What Can I Use for Her Cold?

Patient Presentation
A 2-year-old female comes to clinic after 3 days of clear rhinorrhea. She has been have some coughing and sneezing that her mother says is worse during sleep. She has had a “low grade fever” of 100 degrees Fahrenheit.
She has had no sore throat, ear pain, or rash. She has been drinking normally but has been taking less solid food. She is not playing as much, taking longer naps and wants to be held more. Mother denies seeing her put objects in her nose.
She is in daycare and has had a cold in the past but the coughing is bothering the mother.
The past medical history and family history are negative.
The pertinent physical exam shows an alert female who is afebrile and has a respiratory rate of 24.
HEENT reveals copious clear rhinorrhea anteriorly and in the posterior pharynx. Ears and throat are normal. Lungs are clear.
The diagnosis of an acute upper respiratory infection was made. The mother was counseled about the natural history, and told to give lots of fluids including trying chicken soup.

Discussion
Upper respiratory tract infections (i.e. URIs or common colds) and their potential remedies have been around for centuries.
Adults have about 2 – 4 colds per yearn and children probably more especially those in childcare.
There are at least 200 different viruses identified as causing URIs, most commonly, rhinovirus and coronaviruses but also adenoviruses, enteroviruses, parainfluenza viruses and respiratory syncytial viruses.
Clinically these viruses cause nasal congestion, nasal discharge, post nasal drip. throat clearing and sneezing. Symptoms are usually self-limited lasting 5-7 days.

Many different treatments have been offered over time. Maimonides the Egyptian, Jewish physician and philosopher recommended chicken soup in the 12th century.

Learning Point
Because the numerous studies involving different medications being compared in different populations, it can be difficult to sort out what the research studies show. This is especially true for children whom are often not included in the studies.
Below are recommendations from the Cochrane Collaboration (CC), American College of Chest Physicians (CC) and the American Academy of Pediatrics (AAP).

URI Prevention

  • Echinacea – Does not prevent URIs (CC)
  • Vitamin C – May prevent getting an URI in people exposed to heavy physical or cold stress (i.e. marathon runners and skiers) (CC)

URI Treatment

  • Antibiotics – There is no benefit to using antibiotics. (CC, AACP)
  • Antihistamines – No evidence of significant effects in children or adults using antihistamines alone. (CC, AACP)
  • Decongestants – Single doses may be moderately effective in adults. Repeated doses are not significantly better than placebo. There is no data for children. (CC, they are not recommended by AACP)
  • Antihistamine/Decongestants combinations – Not effective in “small” children, but may cause some general improvement in symptoms in “older children” and adults. (CC) Brompheniramine and sustained-released pseudo-ephedrine are recommended by the AACP but no specific age range is given.
  • Cough suppressants – Cough suppressants (peripheral or central) are not recommended for adults or children. (AACP, AAP) Ipratropium bromide is the only inhaled cough suppressant recommended by the AACP but no specific age range is given.
  • Chicken Soup – Inhibits neutrophil chemotaxis in vitro (see study below)
  • Echinacea – In some preparations might be effective if taken early in adults. There is no data for children. (CC)
  • Heated humidified air (i.e. steam) – Not enough evidence to show if it helps or hinders URI symptoms There is no data for children. (CC) Some people recommend cold humidity but no recommendations are given from these 3 groups.
  • Vitamin C – Taken at onset of cold symptoms shows no consistent effect on duration or severity of symptoms. There is no data for children. (CC)
  • Zinc – Data is conflicting (CC) and it is not recommended by the AACP

Questions for Further Discussion
1. Does green rhinorrhea mean there is a bacterial supra-infection on top of the URI?
2. What are the definitions of acute, sub-acute and chronic cough?

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 these topics: Common Cold and Nose Disorders
and at Pediatric Common Questions, Quick Answers for this topic: Cold/Upper Respiratory Tract Infection

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

American Academy of Pediatrics. Committee on Drugs. Use of Codeine- and Dextromethorphan-Containing Cough Remedies in Children
Pediatrics. 1997;99;918-920.

American College of Chest Physicians. Evidence-Based Clinical Practice Guidelines. Diagnosis and Management of Cough Executive Summary. Chest. 2006;129:1S-23S.

Rennard BO. Ertl RF. Gossman GL. Robbins RA. Rennard SI. Chicken Soup Inhibits Neutrophil Chemotaxis in Vitro. Chest. 2000;118:1150-1157.

Singh M. Heated, Humidified Air for the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab001728.html (cited 8/31/06)

De Sutter AIM, Lemiengre M, Campbell H. Antihistamines for the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab001267.html (cited 8/31/06)

Taverner D, Latte J, Draper M. Nasal Decongestants for the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab001953.html (cited 8/31/06)

Linde K, Barrett B, Wˆlkart K, Bauer R, Melchart D. Echinacea for Preventing and Treatment the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab000530.html (cited 8/31/06)

Douglas RM, Hemila H, Chalker E, D’Souza RRD, Treacy B. Vitamin C for Preventing and Treatment the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab000980.html (cited 8/31/06)

Arroll B, Kenealy T. Antibiotics for the Common Cold and Acute Purulant Rhinitis. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab000247.html (cited 8/31/06)

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.

  • 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.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Systems Based Practice

    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

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

    Date
    September 25, 2006

  • What Should I Do When I'm Called To See A Drug-Exposed Child?

    Patient Presentation
    A 16-month-old male was brought to the emergency room after he was found in a home that a law enforcement officer had been called to about a domestic dispute.
    The officer with the child stated that other officers had found the child unattended in a bedroom.
    There was drug paraphernalia in another room, and equipment for possible drug manufacturing in the basement.
    The parents were currently being held by law enforcement officers.
    The child was brought in for an emergency evaluation and social services has been contacted and are coming to the emergency room.
    There were no other children or adults on the premises, and no other information was available.
    The pertinent physical exam showed a somewhat frightened male who said few words and was appropriately resistant during the examination.
    He was dressed in a long-sleeved shirt and jeans appropriate for the weather which smelled of tobacco smoke.
    His weight, height and head circumference were ~75-90% for age and his vital signs were appropriate for his age.
    Pulse oximetry was 98% on room air. Pupils were 3-4 mm, equal, round and reactive to light.
    Skin examination revealed a few different colored bruises on his shins, and two linear scratches on the dorsal surface of his left forearm.
    His lungs were clear. His heart showed no murmurs and his neurological examination was normal.

    The work-up included liver function tests, electrolytes, BUN, creatinine, complete blood count, and urinalysis. All were normal except for a hematocrit of 32%.
    A skeletal survey was negative for fractures as was his eye examination by ophthalmology. Urine toxicology and a hair sample for illicit substances were sent to the pathology laboratory using chain of evidence procedures.
    A lead level, urine and hair screening for illicit drugs were pending at discharge.
    The child was also decontamined using soap and water and the clothes were given to the officer maintaining the chain of evidence.
    The diagnosis of a child with potential exposure to illicit substances and neglect was made. Iron-deficiency anemia was diagnosed and the patient was begun on iron supplementation.
    The patient’s clinical course at a one week follow-up appointment with the child maltreatment (child abuse) service showed that the child was in and would continue in emergency foster care for the foreseeable future.
    The social worker said that the parents continued to be jailed on charges of manufacturing methamphetamine. The child had been adapting fairly well to the foster care family.
    The follow-up on the laboratory testing showed a lead level of <10 mg/dl, and urine toxicology was positive for methamphetamine. The hair sample was pending.
    The social worker said that his mother stated that he had received some care and vaccinations before his first birthday but no other specific information was available. The social worker would try to obtain medical records.
    He was given one dose of Diphtheria-Tetanus-Acellular Pertussis, Inactivated Polio Virus, Haemophilus influenza B, Hepatitis B, Measles-Mumps-Rubella, Varicella, and Pneumococcal conjugate vaccines.
    The child was referred for a full developmental, mental health and behavioral assessment. He was also referred to a local dentist and family medicine physician for his continued primary care.
    He was to see the family medicine physician in 4-8 weeks to review his immunization records, re-evaluation of his anemia and the pending laboratory tests. He was to return to the child maltreatment service in 6 months.

    Discussion

    Methamphetamine use is increasing in the United States, especially in the rural Midwest.
    Methamphetamine (slang names include: ice, glass, crystal, and tina) was first commercially introduced in the 1940s. The 1960′s saw skyrocketing illicit use.
    Methamphetamine hydrochloride, meth’s free-based form, became widely available in the 1980s.
    It comes as chunky white crystals that is often smoked, nasally inhaled or taken orally. It is hepatically and renally excreted with a half-life of ~10 hours.
    Its affects include wakefulness and physical activity, decreased appetite. Chronic use can also cause psychotic behavior, hallucinations and stroke.

    Methamphetamine is reported to be one of the most commonly made illegal drugs.
    It commonly is manufactured from pseudoephedrine (found in over-the-counter decongestants) and anhydrous ammonia (used in farming fertilizers).
    Laws regarding the control of the quantity of pseudoephedrine that can purchased have been or are being instituted in many states, and in some states have reduced the number of methamphetamine laboratories.

    The exact mechanism of methamphetamine’s effects is unknown, but the ‘highs’ are most likely due to dopamine and other neurotransmitters in the central nervous system.
    Long-term pharmacological effects of methamphetamine are also not well known and there is the possibility of developing chronic psychiatric illnesses such as depression and schizophrenia, or other illnesses such as a Parkinson-like syndrome.

    Learning Point
    Initial evaluation for potential exposure to illicit substances includes:

    • Assessment and treatment for life-threatening findings
    • Decontamination of child with soap and water. Give clothing to law enforcement officials maintaining the chain of evidence
    • Obtain medical history from available sources, e.g. parents, social worker, law enforcement officials, emergency medical technicians, etc.
    • Complete physical examination emphasizing general appearance, affect, neurologic, respiratory and skin examinations
    • Laboratory and other evaluations
      • Urine and hair specimens for toxicology screening. Ask laboratory to report all positive results. Maintain the chain of evidence
      • Liver function tests
      • Electrolytes, BUN, creatinine
      • Complete blood count
      • Lead level
      • Urinalysis including dipstick for blood
      • Skeletal survey for children < 2 years and older child with indicators of skeletal injury
      • Ophthalmological evaluation
      • Head computed tomography or magnetic resonance imaging if ophthalmological or neurological examination are abnormal, or if the child is less than 1 year of age
      • Consider oxygen saturation, carboxyhemoglobin, chest radiograph or pulmonary function tests if child has respiratory abnormalities
      • Consider complete metabolic panel and creatinine phosphokinase and coagulation studies if bleeding or battering appears to have occurred
      • Consider HIV testing if history of parental drug abuse or other concerning history
    • Call Poison Control Center if clinically indicated (800-222-1222)
    • Call social worker, Department of Human Services for social service evaluation and management
    • Call law enforcement officials for evidence management
    • Follow-up with child maltreatment clinic within few days

    Initial follow-up

    • Obtain interval history and past medical history
    • Complete physical examination
    • Check laboratory evaluation already completed and status of those tests, order any missing tests
    • Consider hepatitis screening (for B and C) if liver function tests are abnormal, tuberculosis screening, and nutritional assessment for lack of normal growth if concerns in history or physical examination
    • Referral for complete developmental, behavioral and mental health assessment
    • Referral for dental care
    • Referral for primary care including to follow-up missing immunizations
    • Obtain release of medical records

    Long term follow-up (at 6 and12)

    • Obtain interval history and past medical history
    • Evaluate medical records
    • Repeat abnormal tests until they normalize or are otherwise evaluated
    • Monitor primary care including immunizations, screening tests and anticipatory guidance

    Questions for Further Discussion
    1. How do you maintain the chain of evidence of specimens?
    2. Is a positive neonatal drug screen evidence of child abuse and/or neglect?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed – Street Drugs or PubMed – Child Abuse.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Child Abuse and <a href="Drug Abuse
    and at Pediatric Common Questions, Quick Answers for this topic: Child Abuse

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

    American Academy of Pediatrics Policy Statement. Neonatal Drug Withdrawal. Pediatrics 1998:101;1079-1088. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;101/6/1079 (rev. 6/6/1998, cited 8/20/2006).

    Child Protection Clinical Protocols. Medical Assessment Protocol for Children Exposed to Illicit Substances. University of Iowa. Available from the Internet at: http://forms.uihc.uiowa.edu/pdf/abuseforms/index.htm (rev. 12/2003, cited 8/20/06).

    American Academy of Pediatrics. Active Immunization, 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;28.

    Gettig JP, Grady SE, Nowosadzka I. Methamphetamine: putting the brakes on speed. J Sch Nurs. 2006 Apr;22(2):66-73. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16563028&query_hl=5&itool=pubmed_docsum (rev. 4/2006, cited 8/20/2006).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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
    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.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    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
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    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.

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

    Resmiye Oral, MD
    Clinical Assistant Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    September 18, 2006

  • How Do I Treat Congenital Hypothyroidism?

    Patient Presentation
    The pediatrician received a telephone call from the state newborn screening program’s pediatric endocrinologist about a 3-day old term male infant whose neonatal screening test for TSH (thyroid stimulating hormone) was high and presumptively positive for congenital hypothyroidism.
    The endocrinologist gave the pediatrician specific instructions to re-evaluate the patient, have blood drawn for a free T4 (free thyroxine), TSH and neonatal screening test.
    The pediatrician was also instructed to begin the patient on Synthroid® (levothyroxine) 50 micrograms daily orally.
    The patient was seen later that day.
    His past medical history showed a healthy term male born to a G2P2 mother who had received prenatal care. The intrapartum and post-partum history were negative.
    His birth weight was 3570 g and his discharge weight the previous day was 3490 g.
    He was breast-feeding every 2-3 hours for 15 minutes and having many diapers with stool and urine.
    The family history was negative for endocrine disorders including thyroid disorders. There was a history of stroke.
    The review of systems was negative.
    The pertinent physical exam showed an alert male with a weight of 3290 g (~25%), height of 51 cm (~50%), and head circumference of 35.5 cm (~50%). The anterior fontanelle was 1×1 cm and soft, and there was minimal jaundice of the face. The rest of his examination was normal.
    The laboratory evaluation showed a TSH of 847 micro international units/ml (normal = 0.27-4.20), free thyroxine of 0.43 nano-grams/dl (normal = 0.93-1.7), repeated neonatal screening was again high for the TSH but no other abnormalities.
    The diagnosis of congenital hypothyroidism was confirmed and the patient was continued on Synthyroid. At his two week check-up, his weight had increased to 3730g and he appeared normal. He was to follow-up with an endocrinology appointment within the week.

    Discussion
    Congenital hypothyroidism used to be a common cause of mental retardation. With the advent of neonatal screening programs and treatment within the first two weeks of life, cognitive development can be normalized.
    Usually congenital hypothyroidism is a permanent condition resulting from dysgenesis or agenesis of the thyroid gland. Occasionally it can be caused by a pituitary or hypothalamic abnormality (i.e. secondary or tertiary hypothyroidism).
    Occasionally, there can be altered neonatal thyroid function that can be attributed to maternal medication or antibodies, or due to iodine excess or deficiency.

    Neonatal screening specimens should be drawn optimally by 48 hours to 4 days of age. Testing in the first 24-48 hours may lead to false-positive TSH elevations using any screening method, but this timing is often used because it is convenient for the families and healthcare providers.
    The circles on the approved filter paper forms (i.e. Guthrie cards) need to be filled and saturated to be accurate. The specimens need to be dried at room temperature and should not be subjected to excessive heat.

    Neonatal screening programs use one of two basic methods for detection. As there are potential problems in each method, so a pediatric healthcare provider should be familiar with the limitations of each method.

    Primary TSH with backup T4 measurements

    • Used by most programs in the United States, Canada, Mexico, Japan and Europe
    • The test measures TSH and if high, does subsequent T4 measurements
    • May miss a delayed TSH elevation in babies with thyroid-binding globulin deficiency, central hypothyroidism and hypothroxinemia
    • Delayed TSH elevation is common in low birth weight infants also

    Primary T4 backup TSH measurements

    • The tests measures T4 and if low, does subsequent TSH measurements
    • May detect infants with thyroid-binding globulin deficiency, central hypothyroidism and possibly hypothroxinemia
    • Will miss a baby with an initial normal T4 but delayed elevation in TSH

    Each state in the United States uses a neonatal screening program to screen for different conditions. A current listing by state and condition can be found at National Newborn Screening and Genetics Resource Center.

    Learning Point
    The goal of the evaluation and treatment is to normalize the TSH and to maintain T4 and free T4 levels in the upper half of the normal range.
    The pediatric health care provider and the pediatric endocrinologist should work together to ensure that proper patient and family education occur along with treatment plan and followup.

    Recommendations include:

    • Initial workup – detailed history and physical examination, referral to pediatric endocrinologist, check/recheck serum TSH and free T4, thyroid ultrasonography and/or thyroid scan

    • Medication – Levothyroxine10-15 micrograms/kilogram daily by mouth to be begun as soon as the neonatal screening test is presumably positive for congenital hypothyroidism
    • Monitoring – recheck T4 and TSH 2-4 weeks after initial treatment is begun, every 1-2 months for first 6 months of age, every 3-4 months between 6-36 months of age and then every 6-12 months until the end of growth
    • Monitoring may be more often required if compliance is questionable, abnormalities are found, or the medication source has changed
    • Assessment of permanence of the hypothyroidism – congenital hypothyroidism is considered permanent if the thyroid scan/ultrasonography reveals an ectopic thyroid gland or absent tissue, or if the TSH has increased above 10 micro-units/l after the first year of life.

    Questions for Further Discussion
    1. What are the indications for cord blood screening for congenital hypothyroidism?
    2. When should premature infants be screened for congenital hypothyroidism?

    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: Thyroid Diseases
    and at Pediatric Common Questions, Quick Answers for this topic: Hypothyroidism

    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. 2003:2065-69.

    American Academy of Pediatrics; Rose SR; Section on Endocrinology and Committee on Genetics, American Thyroid Association; Brown RS; Public Health Committee, Lawson Wilkins Pediatric Endocrine Society; Folly T, Kaplowitz PB, Kaye CI, Sundararajan S, Varma SK. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics. 2006 Jun;117(6):2290-303.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectivelyeffectively 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
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    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.

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

    Date
    September 11, 2006

  • When Will His Teeth Fall Out?

    Patient Presentation
    A 5-year-old male came to clinic for his health supervision examination. He and his family had no concerns, but did want to know when they could expect that his primary teeth would fall out.
    He saw a dentist regularly and brushed his teeth regularly with fluoride toothpaste. There was fluoride in the community water supply.
    The pertinent physical exam revealed a healthy male with normal growth parameters. He had 20 deciduous teeth with no obvious caries or gum problems.
    The diagnosis of healthy male was made. The family was counseled that the exfoliation of primary teeth usually begins between 6-7 years of age.
    The health care provider recommended continuing brushing, seeing the dentist and also mouthguards for sports.

    Discussion
    Dental health is an important part of a patient’s overall health and should be screened for during health supervision visits.
    Patients and parents often have questions about timing of eruption or exfoliation, numbers of teeth and tooth coloring.
    See a previous PediatricEducation.org case about abnormally colored teeth.

    Learning Point

    The American Dental Association has tooth eruption and exfoliation charts.

    Eruption of primary (i.e. deciduous) teeth
    Eruption of primary teeth is considered normal if it occurs within 6 months of the expected eruption time.
    Eruption usually occurs in the anterior aspect of the mouth first and follows posteriorly.
    The lower central incisor is usually the first tooth erupted at 6-10 months of age.
    The upper central incisors usually follow at 8-12 months of age.
    The upper central second molar is usually the last tooth erupted at 25-33 months of age.
    Newborn infants may have natal teeth. They may be supernumerary (i.e. extra teeth) or true primary dentitia. They are generally left in place unless they are very loose and a potential choking hazard, or if they interfere with feeding.
    They can be pulled but may leave a defect until the permanent teeth erupt.

    Eruption of permanent teeth
    Exfoliation of primary teeth and eruption of secondary teeth follows a similar anterior to posterior pattern.
    There is often a year time period (or more) between exfoliation and eruption of the permanent teeth.
    Central incisors (upper and lower) exfoliate at 6-7 years and erupt at 7-8 years of age.
    Third molars, or wisdom teeth, generally erupt at 17-21 years of age.

    Causes of delayed eruption of primary and permanent teeth includes numerous systemic and congenital syndromes including Apert syndrome, De Lange syndrome, Down syndrome, Hypothyroidism, and Osteogenesis imperfecta.

    Causes of delayed exfoliation of primary teeth usually are idiopathic, but a dental evaluation should be performed.

    Causes of hypodontia (i.e. too few teeth) again are often congenital including Achrondroplasia, Cleft lip +/- palate, Crouzon syndrome, Down syndrome, Ectodermal dysplasia, and Ehler-Danlos syndrome.

    Causes of hyperdontia (i.e. too many teeth) are often seen in families and can be associated with Cleft lip +/- palate, Crouzon syndrome, Down syndrome, and Sturge-Weber syndrome.

    Questions for Further Discussion
    1. What are the recommendations for the timing of the first dental visit?
    2. What is the primary health care provider’s role in the treatment of dental trauma?
    3. What are the indications for third molar removal?

    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 these topics: Child Dental Health and Tooth Disorders
    and at Pediatric Common Questions, Quick Answers for this topic: Dental Care

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

    Casamassimo P. 1996. Bright Futures in Practice: Oral Health. Arlington, VA: National Center for Education
    in Maternal and Child Health. Available from the Internet at http://www.brightfutures.org/oralhealth/pdf/index.html (cited 8/14/06).

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:88, 1286-1287.

    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.
    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
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

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

    Date
    September 5, 2006