When Will I Know Which Hand She Will Use?

Patient Presentation
A 3-year-old female came to clinic for her health supervision visit.
During the visit she drew on the chalkboard a circle with two lines sticking out of it representing limbs. When she was asked to draw her dog, she switched the chalk to the other hand and continued drawing. Her mother noted that the preschooler switched hands often while drawing, and wanted to know when she would develop a hand dominance. The pertinent physical exam showed a healthy female with growth parameters in the 75-90%. Her examination was normal including her neurological examination. The diagnosis of a healthy preschooler was made. The resident wasn’t entirely sure when children develop hand dominance but told the mother that he was sure that it was common at her age to use both hands with writing but by around kindergarten most children had developed a hand dominance.

Discussion
Most children and adults do develop a hand dominance. Right-handedness is more common (70-90%) than left-handedness (8-10%). In many western cultures, right-handedness was/is considered the “correct” or “right” hand to use, and left-handedness was unlucky, inauspicious or frankly evil. The word “sinister,” meaning left-sided, derives from various sources as early as the 15th century. There are numerous instances of left-handedness being associated with wickedness. For example, the devil is often portrayed as left-handed, and people throw salt over their left shoulder to ward off the evil spirits that dwell there.

Many left-handed people report being able to use their right hand very well for certain tasks because of needing to adapt to tools which are usually designed for right-handed people such as scissors, golf clubs, etc. Some people are also mix-handed, where they perform some tasks with one hand and other tasks with the opposite hand. Some people have true ambidexterity where they can perform tasks equally well with both hands.

Learning Point
Children begin to develop hand dominance around 2-3 years and this should be well developed by age 5 and fully developed by age 6. Use of a dominant hand before 2-3 years time may occur because of abnormal fine motor development. It could also be the result of intracranial injury or injury to a limb with appropriate compensation by the other limb. Development of hand dominance after 6 years, again may indicate abnormal development. Referral to an occupational therapist may be indicated, and referral indications can be reviewed here.

Questions for Further Discussion
1. When do children develop eye dominance?
2. Do people develop right- or left-footedness?
3. What are the potential advantages of right- or left-handedness?
4. What Gessel figures should a 3 year old be able to draw? 4 year old?
5. Can a left-handed dominance be changed after it develops?

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 this topic: Toddler Development

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

To view images related to this topic check Google Images.

Sinister. Merriam-Webster Dictionary. Available from the Internet at http://www.merriam-webster.com/dictionary/sinister (rev. 2011, cited 2/2/11)

Wilms Floet AM, Maldonado-Duran JM, Motor Skills Disorder. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/915251-overview (rev. 1/22/10, cited 2/2/11).

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.
    5. Patients and their families are counseled and educated.
    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.

    Author

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

  • What Causes Rhabdomyolysis?

    Patient Presentation
    A 6-year-old male came to the emergency room with rhinorrhea, fever, and malaise. He also had muscle aches and a cough that were getting worse for 2-3 days. Schoolmates had had similar problems. The past medical history was non-contributory. The pertinent physical exam showed an ill-appearing male with temperature of 101.8 degrees, and normal vital signs. Growth parameters were 25-50%. HEENT showed clear rhinorrhea and an erythematous pharynx. Chest showed some crackles at the right base. Heart had a normal S1, S2 without murmur. Abdomen was mildly tender diffusely that appeared more muscular. There was no hepatosplenomegaly or masses. Muscles were diffusely tender. There was no rash.

    The laboratory evaluation included a complete blood count with a white blood count of 12.8 x 1000/mm2 and some toxic vacuoles. A rapid strep test and rapid influenza test were negative. The radiologic evaluation of a chest radiograph showed a small infiltrate at the right base. The patient was diagnosed with community-acquired pneumonia but during discharge needed to urinate and produced brown-colored urine. The laboratory evaluation included a urinalysis that showed a specific gravity of 1.020, significant protein and no red blood cells. His liver function tests, protein and albumin were normal. Electrolytes were normal except for a potassium of 4.7 mg/dl, BUN of 35 mg/dl and creatinine of 2.1 mg/dl. His creatine kinase was 8735 U/L and the diagnosis of rhabdomyolysis was made. Over the next 12 hours, he was aggressively treated with intravenous fluids with bicarbonate, but developed oliguria. He also became more tachypnea and required oxygen, but did not develop any arrhythmias. He was started on ceftriaxone and azithromycin to treat for possible staphylococcus, streptococcus and mycoplasma. He then developed a pericardial effusion and was transferred to the intensive care unit. During his hospital stay he was diagnosed with Mycoplasma pneumoniae based upon polymerase chain reaction and IgM antibodies. His clinical course included developing pericarditis, myocarditis, oliguria without renal failure and hemolytic anemia in addition to the rhabdomyolysis. He recovered and was doing well 2 years later.

    Discussion
    Rhabdomyolysis was first described in 1881, and in 1941 a case series of crush victims from the Battle of Britain described rhabdomyolysis and subsequent acute renal failure.

    Injury to the skeletal muscle that results in leakage of the intracellular content into the plasma defines rhabdomyolysis or literally the dissolution of the skeletal muscle. Causes of the initial injury are numerous (see below). Rhabdomyolysis in adults is classically described by muscle weakness, myalgia and dark urine. But this triad is not common in children. In a 2005 study of 210 children, 45% had myalgia, 38% had muscle weakness, and 3.6% had dark urine. Only 1 patient had all 3 symptoms. Other signs and symptoms include fever, nausea, emesis, abdominal tenderness and decreased reflexes.

    Laboratory testing for rhabdomyolysis includes creatine kinase (CK) which usually rises within 12 hours, peaks at 24-36 hours and then decreases 35-40% per day. Therefore levels that are not decreasing after the appropriate time indicate continued insult. The peak CK may be predictive of acute renal failure. Urine myoglobin may be helpful when hematuria co-exists but is not as reliable as CK.

    Treatment of the underlying cause is obviously important. Aggressive hydration with initial bolus hydration and then 2-3 times maintenance is usually recommended. Intravenous fluid with sodium bicarbonate to alkalinize the urine is often used. Mannitol may also be used for diuresis. Consultations with nephrology, genetics, rheumatology, surgery, critical care, and others can assist in managing the insult and the treatment of rhabdomyolysis. Dialysis is used to treat acute renal failure. Electrolyte abnormalities including hyperphosphatemia, hyperkalemia, hypocalcemia, hyperuricemia, hypoalbuminemia must be aggressive monitored for and managed. Other complications include disseminated intravascular coagulation, cardiac abnormalities, seizures and death.

    Learning Point
    The list of causes of rhabdomyolysis is extensive. In the pediatric population common causes are viral (especially Influenza A and B), trauma and connective tissue disease.
    Causes of rhabdomyolysis include:

    • Infectious
      • Bacterial
        • Bacillus cereus
        • Borrelia burgdorferi
        • Clostridium perfringens
        • Clostridium tetani
        • Francisella tularensis
        • Escherichia coli
        • Legionella
        • Leptospira
        • Mycoplasma
        • Staphylococcus epidermidis
        • Streptococcus
        • Salmonella
        • Vibrio family
      • Fungal
        • Aspergillus
        • Candida
      • Viral
        • Adenovirus
        • Cytomegalovirus
        • Echovirus
        • Epstein-Barr virus
        • Herpes family
        • Human immunodeficiency virus
        • Influenza A
        • Influenza B
        • Parainfluenza
        • West Nile virus
      • Parasite
        • Plasmodium
        • Rickettsia
      • Pyomyositis
      • Sepsis
  • Drugs (reactions, overdose or abuse)
    • Amphetamine
    • Amphotericin B
    • Aminocaproic acid
    • Anesthetics
    • Anticholinergic agents
    • Antihistamines
    • Antilipemics including statins
    • Antipsychotics
    • Caffeine
    • Corticosteroids
    • CO poisoning
    • Ethanol
    • Ethylene glycol
    • Fibric acid derivatives
    • Heroin
    • Hemlock
    • Isopropranol
    • Ketamine
    • MDMA or Ectasy
    • Lysergic acid diethylamide or LSD
    • Methanol
    • Narcotic – especially cocaine
    • Nutritional supplements
    • Phenylcyclidine
    • Propofol
    • Protease inhibitors
    • Quinine
    • Salicylates
    • Sedatives
    • Selective serotonin reuptake inhibitors
    • Sympathomimetic agents
    • Theophylline
    • Toluene
  • Genetic
    • Carnitine deficiency
    • Carnitine palmityl transferase deficiency
    • Glycogen phosphorylase deficiency
    • Mitochondrial respiratory chain enzyme deficiencies
    • Myoadenylate deaminase deficiency
    • Neuroleptic malignant syndrome
    • Malignant hyperthermia
    • Phosphofructokinase deficiency
    • Phosphoglycerate mutase deficiency
    • Phosphoglycerate kinase deficiency
    • Porphyria
  • Metabolic
    • Diabetic ketoacidosis
    • Hypokalemia
    • Hypo- or hypernatremia
    • Hypophosphatemia
    • Hypo- or hyperthyroidism
    • Non-ketotic hyperosmolar diabetic coma
  • Neurological
    • Dystonia
    • Guillain-Barre syndrome
    • Muscular dystrophy
    • Myalgias
    • Seizures
  • Rheumatological
    • Inflammatory myositis
    • Systemic lupus erythematosis
    • Sarcoid
  • Trauma
    • Asphyxia
    • Burns
    • Compartment syndrome
    • Crush injury
    • Electric shock
    • Envenomation (snake or insect)
    • Exertion – particularly if deconditioned
    • Heat related injuries – both hypo- and hyper-thermia
    • Near drowning
    • Lightening strike
    • Shaken-baby syndrome
  • Miscellaneous
    • Acute psychosis
    • Hyperosmotic conditions
    • Prolonged immobilization
    • Status asthmatics

    Questions for Further Discussion
    1. What are the clinical manifestations of mycoplasma?
    2. How common is rhabdomyolysis?

    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: Pneumonia and Muscle Disorders.

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

    To view images related to this topic check Google Images.

    Bywaters EG, Beall D. Crush injuries with impairment of renal function. Br Med J. 1941;1:427-432.

    Bywaters EG, Stead J. The production of renal failure following injection of solution containing myohaemoglobin. Q J Exp Physiol. 1944;33:53-70.

    Kasik JW, Leuschen MP, Bolam DL, Nelson RM. Rhabdomyolysis and Myoglobinemia in Neonates. Pediatrics 1985;76;255-258.

    Berger RP, Wadowksy RM, Rhabdomyolysis Associated With Infection by Mycoplasma pneumoniae: A Case Report. Pediatrics 2000:105;433-436.

    Mannix R, Tanb ML, Wright R, Baskin M. Acute Pediatric Rhabdomyolysis: Causes and Rates of Renal Failure. Pediatrics 2006:118;2119-2125.

    American Academy of Pediatrics. 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;227,731.

    Muscal E, Morales de Guzman M, Rhabdomyolysis. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/1007814-overview (rev. 4/27/2010, cited 1/31/11).

    Craig S, Rhabdomyolysis. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/827738-overview (rev. 12/6/2010, cited 1/31/11).

    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.
    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.

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

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

  • 300th Case for PediatricEducation.org

    We are pleased to announce that the case today is PediatricEducation.org’s 300th case!

    Over the past 6 years, we have tried to offer a breadth of cases, which have aggregated into this unstructured curriculum of pediatric topics that also closely parallels the structured curriculum of a pediatric residency, fellowship and continuing medical education programs.

    We appreciate your continued patronage. As always we are looking for suggestions for new cases, ideas to improve the digital library and we would also like to hear about how you are using the cases for self-education or teaching of students.
    Please send your comments to: http://www.pediatriceducation.org/sendcomments

    Respectfully yours,
    Donna M. D’Alessandro and Michael P. D’Alessandro
    Curators, PediatricEducation.org

    What Causes a Bulging Anterior Fontanelle?

    Patient Presentation

    A 6-month-old female was admitted with fever, fussiness and a bulging anterior fontanelle. The symptoms began approximately 8 hours before coming to the emergency room. The experienced mother noted the bulging fontanelle and said that “I just can’t get her to calm down.” The past medical history showed a healthy term female with current immunization status. The last set of immunizations had occurred two weeks previously. The review of systems showed no emesis, diarrhea, rash, localized pain, or strange movements. She had been drinking and was making wet diapers.

    The pertinent physical exam on admission to the floor after the emergency medicine evaluation revealed a tired and very fussy infant with temperature of 38.4 degrees C, with other vital signs normal and growth parameters of 75-90%. She had a bulging but balottable anterior fontanelle when in a seated position. There was no head bruit. The rest of the examination was normal including her neurological examination. The work-up in the emergency room included complete blood count with a white blood cell count of 8.8 x 1000/mm2, C-reactive protein of 1.4 mg/dl and a lumbar puncture with 3 red blood cells, no white blood cells, glucose of 62 mg/dl and protein of 14 mg/dl with a negative gram stain. Electrolytes including phosphorous, urinanalysis, and a respiratory viral panel including influenza and respiratory syncytial virus were normal. The radiologic evaluation included a normal chest radiograph and head computer tomography.

    The diagnosis of possible meningitis was made. The patient’s clinical course showed that she was given meningitic doses of ceftriaxone and over the next 36 hours her temperature became normal and her anterior fontanelle returned to normal. She had become happy and playful by 24 hours after admission. All cultures were eventually negative including testing for herpes simplex virus. Because she had bulging fontanelle and laboratory testing was negative and also not consistent with aseptic meningitis, a small workup for causes of benign intracranial pressure was performed during admission including Vitamin A and D levels and thyroid levels. The mother denied any medications, soaps, lotions or other products which may have contained Vitamin A or steroids. Her neonatal metabolic screening was also rechecked and was negative including galactosemia. She was discharged home to follow with her regular care provider but her workup had not identified a specific cause of the bulging fontanelle.

    Discussion
    Included in the physical examination of the young child is palpation of the head. The posterior fontanelle is usually 1-2 cm at birth and closes around 1-2 months of age. The anterior fontanelle is usually 4-6 cm in size at birth and closes at 4-26 months of age. The fontanelle should be palpated in the upright position, and usually it is slightly depressed relative to the bony rim. Therefore a fontanelle that is level with the rim, or bulging above the rim, are both considered abnormal. A child in a recumbent position will normally have a fontanelle that is level or above the bony rim because of differences in pressure recumbent. A sunken or depressed fontanelle is usually caused by dehydration.

    A more extensive discussion about fontanelles can be found here.

    Learning Point
    The differential diagnosis of bulging fontanelle in infancy includes:

    • Infectious
      • Meningitis
      • Encephalitis
    • Cerebrospinal Fluid or Pressure Problem
      • Hydrocephalus
      • Benign intracranial hypertension
      • Crying
      • Emesis
    • Space Occupying Lesion
      • Cerebral hemorrhage
      • Intracranial abscess
      • Subdural hematoma
      • Tumor
    • Vascular
      • Sinus thrombus
    • Miscellaneous
      • Recumbent position
      • Lead poisoning
      • Transient bulging fontanelle associated with (not caused by) vaccination

    Causes of benign intracranial hypertension that would be important to consider in infancy include:

    • Drugs
      • Hypervitaminosis A
      • Steroid therapy withdrawal
    • Metabolic/Nutritional
      • Galactosemia
      • Hypoparathyroidism
      • Hypophosphatasia
      • Hypothyroidism
      • Hypovitaminosis A
      • Rapid brain growth after starvation
    • Infections
      • Roseola infantum
      • Otitis media
    • Miscellaneous
      • Allergic disease
      • Anemia
      • Carbon dioxide retention
      • Heart disease
      • Migraine
      • Polycythemia vera
      • Systemic Lupus Erythematosus
      • Wiskott-Aldrich syndrome

    Questions for Further Discussion
    1. What is the differential diagnosis of a large anterior or posterior fontanelle?
    2. Why is it called a fontanelle?

    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 this topic: Brain Malformations

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

    To view images related to this topic check Google Images.

    Stockman JA, Corden TE, Kim JJ. The Pediatric Book of Lists. Mosby Year Book, Philadelphia, PA. 1991;225-226.

    Bates B. A Guide to Physical Examiation. 3rd edition, J.B. Lippincott, and Company. Philadelphia, PA. 1983;465.

    Robertson WC. Pseudotumor Cerebri, Pediatric Perspective. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/1179733-overview (rev. 11/30/2009, cited 1/28/11).

    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.
    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
    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.

    Author

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