What Causes Diurnal Enuresis?

Patient Presentation
A 4-year-old male came to clinic with a 1 week history of daytime enuresis. He was toilet trained for urine during the day for 9 months and used diapers at night. Over the past week his babysitter and family noticed that he would be playing, then ran for the bathroom but often would have urinary incontinence. He denied dysuria. Parents denied constipation, but did say that he was urinating more frequently and seemed to be drinking more for the past 3 weeks. The past medical history showed a healthy male. The family history was positive for type 2 diabetes mellitus and hypothyroidism. The social history revealed that his mother had recently returned from a military deployment. The review of systems showed no weight loss, nausea, emesis, or fever. The family denied concerns of abuse.

The pertinent physical exam showed a well appearing male with normal vital signs. His growth parameters were 50-75%. His weight was 16.4 kilograms which was the same as 6 months previously. His mucous membranes appeared slightly dry. The work-up showed a urine dipstick with large ketones and glucose. His glucometer reading was 434 mg/dl and a true glucose was later 612 mg/dl and his hemoglobin A1c was 8.1 %. Thyroid studies were eventually normal. The diagnosis of new onset type 1 diabetes mellitus was made. The patient’s clinical course had him admitted to the hospital where he was started on an insulin drip, and he was later changed to insulin injections and scheduled meals and snacks. His parents and grandparents were educated regarding daily management including common problems such as toddler/preschoolers refusing to eat, management during intercurrent illnesses and emergency treatment for hypoglycemia.

Discussion
Type 1 diabetes mellitus or insulin-dependent diabetes mellitus (DM) is a chronic metabolic disorder caused by the lack of insulin. Langerhans cells in the pancreas make insulin and congenital absence or destruction of the cells produces DM where patients are dependent on exogenous insulin. An estimated 3/1000 children develop DM by age 20. Overall there is an incidence of 15/100,000 annually for DM.

Insulin and diet treatment is necessary but needs to be tailored to the individual. Intercurrent illnesses also require special treatment so patients do not progress to ketoacidosis. To read more about intercurrent illness treatment click here. Patients can also have long-term side effects of their diabetes including other endocrinopathies/autoimmune diseases, growth problems and retinopathy. Endocrinopathies are generally screened for yearly and growth is monitored closely during regular diabetes and well-child care follow-up. Yearly retinopathy screening generally starts ~5 years after diagnosis.

Learning Point
Primary nocturnal enuresis is a common developmental problem in children that improves overtime. Although organic causes can present with primary nocturnal enuresis, these more commonly present with diurnal or daytime enuresis. Secondary diurnal enuresis should raise the clinicians suspicion for further history, careful physical examination, evaluation and management.

Primary enuresis is defined as a child who has never gained urinary control, and secondary enuresis is a child who has gained control and how does not have control. Click on the links to learn more about bladder dysfunction and primary nocturnal enuresis.

The causes of diurnal enuresis include:

  • Increased urine output
    • Excessive water intake
    • Diabetes mellitus
    • Diabetes insipidus
    • Sickle cell anemia
  • Structural problems
    • Epispadias
    • Ectopic ureter
    • Vesicle sphincter dyssynergy
    • Labial adhesions
    • Vaginal reflux
    • Meatal stenosis
    • Posterior urethral valves
  • Bladder instability or decreased size
    • Bladder spasm
    • Constipation
    • Hypercalciuria
    • Pregnancy
    • Urinary tract infection
    • Vulvitis/vaginitis
  • Neurological problems
    • Spinal cord abnormalities
    • Sphincter weakness
  • Other
    • Sexual abuse
    • Central nervous system or developmental anomalies
    • Foreign body
    • Food sensitivities
    • Irritation – i.e. soaps, bubble bath, tight undergarments
    • Inattention to normal voiding signals – i.e. not paying attention to need to void until too late to void in toilet
    • Pinworms
    • Stress incontinence (often associated with large bladder capacity)

Questions for Further Discussion
1. What treatments are available for primary nocturnal enuresis?
2. What multiple endocrinopathy syndromes is diabetes associated with?
3. What are the indications for a urology consultation for diurnal enuresis?
4. What workup should be considered for diurnal enuresis?

Related Cases

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

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

Information prescriptions for patients can be found at MedlinePlus for these topics: Type 1 Diabetes and Bedwetting.

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

To view images related to this topic check Google Images.

Cooper CS, Nepple KG, Hellerstein S, Glassock EL. Voiding Dysfunction. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1016198-overview (rev. 6/24/08, cited 1/5/10).

Lui P. Urinary Incontinance. Merck Manual.
Available from the Internet at http://www.merck.com/mmpe/sec17/ch228/ch228b.html#sec17-ch228-ch228b-344 (rev. 3/08, cited 1/5/10).

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 competently 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
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

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

  • What is the Seroconversion Rate of Mumps Vaccine?

    A 16-month-old male came to the emergency room with a 2-3 day history of fever to 101° F. He had emesis 3 times over the first two days. His mother noted that he was somewhat fussier when eating but he had good oral intake and urine output. She also thought his left face was slightly swollen. There is documented mumps in his community and he was vaccinated with the measles-mumps-rubella vaccine (MMR) 1 month earlier. The past medical history, family history, and review of systems were negative. The pertinent physical exam revealed him to be afebrile with normal vital signs and growth. HEENT examination showed his pharynx to be minimally erythematous, and diffuse swelling along the lower left mandible. There was a 1 x 1 cm lymph node at the angle of the left mandible and diffuse cervical lymphadenopathy bilaterally. The rest of his physical examination was normal. The diagnosis of of presumed mumps was made. The work-up included serology for mumps IgM, urine culture, and parotid massage with oral culture. A rapid strep test was also negative. The family was sent home with instructions for mumps exposure, oral hygiene precautions, and symptomatic treatment. The patient’s clinical course over the next few days saw him without fever and a decrease in the facial swelling. One week later, the laboratory evaluation was positive for a urine IgM, but was negative for serum or oral culture.

    Discussion
    Mumps is caused by a paramyxoviridae family virus and humans are the only known host. The spread is from infected respiratory tract secretions. Mumps causes swelling of one or more salivary glands, in particular the parotid glands. Up to 1/3 of patients do not have salivary swelling that is apparent. Parotitis in children is usually not due to mumps and can be caused by several other viruses including coxsackieviruses, cytomegalovirus, enteroviruruses, human immunodeficiency virus, and parainfluenza virus. It can also be causes by Staphlococcus aureus, mycobacterium (nontuberculous), cirrhosis, diabetes, drug reactions and malnutrition.

    Mumps complications include central nervous system problems (including hearing problems, cerebellar ataxia, radiculitis), arthritis, myocarditis, mastitis, thyroiditis, myocarditis, oophoritis, orchitis (with rare sterility), and pancreatitis. Death is rare and infection in the first trimester of pregnancy is associated with an increased risk of spontaneous abortion. It does not appear to increase the risk of congenital malformations. Most cases are in children 5-15 years of age. Incubation is 16-18 days but can occur between 12-25 days after exposure. Highest infectivity is from 1-2 days before the parotid swelling to 5 days after the swelling, but the virus may be shed from 7 days before swelling to 9 days after.

    In 2006, a resurgence occurred in the United States, with the highest attack rate among persons aged 18-24 years and 57% of patients had previously received 2 doses of vaccine. In 2007 and 2008, incidence declined but unfortunately another outbreak occurred in 2009, mainly among unimmunized or underimmunized populations.

    Learning Point
    Mumps vaccine is highly effective. Its effectiveness has been estimated at 73%-91% for 1 dose and 76%-95% for 2 doses. However these recent outbreaks may show that vaccine induced immunity may wane after > 10 years since the second dose of vaccine.

    Recommendations for vaccination are that MMR be given at 12-15 months of age and again at 4-5 years of age. Recommendations for potentially susceptible individuals during an outbreak should be individualized based upon age and can be found from the Centers for Disease Control.

    Questions for Further Discussion
    1. What is the seroconversion rate for measles vaccination?
    2. What is the seroconversion rate for hepatitis A vaccination?
    3. What are the potential side effects of MMR vaccination?

    Related Cases

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

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Mumps and Immunization.

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

    To view images related to this topic check Google Images.

    American Academy of Pediatrics. Mumps, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;468-472.

    Centers for Disease Control. Mumps Outbreak — New York, New Jersey, Quebec, 2009. MMWR. November 12, 2009 / 58(Dispatch);1-4
    Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d1112a1.htm?s_cid=mm58d1112a1_e (rev. 11/12/2009, cited 12/17/2009).

    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.

  • 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.

    Author

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

  • What is the Differential Diagnosis of Failure to Thrive?

    Patient Presentation
    A 17-month-old male was admitted for nutritional resuscitation. According to records, his weight tracked around the 3rd percentile for the first 6 months of life, and his height as 25-50%. At 14 months his weight was 50% for a 5 month old, height was 50% for a 9 month old and head circumference was 50% for a 6 month old. He had a complex social situation and was currently in foster care. Unfortunately there were ongoing problems with the foster care placement also. The social worker who brought him to clinic earlier in the day stated that he takes 3 meass and 5 cans of Pediasure®/day per foster care. There is no history of emesis, reflux, diarrhea, constipation, or food refusal. The past medical history showed that he was a full term infant with no problems prenatally or postnatally and his mother received routine prenatal care. He had a previous evaluation by a feeding/speech and language specialist that found no problems with oromotor feeding or swallowing but was severely delayed in speech. He was receiving speech therapy. He had had an extensive laboratory evaluation in the specialty nutrition clinic at 15 months of age, that showed no obvious cause of his poor growth. The family history showed that his mother’s height is 4 foot 10 inches, and father is 5 foot 7 inches. There are family members with developmental delay, hypothyroidism, and learning problems.

    The pertinent physical exam shows a small, thin child with little subcutaneous fat. He is smiling and interactive, but he only babbles consonants and vowels without recognizable words. Gross motor and fine motor skills appear normal for age. His weight was 7.84 kg (50% for a 6 month old), height was 74.5 cm (50% for a 12 month old) and head circumference was 45 cm (50% for an 8 month old). This was only 1 g/day weight gain since his last visit. His physical examination was normal otherwise. The diagnosis of failure to thrive with failed outpatient management, language developmental delay and a complex social situation was made. The patient was started on a general toddler diet with strict calorie count which included 6 small meals and 3 servings of Pediasure®/day. He had no water or juice and a total of 25 minutes maximum time allotted for all meals. A behavorial psychologist also worked with him regarding feeding. Speech continued his therapy. The patient’s clinical course showed that he was eventually discharged back to his biological parents with community social service support. He continued to have some problems with feeding over the next 3 years. Consistent calorie boosting at home and daycare caused him to regain and stabilize his weight and height at the 5th percentile. His clinical course also showed a growth pattern consistent with genetic short stature in addition to the resolving failure to thrive.

    Discussion
    Failure to Thrive (FTT) is defined as persistent weight below the 3rd percentile for age in infants and young children. The associated terms “Failure to gain weight” (FGW) or “Lack of Normal Physiologic Growth and Development” are more precise, especially for children who are not below the 3rd percentile but are losing weight over time and/or crossing percentile lines on their growth curve. For general growth parameters see How Do I Calculate Mid-Parental Height and Other Growth Parameters? About 70-80% of FTT cases have psychosocial problems that are associated with the FTT or the primary cause of the FTT. Children of older ages may also have FTT such as those with psychosocial dwarfism or eating disorders.

    Children with FTT have a wide range of appearances from ill and emaciated to well but small, depending on the cause. History and physical examination are the mainstay of diagnosis. A detailed nutritional history including caloric assessment, who feeds the child, type of food offered, when/where food is offered, and weaning are important. Birth history (including possible teratogens and substance abuse), developmental history(including loss of milestones for possible metabolic or genetic abnormality), and past medical history for chronic infections or other medical problems. Family history should including miscarriages or early childhood deaths and also weight/height of parents and siblings (for possible genetic abnormalites). Social history including exploration of stressors are very important. A complete physical examination (including accurate weight, height and head circumferences and their trends) with directed emphasis in areas clued by the history is important. Laboratory evaluation should be limited and guided by the history and physical examination. It should also be staged.

    Initial clinical evaluation may include:

    • Albumin
    • CBC, Differential, Platelet count
    • ESR, C-Reactive Protein
    • Electrolytes, BUN, Creatinine
    • PPD with Control
    • Total Protein
    • Urinalysis and Urine pH
    • Stool Guiac (consider fecal fat, stool Clinitest)
    • Dietary Consultation

    Other tests which may be ordered depending on clinical suspicion include:

    • ALT, AST
    • Calcium, Phosphorus
    • HIV/AIDS
    • Iron Studies
    • Lead
    • Thyroid Function Tests
    • Quantitative Immunoglobulins
    • Urine for Reducing Substances, Culture
    • Stool for Malabsorption
    • Stool for Ova and Parasites
    • Bone Radiographs
    • Chest Radiograph
    • Neuroimaging
    • Sweat Test
    • Cardiac Evaluation

    Treatment depends on the probable underlying cause of the FTT. If nutritional deficiencies are indicated, appropriate dietary counseling and supplementation are needed. Counseling for psychosocial stressors in the caregivers (and patient) may also be appropriate. Other specific treatments will vary. Patients should be hospitalized for severe malnutrition or dehydration, extreme parental anxiety, or failure of outpatient treatment.

    Learning Point
    The differential diagnosis of failure to thrive includes:

    • Chronic Disease
      • Cardiac
        • Cardiac Failure
      • Neoplasia
      • Pulmonary
        • Bronchopulmonary Dysplasia
        • Cystic Fibrosis
      • Renal
        • Renal Failure
        • Renal Tubular Acidosis
      • Rheumatology
        • Systemic Lupus Erythematosus
    • Congenital/Genetic/Neurological Disease
      • Cerebral Palsy
      • Craniofacial Abnormalities
      • Fetal Alcohol Syndrome
      • Intrauterine Growth Retardation
      • Mental Retardation
      • Myopathies
      • Neurocutaneous Syndromes
        • Neurofibromatosis
      • Prematurity
      • Primary CNS abnormality
      • Genetic Syndromes
        • Cystic Fibrosis
        • Russell-Silver Syndrome
        • Williams Syndrome
      • Muscle weakness
        • Prader Willi Syndrome
      • Inborn Error of Metabolism
    • Endocrinological Disease
      • Diabetes Mellitus
      • Hypopituitarism
      • Hyperthyroidism
      • Growth hormone Deficiency
    • Gastrointestinal Disease
      • Celiac Disease
      • Chronic Diarrhea
      • Chronic Emesis
      • Esophagitis
      • Gastrointestinal Reflux
      • Inflammatory Bowel Disease
      • Malabsorption
      • Protein Losing Enteropathies
    • Infectious Disease
      • Congenital infections
      • HIV/AIDS
      • Recurrent infections
      • Parasites
      • Tuberculosis
    • Immunological/Rheumagological Disease
      • Immunodeficiencies
    • Other
      • Anemia
      • Heavy Metals
        • Lead
        • Drugs
          • Amphetamine
          • Cocaine
          • Hydantoin
          • Phenobarbital
      • Dental Caries
    • Nutritional Problems
      • Inadequate Calories
      • Inadequate Protein
      • Poor Appetite
      • Maternal Malnutrition
    • Psychiatric Problems
      • Depression
      • Eating Disorders in Patient or Mother
      • Munchausen’s Disease by Proxy
      • Psychosis
    • Social Problems
      • Child Abuse
      • Caregiver/Child Interaction Abnormalities
        • Emotional Deprivation
        • Difficult Child
      • Family Stress
      • Parenting, Ineffective
      • Poverty

    Questions for Further Discussion
    1. What is the differential diagnosis for short stature?
    2. What signs, symptoms or testing may help to distinguish between failure to thrive versus low weight in a child with a chromosomal abnormality?
    3. What social services are available locally to assist families with failure to thrive children?

    Related Cases

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

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Growth Disorders and Infant and Toddler Health.

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

    To view images related to this topic check Google Images.

    Kleinman RE, edit. Pediatric Nutrition Handbook. American Academy of Pediatrics. 6th edit. 2009;601-636.

    El-Baba MF, Bassali RW, Benjamin J, Mehta R. Failure to Thrive. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/985007-overview (rev. 5/4/09, cited 12/10/09).

    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.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently 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.

  • 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
    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.
    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
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Is the Differential Diagnosis of Attentional Problems?

    Patient Presentation
    A 7-year-old male came to clinic for his health supervision visit. His mother noted that over the 2nd grade school year he seemed to be having more problems with reading and the teachers noted that he had more inattention in the afternoon when they did language arts.
    He had been previously diagnosed with attention deficit hyperactivity disorder (ADHD) in kindergarten. She said that otherwise he was his energetic self and that the teachers didn’t complain of other behaviors.
    The teachers had not done any specific evaluations that the mother was aware of.
    The past medical history showed a healthy male with an unremarkable past medical history ADHD that was diagnosed after parent and teacher evaluations, a psychosocial assessment and normal hearing, vision and laboratory screening. He had done well in school and home with some behavioral modification.
    The family and social history showed the father was described as “energetic” and had had some difficulties reading as a child. He graduated from college and was a businessman with steady employment. Other paternal relatives were described as “energetic” also.
    There were no recent medical or psychosocial changes in the family. There were no mental illness reported in the families.
    The review of systems was negative.

    The pertinent physical exam showed a healthy 7 year old with normal growth parameters and vital signs. His examination was negative except that he was very verbal in the office describing his school and after-school activities.
    The work-up included a fuller interview with the patient who said that he liked school, had friends, and denied bullying or other problems at school or home. He said that he didn’t read as well as most of the other kids and found it hard to pay attention to the reading.
    The diagnosis of a possible learning problem in addition to the ADHD was made but the pediatrician suggested that he be re-screened for vision and hearing problems that may not have been picked up previously.
    She suggested that the school may also want to do some basic cognitive testing in addition to specific educational testing.
    The patient’s clinical course showed that he was found to have an average to above average intelligence quotient, but was borderline for his age in reading skills.
    He started a special reading program in the regular classroom and was making good progress by the end of the school year. Over the summer, the family was gong to do extra reading with him.

    Discussion
    Attentional problems are a clinical diagnosis.
    Some people use a functional definition of attentional difficulties that disrupt the normal activities of the patient and/or family.
    Attention Deficit Disorder (with or without hyperactivity, i.e. ADD, ADHD) has specific criteria for its diagnosis using the Diagnostic and Statistical Manual (version IV).

    Children with attentional problems present in a wide variety of ways, including poor school performance, behavioral problems, personality changes, and inappropriate or antisocial behavior. History is very important and should include school history with results of other evaluations, typical day activities and behaviors, birth history (including possible teratogens and substance abuse), developmental history (including possible loss of milestones), social history including use of discipline and possible abuse, and family history (including learning disabilities, mental illness and genetic abnormalities).
    Family members impressions of strengths, weaknesses, and if the child reminds them of another family member are often revealing.
    ADD/ADHD can exist alone, be co-morbid or be mistaken for another problem. Co-morbid conditions include various developmental disorders (including learning disorders), anxiety disorders, conduct disorder, oppositional defiant disorder, and mild mental retardation.
    Physical examination should include a thorough neurological examination for subtle or overt neurological abnormalities (for immaturity or gross abnormality of the CNS, and sensory deficits).
    The evaluation should include an extensive history and physical examination, vision and hearing testing (for sensory deficits), academic assessment including observations from classroom teachers (for learning disabilities), and psychological screening (for psychological/social assessment).
    Parental observations by structured questionnaires may reveal other information not gathered by interview.
    The initial evaluation may necessitate further workup with cognitive testing (for mental retardation), EEG (for seizures), blood testing (for substance abuse, lead, hyperthyroidism), etc.

    Treatment depends on the underlying cause. Often, acknowledgment of the problem and appropriate educational, psychological, and social supports will improve the attention of the child. Supporting the parents in understanding the problem and supporting their efforts with the patient are very important.
    Treatment of primary ADD/ADHD requires a multimodal approach. The mainstays are the understanding of the problem by parents, family, and teachers, behavioral modification, appropriate educational placement, and psychological support. Stimulant medication may also be used for certain patients but is not effective by itself and should only be used in addition to other services. Stimulant medication should never be viewed as a “magic pill.” Consultations with psychiatrists, psychologists, developmental pediatricians or other qualified consultants are often also helpful.

    Learning Point
    The differential diagnosis for attention problems includes:

    • Normal Development
    • Prematurity
    • Developmental Disorders
      • Autism/Pervasive Developmental Disorder
      • Language Disorder
      • Learning Disabilities
      • Primary Attention Problems, i.e. ADHD, ADD
      • Sensory Deficit – hearing, vision
    • Metabolic Disease
      • Iron Deficiency
      • Heavy Metals – lead
      • Hyperbilirubinemia
      • Medication Side Effects
    • Congenital/Genetic/Neurological Disease
      • Congenital Infection
      • Fetal Alcohol Syndrome
      • Genetic Disorders, i.e. Fragile X, Turner Syndrome
      • Inborn Errors of Metabolism
      • Neurotrauma
      • Mental Retardation
      • Seizures, i.e. petite mal, temporal lobe
    • Other
      • Boredom
      • Fatigue
      • Hunger
      • Hyperthyroidism
    • Psychiatric Problems
      • Anxiety
      • Attachment Disorder
      • Bipolar Disorder
      • Conduct Disorder
      • Dissociative Disorder
      • Depression
      • Disruptive Behavior Disorder
      • Mood Disorder
      • Oppositional Defiant Disorder
      • Personality Disorder, i.e. aggression, antisocial behavior
      • Post-traumatic Stress Disorder
      • Psychosis, i.e. schizophrenia
      • Substance Abuse
      • Tourette Syndrome
    • Social Problems
      • Abuse
      • Family Stress (including Attachment Disorder)
      • Normal communication problems – i.e. different languages, cultural and ethnic differences
      • Parenting, Ineffective
      • Poverty
      • Teaching, Ineffective

    Questions for Further Discussion
    1. What standardized parent and teacher questionnaires are available for evaluating attentional problems?
    2. What types of behavior modifications are often recommended in educational settings for children with attentional problems?
    3. What mental health professionals are available in your local community to help co-manage children with attentional problems?
    4. What educational professionals are available in your local community to help co-manage children with attentional problems and learning problems?

    Related Cases

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

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Learning Disorders and Attention Deficit Hyperactivity Disorder.

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

    To view images related to this topic check Google Images.

    Wender E. Hyperactivity in Behavioral and Developmental Pediatrics. Parker S and Zuckerman B. eds. Little Brown and Co. Boston, MA. 1995;185-94.

    Borowsky, IW. Attention Deficit/Hyperactivity Disorder, in Pediatrics A Primary Care Approach. Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;404-407.

    American Academy of Pediatrics. Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics. 2000;105(5):1158-1170.

    Behavenet Clinical Capsule. Bellevue, WA.
    Available from the Internet at http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm (rev. 2009, cited 12/7/2009).

    Wilms Floet A, Scheiner C, Grossman L, Attention-Deficit/Hyperactivity Disorder. Pediatrics in Review. 2010;31:56-69

    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 competently 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.

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

    Author

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