How Do You Differentiate Fears and Phobias?

Patient Presentation
A 7-year-old female came to clinic with her mother for her health maintenance visit. They had no concerns but her mother wanted to know what she could do to comfort her daughter during thunderstorms.
The previous spring, there had been a series of thunderstorms that had made the girl very upset. Since then, the girl has become very afraid during thunderstorms and is very anxious even during rainstorms.
Her mother states that if she even hears that there may be a thunderstorm she begins to become upset. She also does not like to read books where thunderstorms or rainstorms occur.
During the storms, she is comforted by her mother, siblings or other adults. She continues with her activities but does remains vigilant.
If it is actively lightening and thundering though she sometimes wants to cover up under a blanket or pillow.
If the storms occur at night, she comes to her mother’s bed for comfort, and falls back to sleep without much difficulty.
If it is just raining, but the storms continue for a long period of time, she is less anxious overall and becomes less so with time.
She is not scared of other weather conditions and has no other exaggerated fears.
The symptoms are not increasing and possibly may be slightly better according to her mother.
The social history shows a second grader doing well in school, with many friends, who likes swimming and drawing.
The family history is negative for any psychiatric illness
The pertinent physical exam shows a normal healthy female, who simply states, “I don’t like storms!”After consulting an electronic version of the Diagnostic and Statistical Manual of Mental Disorders to review the criteria for a phobia, the diagnosis of an exaggerated fear is made. Since the symptoms are limited only to various storms, are not increasing in quantity or quality, and the current emotional support seems to help the child,
the mother was reassured to just continue to comfort the girl during storms. However, the mother was told to call if the symptoms seem to be worsening and potentially short term counseling would be beneficial.

Discussion
Fears are protective. They help to keep people safe from a variety of potentially harmful factors in the environment.
“Fear is an unpleasant emotion with cognitive, behavioral, and psychological components. It occurs in response to a consciously recognized source of danger, either real or imaginary.””Phobia [or a specific phobia] is a persistent and compulsive dread of and preoccupation with the feared object or event.” Phobias interfere with a child’s functioning.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for a specific phobia includes:

  • The patient has persistent or irrational fear that is unreasonable or excessive and is triggered by the presence or anticipation of a specific object or situation.
  • Exposure to the above noted event or object almost always results in an immediate anxiety response.
  • The person acknowledges this response to be unreasonable or excessive.
  • The person either avoids such situations or objects or else experiences exposure with intensive anxiety or distress.
  • The avoidance or distressful response significantly interferes with a person’s daily functioning.
  • Duration is at least 6 months for individuals younger than 18 years.
  • The anxiety, distressful response, or avoidance is not accounted for by other mental disorders .
  • The patient must have 1 of the following 5 subtypes that best describe phobias: animal, natural environment, blood-injection injury, situation or other (which must be distinguished from normal fear and anxiety).

Often there is a triggering event for a fear or phobia, e.g. thunderstorm. The fear can build because the child is not developmentally old enough to allay the fear or be able to be emotionally comforted with a reasonable explanation.
Cognitively and emotionally the child may not be able to understand that the current situation is safe or that the situation is not likely to be repeated. For example, a large dog knocks over a 3 year old boy and he has a few scratches.
The child may not be old enough to understand that he is now safe with an adult and the dog is unlikely to come back and hurt him again.
Instead the next time the boy encounters a dog, he seeks an adult, climbs play equipment or runs behind an object. These actions would be protective. But if he would cry uncontrollably after the dog was gone, and after a reasonable time of being comforted, then he may be having an exaggerated fear or even a phobia.

Fears are normal and occur in all children. Phobias occur in 7-9% of children. Different fears occur at different ages:

  • Infant and Toddler – separation, noises, falling, animals, toilet training, bath, bedtime
  • Preschoolers – animals, bedtime, monsters/ghosts, getting lost
  • School age (5-9 years) – separation, noises, falling, animals, bedtime, monsters/ghosts, divorce, getting lost, loss of parent
  • School age (9-12 years) – falling, social rejection, war, new situation, adoption, burglars
  • Teenagers – adoption, burglars, injections, sexual relations

Treatment is generally supportive. Parents need to understand that the fear is real to the child and that the child wants to withdraw from the feared object or situation.
Over time with support, the child will gain increased skill at handling the feared object or situation.
Counseling is recommended when a fear becomes more generalized, is impeding activities or if the fears are a realistic response to a threatening environment.
Medication is sometime recommended for phobias.

Learning Point
Diagnostic and Statistical Manual of Mental Disorders should be consulted when symptoms may be more than a simple fear. In general, fears and phobias can be differentiated based upon the following:

				Fear	Phobia
Reasonable triggering
  event as likely cause		Yes	No
Responds to reassurance		Yes	No
Is distractible			Yes	No
Interferes with activities	No	Yes

Questions for Further Discussion
1. What other disease/problems should be considered in the differential diagnosis of a fear or phobia?
2. What are the other anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders?

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: Anxiety and Phobias

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

Augustyn M. Fears. In Behavioral and Developmental Pediatrics. Parker S, Zuckerman B. Little, Brown and Company. Boston, MA. 1995;140-142.

Friedman SL, Munir KM.
Anxiety Disorder: Specific Phobia. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2659.htm (rev.8/7/2006, cited 1/31/2007).

American Psychiatric Association. Specific Phobia. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Available from the Internet at: http://www.behavenet.com/capsules/disorders/specphob.htm(rev. 2000, cited 1/31/2007)

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.
    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
    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.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

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

    Date
    February 26, 2007

  • How Does Transverse Myelitis Present?

    Patient Presentation
    An 8-year-old female came to clinic for back pain and fevers. She complained of thoracic back and chest pain for two weeks.
    The pain increased over the two weeks with shooting pains into her hands and feet. During one of these episodes, three days prior, she complained of severe chest pain and was taken to the local emergency room where she was diagnosed with pneumonia and pleurisy but was not begun on any medications.
    She had intermittent fevers to 101º Fahrenheit. The fevers and pain improved with acetaminophen or ibuprofen, but would return when the medication wore off.
    Over the previous week, she had several episodes of urinary incontinence, intermittent headache and several episodes of emesis.
    The parents also noted that the pupils of her eyes seem to be different sizes in the morning which prompted the return visit.
    The patient also says that she has been dizzy at times and the parents said that she seemed disoriented occasionally. She had an upper respiratory infection about 3 weeks ago but has had no trauma or other illnesses.
    The past medical history was non-contributory.
    The family history is positive for seizures in a cousin.
    The review of systems revealed no weakness, sore throat, rhinorrhea, constipation, diarrhea, dysuria, rashes or heart palpitations. She had not been eating or drinking well.
    The pertinent physical exam shows normal vital signs and the patient was not experiencing pain. Eyes showed a right pupil of 4 mm and left pupil of 2 mm in size; both were reactive to light.
    Ears, nose and throat were negative.
    Neck was supple with shoddy anterior cervical lymphadenopathy and no change in symptoms with motion.
    Heart, lungs and abdomen were normal. No pain could be elicited on palpation or motion of the spine or chest.
    Neurological examination showed cranial nerves were normal other than her anisocoria. Deep tendon reflexes were 2+/2+ throughout. She had no motor or sensory abnormalities. She had a normal Romberg test and normal gait but was somewhat hesitant to move much for fear of the pain.
    Tone was normal as was cerebellar testing.
    The laboratory evaluation included normal electrolytes and glucose, erythrocyte sedimentation rate of 6 mm/hr, and C-reactive protein of 0.5 mg/dl.
    Her complete blood count had a hemoglobin of 15 mg/dl, hematocrit of 40%, platelets of 239 x 1000/mm2 and a white blood cell count of 8.3 x 1000/mm2 with 5204 neutrophils, no bands, and 2117 lymphocytes.
    Because of the concerning neurological examination and a differential diagnosis that included diseases which required neurosurgical intervention, the radiologic evaluation of a magnetic resonance imaging study of her spinal cord and head was ordered.
    The head was normal but the spine showed extensive T2 signal involving the cervical spine that was consistent with transverse myelitis.
    The diagnosis of transverse myelitis was made and the patient was begun on methylprednisolone intravenously for 3 days and then discharged home on oral prednisone.
    She had some improvement of her symptoms at discharge.
    Mycoplasma pneumoniae titres were positive during her hospitalization and she was treated with a 5 day course of oral azithromycin.
    The patient’s clinical course over the next 2 months showed her to improve with occasional episodes of mild back pain but with no radiation. The family has also noticed a few episodes of short duration anisocoria. Both of these symptoms are decreasing in frequency.
    The patient was to continue tapering the prednisone and follow-up in another month.



    Figure 46 – Magnetic resonance imaging including sagittal (left) and axial (right) T2-weighted images through the thoracic spine demonstrate bright signal intensity in the center of the thoracic spinal cord throughout its length. The thoracic spinal cord showed no enhancement after the administration of intravenous gadolinium contrast.

    Discussion
    Transverse myelitis is a segmental spinal cord disease that usually has both sensory and motor abnormalities at and below the lesion.
    The onset of symptoms is hours to days and is often associated with respiratory infections or viral illnesses such as Epstein-Barr, mumps or varicella viruses.
    Mycoplasma pneumoniae is also a known cause of transverse myelitis.

    Differential diagnosis includes:

    • Intraspinal problems
      • Abscess
      • Hematoma
      • Intraspinal cyst
      • Necrosis, idiopathic
      • Neoplasm
      • Syringomyelia
      • Vascular occlusion or accident
    • Extraspinal problems
      • Arteriovenous malformation
      • Epidural abscess
      • Hematoma
      • Neoplasm

    Other flaccid paralyses that should be distinguished from transverse myelitis include poliomyelitis, Guillian-Barré and traumatic neuritis following injections.

    Evaluation usually includes magnetic resonance imaging to look for a surgically-treatable condition.
    Cerebrospinal fluid testing may be necessary but should be done only after consultation with neurology and neurosurgery because of the risk of further damage from a mass lesion.
    If performed, it may be normal or show mild inflammatory changes.
    Nerve conduction velocities and electromyograms usually are normal.

    Treatable causes of transverse myelitis should be given specific appropriate treatment.
    Treatment for idiopathic transverse myelitis is usually steroid medications but sometimes intravenous immunoglobulin is used. Both are used for their immunomodulatory effects.

    Outcome for children is better than adults with often complete recovery.

    Learning Point

    The level of the spinal lesion determines the clinical symptoms of transverse myelitis.

    Above the lesion – no abnormalities

    At the level of the lesion

    • Paraesthesias that are usually painful. They begin at the back and circumferentially radiate.
    • Cranial nerves are often not involved unless the lesion is cervical.

    Below the level of the lesion

    • Motor abnormalities – flaccid paralysis is common, but this depends on the extent of the lesion
    • Sensory abnormalities – loss of pain but depends on the extent of the lesion. Posterior columns are usually spared.
    • Autonomic abnormalities – loss of temperature control
    • Reflex loss

    Questions for Further Discussion
    1. What clinical features distinguish poliomyelitis and Guillian-Baré from transverse myelitis?
    2. What are the treatment options for recurrent transverse myelitis?

    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: Spinal Cord Diseases.

    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. 2003:1061, 2315.

    Lucchinetti CF, Pittock SJ. Inflammatory tranverse myelitis: evolving concepts. Current Opinion in Neurology. 2006;19:362-368.

    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.
    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
    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
    February 19, 2007

  • What Treatments are Recommended for Head Lice?

    Patient Presentation
    A 4-year-old male came home with a note from school that stated that head lice was being seen in the classroom and that he had been found with some nits in his hair (see Figure 41).
    The school health department and local public health agency recommended over-the-counter Permethrin 1% to be used once and then again one week later.
    Additionally, they recommended combing the wetted, shampooed hair with a nit comb nightly for 1-2 weeks after shampooing (see Figure 42 for an example, note the very fine teeth). Other control measures for the household were recommended such as treating the rest of the household members with the same medication and washing bedding, cleaning toy animals and other household items the child had contact with.
    The parents noted on their physical exam of the child that he had several white spots stuck to the shaft of the hair but no obvious lice.
    The work-up included the sibling and parents being inspected and they did not have any spots or lice noted by the parents.
    The diagnosis of head lice was made. The child was treated according to the school’s recommendations and he had no recurrences of infestation.


    Figure 44 – Photograph of head lice.


    Figure 45 – Example of nit comb.

    Discussion
    Pediculosis capitis or head lice is a common human infestation. Patients often are asymptomatic but itching is a common symptoms. Adult lice may be seen and nits (eggs) are found on the hair shafts.
    Lice lay eggs within 3-4 mm of the scalp and so the time since infestation can be approximated because hair grows at a rate of ~1 cm/month.

    Parents often worry that infestation is a sign of poor hygiene but all socioeconomic groups are affected. Lice do not spread disease and therefore are not a health hazard.

    Transmission is by direct contact with the hair of infested persons or objects such as hats, combs and brushes. The incubation period is 10-14 days but can be lengthened in cold climates and shortened in warm climates. Adult lice can produce eggs after 2 weeks.

    Learning Point
    According to the American Academy of Pediatrics, first line pediculicide treatment should be with Permethrin 1% over-the-counter topical medication, noting there is resistance to it commonly.
    Treatment failure should then be treated with Malathion 0.5% topically. If there is treatment failure with Malathion, then oral Ivermectin is recommended.
    All medications should be used as directed. The major safety risk is the medication itself as the infestation does not cause disease.

    Permethrin 1% is an over-the-counter topical medication that is applied to the hair for 10 minutes after regular washing and towel drying. One treatment is thought effective since it last for 2 weeks but some people recommend a second treatment at 7-10 days. Permethrin 5% is available by prescription for treatment of scabies but not for lice.

    Malathion 0.5% is available by prescription and is an organophosphate pesticide. It is approved for children 6 years and older. It is contraindicated in children < 2 years. It is applied to dry hair and left for 8-12 hours. It is reapplied at 7-10 days only if lice are still present.

    Ivermectin is not currently approved by the FDA as a pediculicide. It is given as a single oral dose of 200 micrograms/kilogram with a second dose at 7-10 days. It should not be given to children less than 15 kilograms in weight.

    Other medications that are used include various Pyrethrin products, Lindane, Crotamiton, and oral Trimethoprim-sulfamethoxazole.

    Efficacy by suffocation of occlusive agents such as petroleum jelly or mayonnaise has not been determined. One recent study showed that hot air was effective.

    Manual removal of nits is not necessary to prevent spreading. If nits are still visible, particularly close to the scalp, manual removal may increase success.

    Household contacts and other close contacts should be treated prophylactically with a pediculicide. Combs, brushes, etc. should be treated with a pediculicide shampoo or in hot water (> 53.5 degrees Celsius or 128.3 degrees fahrenheit) for more than 5 minutes. Bedding and clothing should be washed in hot water and dried on the hot cycle. Dry cleaning or storing items in sealed plastic bags for 2 weeks also is an effective environmental control. Vacumning is also effective.
    Pets do not need to be treated.

    Questions for Further Discussion
    1. How do you treat Pediculosis corporis or Pediculosis pubis?

    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: Head Lice and Parasitic Diseases
    and at Pediatric Common Questions, Quick Answers for this topic: Head Lice

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

    American Academy of Pediatrics. Pediculosis Capitis, 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;488-492.

    Goates BM,
    Atkin JS,
    Wilding KG,
    Birch KG,
    Cottam MR,
    Bush SE,
    Clayton DH. An effective nonchemical treatment for head lice: a lot of hot air. Pediatrics. 2006 Nov;118(5):1962-70.

    Centers for Disease Control. Head Lice Infestation.
    Available from the Internet at http://www.cdc.gov/ncidod/dpd/parasites/lice/factsht_head_lice.htm (rev. 8/12/2005, cited 1/22/07).

    National Pediculosis Association. Licemeister Nit Comb.
    Available from the Internet at http://www.headlice.org/ (rev. 2007, cited 1/22/07).

    ACGME Competencies Highlighted by Case

  • Patient Care

    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.

    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

    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
    February 12, 2007

  • What Causes SIDS?

    Patient Presentation
    A 74-day-old premature twin male stopped breathing while on his father’s lap. His father was doing computer work and stated that he looked down and the baby was no longer alive. The baby was lying on his back and not swaddled in a blanket.
    His father states that there were no sounds or struggling. The father also said that he had no idea how long it had been since he had noted the baby to be alive. The baby was not revived with cardiopulmonary resuscitation.
    The past medical history revealed a twin male who had been in the neonatal intensive care unit with some episodes of apnea after birth. He did not go home with an apnea/bradycardia monitor and had been otherwise healthy.
    The twin had also been healthy.
    The review of systems revealed that the father said that the infant’s breathing was labored but that it seemed like a cold.
    A full work-up included an investigation by the local police department for possible child abuse. The diagnosis of sudden infant death syndrome was made. The father later was told that the most likely cause was acid reflux leading to heart and respiratory failure.

    Discussion
    Sudden Infant Death Syndrome (SIDS) is a clinical diagnosis with the sudden death of an under one year of age infant that remains unexplained after a thorough case investigation, including examination of the scene of death, a complete autopsy, and review of the clinical history.
    Cases not meeting these standards, should not be classified as SIDS, such as those without an autopsy.

    SIDS is the most common cause of death in the postneonatal period (i.e., in infants aged 1 month to 1 year).
    Most occur in infants 2-4 months, with 90% of cases occuring in &lt; 6 month old infants, and 95% of deaths occuring in < 8 month old infants.
    The male-to-female ratio is 3:2 in most population studies, and SIDS is higher in African Americans and Native Americans for unknown reasons.

    After studies completed in multiple developed countries internationally, the U.S. began recommending placing infants on their back for sleeping, i.e. the “Back to Sleep” campaign in 1994.
    SIDS rates have fallen approximately ~75% since then. In 2002, a total of 2295 SIDS deaths were reported nationwide.

    An ALTE (apparent life-threatening event) is different than SIDS and is defined as an event “???that is frightening to the observer and is characterized by some combination of apnea (central or obstructive), change in muscle tone (usually diminished), and choking or gagging.”ALTE frequency in healthy term infants is estimated to be 1-3%. The subsequent death among infants with an ALTE is 1-2%. The rate increases to 4% if the infant had respiratory syncytial virus, and goes up to 8% if the infant had the ALTE during sleep or required cardiopulmonary resuscitation. Thus, there may be a relationship between ALTE and SIDS.

    Learning Point
    The cause or causes of SIDS is not currently known. Many people believe that SIDS is multifactorial. Potential causes of SIDS include:

    • Triple risk model – where an infant with intrinsic abnormalities of cardiorespiratory control is in a critical period of homeostatic cardiorespiratory development, and then has external stressors that cause the infant to have inadequate cardiorespiratory homeostasis and results in cardiorespiratory failure.
      • Critical developmental period – the peak time period for SIDS is also the time when the brain undergoes rapid developmental change for sleep, arousal, cardiorespiratory homeostasis and metabolism.
      • Stressors could include the concentration of oxygen and carbon dioxide in the infant’s microenvironment, temperature, and infections. This may explain why smoking, especially maternal smoking, appears to increase the risk of SIDS.
        Additionally, asphyxiation though co-sleeping and prone sleeping may also be explained though this mechanism.
        This may also explain why the father of the patient in the case above was told that acid reflux may have been the cause of his son’s death (e.g. possibly through aspiration leading to asphyxia).
    • Neurodevelopmental pathology – various studies have found differences in neurotransmitters and neuropathways in various parts of the brain. These include dopamine, tyrosine and serotonin. Potentially involved areas include the medulla, cerebellum, and pre-frontal cortex.
      A recently study found medullary sertonin pathology to be more extensive in SIDS than previously thought.
      An increased risk of SIDS in premature infants may possibly be explained through this mechanism.

    • Long QT Syndrome – may contribute to some cases of SIDS. It appears that certain sodium channel mutations, such as SCN5A, may contribute to arrhythmias and thus potentially death.
    • Fatty acid oxidation defects – At autopsy some infants have fatty changes in their liver. Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) is a proposed cause.
    • Child abuse – is estimated to cause 1-10% of all unexplained, sudden deaths in infancy. Most SIDS cases do not have any risk factors for child abuse, but it does emphasize the need for a through death investigation to be completed.

    Questions for Further Discussion
    1. What are current indications for using an apnea/bradycardia monitor?
    2. What are the recommendations for using pacifiers, bundling of infants and side-lying sleeping position?

    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: Sudden Infant Death Syndrome (SIDS).

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

    Carolan PL. Sudden Infant Death Syndrome. eMedicine.
    Available from the Internet at http://www.emedicine.com/ped/topic2171.htm (rev. 6/8/2006, cited 1/22/07).

    Paterson DS,
    Trachtenberg FL,
    Thompson EG,
    Belliveau RA,
    Beggs AH,
    Darnall R,
    Chadwick AE,
    Krous HF,
    Kinney HC. Multiple serotonergic brainstem abnormalities in sudden infant death syndrome. JAMA. 2006 Nov 1;296(17):2124-32.

    Wang DW, Desai RR, Crotti L, Arnestad M, Insolia R, Pedrazzini M, Ferrandi C, Vege A, Rognum T, Schwartz PJ, George AL Jr.
    Cardiac Sodium Channel Dysfunction in Sudden Infant Death Syndrome.
    Circulation. 2007

    ACGME Competencies Highlighted by Case

  • Patient Care

    5. Patients and their families are counseled and educated.

    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.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

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

    Date
    February 5, 2007