disease?

    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 MedlinePlus for this topic: Tailbone Disorders.

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

    Ringelheim R, Silverberg MA. Pilonidal Cyst and Sinus. eMedicine.
    Available from the Internet at http://www.emedicine.com/emerg/topic771.htm (rev. 06/06/2006, cited 8/7/2006).

    Aydede H, Erhan Y, Sakarya A, Kumkumoglu Y. Comparison of three methods in surgical treatment of pilonidal disease. ANZ J Surg. 2001 Jun;71(6):362-4.
    Available from the Internet at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11409022&query_hl=2&itool=pubmed_docsum (cited 8/7/2006).

    Mohamed HA, Kadry I, Adly S. Comparison between three therapeutic modalities for non-complicated pilonidal sinus disease. Surgeon. 2005 Apr;3(2):73-7. Available from the Internet at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15861940 (cited 8/7/2006).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice

    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

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

    Date
    August 21, 2006

  • What are the Indications for a Referral to Speech Therapy?

    Patient Presentation
    A 40 month-old male came to clinic for his health maintenance examination. His parents had no concerns.
    During the examination, the experienced physician noted that it was extremely difficult to understand the boy’s words. The child could follow simple instructions, and he made lots of sounds that had good tone and inflection like a sentence. He also took turns in the conversation and used non-verbal communication with facial expressions and gesturing.
    His words did not appear consistent in that either initial or ending sounds were dropped, nor were particular sounds consistently difficult to understand. The physician estimated that she could understand only 30-40% of what he said. The parents also could not translate his words, but said they just understood what he wanted.
    The boy’s uncle that he doesn’t see very often had noted to the parents previously that he had a hard time understanding the boy.
    The boy’s aunt babysits him and has said that sometimes she has a hard time understanding him.
    The past medical history reveals 2 episodes of otitis media.
    The family history is negative for speech or hearing problems, and developmental or learning problems.
    The review of systems is negative.
    The pertinent physical exam reveals a happy, developmentally-appropriate male with growth parameters in the 25%. He has grossly normal hearing. His examination is otherwise negative.
    The diagnosis of probable speech delay was made and the patient was referred for a hearing test and speech and language evaluation. In the meantime, the family was instructed to have a language-rich environment with lots of conversation about daily activities. They were to encourage him to use his words more than gestures, but also not to force him to use his words and become frustrated.

    Discussion
    Speech and language acquisition and use is a complex process. Speech production by one person must be heard, processesd and then responded to by another person.
    Speech and language problems are grossly categorized as receptive problems (i.e. receiving the information) or expressive problems (i.e. processing and responding to the information).
    In very simplistic terms, there can therefore be a problem with the auditory system, the central nervous system, or the oral motor system.
    In reality, many more systems (e.g. respiratory for speech production) are involved and each system must coordinate with the others to have appropriate speech and language acquisition and use.

    Developmentally, children learn to make sounds and later words and phrases in a fairly characteristic developmental pattern. Vowels sounds first (i.e. o, a), then consonant sounds next (e.g. m, b,), with individual vowel consonant syllables appearing (e.g. ma, ba), followed by vowel-consonant syllable repetitions (e.g. ma-ma-ma-ma), then single words, and finally phrases/sentences.
    A general rule is that for each year of age a child should add 1 word to the number of words they have in the sentence they are making (i.e. 1 word sentence at age 2, 2 word sentence at age 2, 3 word sentence at age 3, etc.) They also should gain ~25% more intelligibility with each year (i.e. 25% of their speech is intelligible at age 1, 50% is intelligible at age 2, 75% intelligible at age 3, etc.).

    Children can have normal disfluencies such as repeating initial sounds (e.g. li-li-like this) or whole words (e.g. this-this-this is an animal) especially when they are excited, tired, or talking to inattentive listeners. They also have occasional pauses, hesitations or fill in sounds (e.g. um or uh). Disfluencies should not be consistently present after the age of 7 years.

    Screening tests can be administered in the health providers office including the Denver Developmental Screening Test, Early Language Milestone and CLAM (Child Language Ability Measures).

    Learning Point
    Indications for referral to a speech and language pathologist includes:

    • Parental concerns, especially if there is a family history of speech, hearing, or other developmental problems
    • Other caregiver concerns, particularly if more than one caregiver is concerned
    • Formal screening tests below age norms, particularly if the child has other developmental delays or if both expressive and receptive language appear affected
    • Speech sounds are more than 1 year late in appearing by the normal developmental sequence
    • Child is frustrated, has poor self-esteem or is being teased/shunned by other children or adults because of the possible speech and language problem
    • No speech production or does not follow simple directions by age 18 months
    • Speech is frequently unintelligible after 2.5 years
    • No sentences by age 3 years
    • Child is distorting, omitting or substituting any speech sound after age 7 years
    • There are unusual confusions, or reversals in connected speech
    • Many omissions of initial consonant sounds at any age (e.g. “ish” for fish, ‘owl’ for bowl)
    • Child uses mostly vowel sounds
    • Word endings are consistently dropped
    • Child’s speech has abnormal rhythm, rate or inflection or is noticeably non-fluent
    • Sentence structure is noticeably faulty
    • Voice is monotone, extremely loud, largely inaudible or of poor quality
    • Voice pitch is not appropriate to child’s age or sex
    • Voice is noticeably hypernasal or has lack of nasal resonance

    Questions for Further Discussion
    1. Why should a hearing test be performed if a speech and language problem is suspected?
    2. How do hearing impaired children present?
    3. How to language impaired children present?

    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 MEDLINEplus for this topic: Speech and Communication Disorders.

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

    Merrifield B. “Common Speech Problems – What is Normal?” Lecture notes. 1997.

    Grizzle KL, Simms MD. Early language development and language learning disabilities. Pediatr Rev. 2005 Aug;26(8):274-83. Available from the Internet at: http://pedsinreview.aappublications.org/cgi/content/full/26/8/274 (cited 7/19/06).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

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

    Sarah A. Michaels, MA, CCC-SLP
    Speech and Language Pathologist

    Date
    August 14, 2006

  • What are the Advantages and Disadvantages of Different Types of Child Care?

    Patient Presentation
    A 27-year-old female came to clinic with her husband at 36 weeks gestation for a prenatal appointment. This was their first pregancy and there were no problems to date.
    The parents had several questions regarding immunizations, car seats and circumcision. Their biggest concern was appropriate child care when the mother returned to work part-time after the delivery.
    The diagnosis of a healthy near-term pregnancy was made. The physician talked about some of the potential options based upon the family’s description of their needs, gave the family a handout which included an information prescription for authoritative information on the Internet about child care options, and gave them the phone number for the local child care resource and referral agency.
    After delivery, the family returned for health maintenance visits and reported that the child care resource and referral agency had been very helpful in locating a family-based child care placement for their daughter. Over time, the family continued to be very happy and expressed continued confidence with their daughter’s caregiver.

    Discussion
    There are 5 steps to choosing quality child care. The steps may seem simple but the decision is a difficult one:

    • Starting early – finding the right care takes time
    • Researching and calling caregivers
      • Contact the experts at the local child care resource and referral center. They can help a parent to learn more about child care options and what may be right for the child and family.
      • The resource and referral agency can also provide lists of accredited child care centers, family care caregivers, financial assistance programs, emergency child care options, sick child care options, etc.
      • The resource and referral agency can also offer information about accreditation and licensing requirements, where the parent can get information about complaints and/or violations, etc.

    • Visiting and asking questions
      • The location and the caregivers should be visited and talked with.
      • Some key indicators of quality include:
        • Adult to child ratios or how many children does each adult take care of. The fewer the children, the better. The younger the child is the fewer number of children an adult should take care of.
          For babies it should be no more than 1:4, but for four year olds it can be 1:10.

        • Group size or how many children are in the group. Again, the smaller the group the better. Compare a group of 10 children with 2 adults, versus 25 children with 5 adults.
        • Caregiver qualifications – The parent should inquire about the caregiver’s training and education. What training and classes have they attended or are attending? Do they have first aid and CPR training?
          Obviously a caregiver with special training or education for young children will be better able to help the child learn. Ongoing education also helps to support the caregiver and they can receive new information.

        • Turnover – It is a reality of the child care industry that there is higher turnover than in some other businesses. It is best to stay with one caregiver for at least 1 year if possible. Ask about ways that the business is structured to decrease the turnover and help the children
          in transitioning from one care caregiver to another.

        • Licensing and accreditation – The parents should inquire if the caregiver and/or the business has been licensed and/or accredited by the state government and/or national organization. Caregivers that are voluntarily accredited often must meet higher standards than most state licensing requirements.

    • Making a choice
      • Parents make this choice over and over each day as they leave their child and come back to thir child. It is not a one time choice.
      • Parents need to remain flexible because what may be the perfect choice now may not be the perfect choice in the future as circumstances change, (e.g. caregiver goes out of business, family member moves to town, new center opens at work, etc.)

    • Staying involved
      • Parents must continue to communicate with their caregiver through talking, written notes, e-mail, phone calls, parent-caregiver meetings, etc.
      • Parents can stay involved by volunteering in the classroom, going to special events such as birthday parties, coming early and visiting/observing their child, the other children and the caregivers, etc.
      • Parents can provide curriculular materials and expertise such as loaning books, talking about their careers/hobbies, providing ingredients for simple cooking activities, etc.
      • Parents can remember to say thank you to their caregiver for the good and often difficult job they do in helping to care for and teach their child.

    Learning Point

    Types of child care generally fall into four categories:

    Center-based child care – care for children in groups, generally in a location seperate from a home and operated as a business

    • Advantages

      • Larger groups – children can learn from more than one child, and learn in larger group situations.
      • Multiple caregivers – children can learn from more than one person, more caregivers are available to the child, caregivers can help support each other.
      • Licensing – done by state agencies, potentially safer but does not insure quality. Regulation does set minimum health, safety and caregiver training standards that must be maintained. Centers are inspected yearly.
      • Curriculum – more options are potentially available because more resources are available such as staff, toys, equipment, etc.
      • Cost – potentially less expensive especially for a single child because more families support the business.
      • Dependability – this is a business and therefore the hours, days of operation, policies etc. are known in advance and can be depended on by the parents.
      • Reputation – this is a business and therefore people in the community have had experience with the business and can give their point of view to parents.
    • Disadvantages

      • Larger groups – there are more children to take care of.
      • Multiple caregivers – there may not be one specific caregiver for an individual child or the usual caregiver may not be available.
      • Cost – potentially more expensive, especially if there are multiple children.
      • Operating hours/Flexibility – the business operating hours may not work with the parental work hours, there may be no flexibility in picking a child up late, or for occasional care, etc.
      • Sick children – sick children are generally excluded from center-based child care.

    Family-based child care – care for children in smaller groups, generally located in the caregiver’s home and operated as a small business

    • Advantages

      • Smaller groups – there are fewer children to take care of.
      • Single or small number of caregivers – fewer caregivers to take care of the child, may increase consistency.
      • Licensing – possibly licensed by state agencies.
      • Cost – potentially less expensive because there are fewer business costs.
      • Operating hours/Flexibility – potentially hours and days of operation can be tailored to parents work schedule.
      • Sick children – may be available for occasional child care and for emergencies such as sick children.
      • Reputation – this is a business and therefore people in the community have had experience with the business and can give their point of view to parents.
    • Disadvantages

      • Smaller groups – not as many children to interact with and learn from.
      • Single or small number of caregivers – fewer caregivers to provide the care, less support for the caregiver.
      • Licensing – caregivers may be required to be licensed but often there is less oversight for continued compliance, and fewer incentives for exceeding the minimum standards.
      • Curriculum – may not be as diverse or have as many opportunities because of fewer resources available.
      • Dependability – potentially the caregiver can stop providing care with no or little advanced notice.

    In-home child care – provides care in the child’s home. This includes live-in or live-out caregivers such as nannys and housekeepers

    • Advantages

      • Smaller groups – generally only the siblings are cared for.
      • Single caregiver- often a single care caregiver which may increase consistency.
      • Cost – can be less expensive, especially if there is more than one child.
      • Operating hours/Flexibility – this is often cited as a major advantage for parents using this type of child care.
      • Other caregiver duties – the caregiver may also provide other services such as housekeeping, errands, transporting children, etc.
      • Confidence – parents often feel comfortable with care being provided in their own home.
    • Disadvantages

      • Smaller groups – not as many children to interact with and learn from
      • Single caregiver – single caregiver to provide the care and may not be available, less support for the caregiver.
      • Licensing – generally not licensed.
      • Cost – can be more expensive for fewer children.
      • Curriculum – may not be as diverse or have as many opportunities because of fewer resources available.
      • Dependability – potentially the caregiver can stop providing care with no or little advanced notice.

    Relatives, Friends and Neighbors – care provided in the child’s or caregiver home by a caregiver with a familial relationship

    • Advantages

      • Smaller groups – generally only the siblings or other relatives are cared for.
      • Single or small number of caregivers – often a single caregiver which may increase consistency.
      • Cost – can be less expensive, especially if there is more than one child.
      • Dependability – caregivers with close relationships can often provide more dependable care.
      • Reputation – parents know the caregiver usually very closely.
      • Operating hours/Flexibility – this is often cited as a major advantage for parents using this type of child care.
      • Sick children – may be available for occasional child care and for emergencies such as sick children.
    • Disadvantages

      • Smaller groups – not as many children to interact with and learn from
      • Single or small number of caregivers – single caregiver to provide the care and may not be available, less support for the caregiver, may be difficult to resolve differences because of the close relationship with the caregiver.
      • Licensing – generally not licensed.
      • Curriculum – may not be as diverse or have as many opportunities because of fewer resources available.

    Questions for Further Discussion
    1. What are the appropriate adult to child ratios for different ages of children?
    2. List some of the national organizations that voluntarily accredit child care centers?
    3. Where can a parent find their local child care resource and referral agency?

    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 MEDLINEplus for this topic: Child Care
    and at Pediatric Common Questions, Quick Answers for this topic: Finding the Right Child Care

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

    Child Care Aware. Steps to Choosing Quality Child Care.
    Available from the Internet at http://www.childcareaware.org/en/5steps/ (cited 7/17/2006).

    National Child Care Information Center. Available from the Internet at http://nccic.org/ (cited 7/17/2006).

    National Network for Child Care. Available from the Internet at http://www.nncc.org/homepage.html (cited 7/17/2006).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge

    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

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

    Date
    August 7, 2006