When Should a Child Start Toilet Training?

Patient Presentation
A 2-year-old female came to clinic for her well child check. The parents had no concerns and she was developing normally. The past medical history was non-contributory. The pertinent physical exam showed a healthy female with growth parameters in the 75-90%.

The diagnosis of a healthy female was confirmed. The parents asked about when to begin toilet training. The pediatrician recommended to follow the child’s cue and when she seemed interested, could verbalize her toileting wants/needs, seemed to not like soiled or wet diapers, and could take care of at least part of her clothing, then they probably would have more success with trying to train her. The pediatrician warned that the child could be slow to toilet train while others did it quite quickly, and that staying dry at night would come much later.

Discussion
Toilet training is a normal developmental process but has very little research. In 1962 Dr. Barry Brazleton published the first standardized method using a “child readiness” approach that was unregimented and child-focused. The child had to be physiological and psychologically ready and the parent had to be psychologically ready to proceed with toilet training. Studies beginning at 18 months of age using this approach had a mean daytime continence achieved by 28 months. In 1973, Azrin and Foxx described a method that was structured and parent-focused. Again both the child had to be physically and psychologically ready and the parents had to be psychologically ready. In smaller studies this approach were trained in several hours.

Readiness cues for toilet training from the literature have been looked at. Unfortunately which signs predict success are lacking. Part of this is due to the inconsistent definitions. For example does toilet training success mean being dry when while awake (i.e. still needs a diaper during naps) or is dry during all daylight hours? Does success mean recognizing that he/she needs to toilet and can wait until an adult helps with clothing, or does that mean that the child recognizes the urge, takes care of all clothing, successfully uses the toilet and performs all his/her own hygiene along with replacement of clothing? Developmental readiness also depends on which cue is used to determine the readiness. Below is a list developed from the literature and the range of ages in months when most children can perform them.

    Months Cue
    2-25 – Child imitates toileting behavior
    4-16 – Child is capable of sitting stable and without assistance on toilet/potty chair
    8-18 – Walks without help
    9-18 – Able to pick up small objects
    9-24 – Can say No as sign of independence
    9-24 – Has voluntary control over bladder and bowel reflex actions
    9-27 – Responds to directions and simple commands
    9-36 – Indicates need to toilet by non-verbal cues or by words
    10-22 – Enjoys putting things in containers
    12-24 – Awareness of bladder sensations and need to void
    12-27 – Understanding toilet-related words and has adequate vocabulary him/herself
    12-28 – Shows interest in toilet training
    12-32 – Has a larger bladder capacity
    12-36 – Insists on completing tasks him/herself and is proud of new skills
    12-36 – Asks for toilet/potty chair
    18-24 – Is distressed by wet/dirty diapers/clothing
    18-24 – Wants to wear grown-up clothing
    18-36 – Able to pull clothing up and down
    22-26 – Is Bowel movement-free overnight
    22-27 – Able to put items where they belong
    25-32 – Can sit still on toilet/potty chair for 5-10 minutes

Learning Point
When should children start toilet training depends and there is little data to support exact timing or the best method. Today most children start to train between 18-24 months with more intensive training starting at ~27 months. When asked, parents in one study said 20.6 +/- 7.6 months.

A systematic review of 34 studies found “Both the Azrin and Foxx method and the child-oriented approach resulted in quick, successful toilet training, but there was limited information about the sustainability of the training. The two methods were not directly compared; thus, it is difficult to draw definitive conclusions regarding the superiority of one method over the other. In general, both programs may be used to teach toilet training to healthy children. The Azrin and Foxx method and operant conditioning methods were consistently effective for toilet training mentally handicapped children. Programs that were adapted to physically handicapped children also resulted in successful toilet training. A lack of data precluded conclusions regarding the development of adverse outcomes.”
An author of this systematic review states that “Toilet training should be started when both the child and parent are willing to participate” and that, “[a] positive, consistent approach to toilet training is unlikely to cause long-term harm.”

Questions for Further Discussion
1. When do you recommend that children begin toilet training?
2. Do you use any readiness cues and which ones?

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: Toilet Training

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

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Klassen TP, Kiddoo D, Lang ME, Friesen C, Russell K, Spooner C, Vandermeer B. The effectiveness of different methods of toilet training for bowel and bladder control. Evid Rep Technol Assess (Full Rep). 2006 Dec;(147):1-57.

Vermandel A, Van Kampen M, Van Gorp C, Wyndaele JJ. How to toilet train healthy children? A review of the literature. Neurourol Urodyn. 2008;27(3):162-6.

Kaerts N, Van Hal G, Vermandel A, Wyndaele JJ. Readiness signs used to define the proper moment to start toilet training: a review of the literature. Neurourol Urodyn. 2012 Apr;31(4):437-40.

Kaerts N, Vermandel A, Lierman F, Van Gestel A, Wyndaele JJ. Observing signs of toilet readiness: results of two prospective studies. Scand J Urol Nephrol. 2012 Dec;46(6):424-30.

Kiddoo DA. Toilet training children: when to start and how to train. CMAJ. 2012 Mar 20;184(5):511-2.

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.
    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 Foods Contain Carotene?

    Patient Presentation
    An 8-month-old white male came to the emergency room with his mother visibly upset. She had been in the grocery store, when a well-meaning person asked her if she knew that her son was very yellow-colored. The mother recognizing this for the first time panicked, grabbed him from the cart and came immediately to the emergency room located a few blocks away. The past medical history revealed a previously full-term, healthy infant who had been gaining weight and developmental milestones appropriately. After his 6-month health supervision visit, she had started giving him sweet potatoes, carrots and squash as part of his diet. The family history and review of systems was negative.

    The pertinent physical exam showed a smiling infant with growth parameters in the 50-75% and normal developmental milestones. HEENT showed no scleral icterus or yellowing of the mucous membranes. He was obviously yellow-colored generally with increased coloring around the nose and palms and soles. His abdominal examination was negative along with the rest of the examination. The diagnosis of carotenemia was made. The mother was calmed down and was educated about carotenemia. The infant already had a follow-up appointment with his primary care provider within the following month.

    Discussion
    Carotenemia is a common problem in infants as carotene containing foods are often the first solid foods for infants. This is a benign problem and families can be reassured. It resolves in weeks to months depending on the diet. Carotenes are not synthesized by humans and are obtained through the diet. Carotenes are ingested as amorphous solids and crystals and breakdown of cellular membranes increases the bioavailability of the carotenes. Breakdown of the walls is often mechanical (e.g. grinding up of the food), but absorption is also affected through pancreatic lipases, thyroid hormone, bile acids, dietary fiber and dietary fat.

    Carotene occurs in different forms with the most common being α, β, and γ. β-carotene is converted to Vitamin A but the conversion is so slow that even with large amounts of β-carotene Vitamin A toxicity does not occur. Carotenemia is also seen in anorexia nervosa, diabetes, hypothyroidism, liver disease and kidney disease. Some familial forms have been noted. It has also been described in large scale populations when food shortages changed diets significantly to plant-based diets such as in Europe during World War I and II.

    Carotenes are deposited in the stratum corneum of the skin because it is fat-soluble giving the skin a yellow color. It is most easily seen in the nasolabial folds, palms and soles and takes about 2 weeks to equilibrate with the blood level. As they do not have a stratum corneum, the yellow discoloration is not seen in the conjunctiva or mucous membranes making it distinguishable from hyperbilirubinemia. Also patients with carotenemia are well and do not have other symptoms of hyperbilirubinemia. To see differential diagnoses for different types of hyperbilirubinemia, click on the following: Direct Hyperbilirubinemia, Indirect Hyperbilirubinemia in Older Children, or Indirect Hyperbilirubinemia in Neonates.

    Learning Point
    Most people know that carotenes are found in yellow and orange vegetables and fruits, but they often do not appreciate the green vegetables can contain significant amounts. The underlying yellow color is masked by the presence of chlorophyll within the plants.
    Common foods that contain carotene include:

    • Fruit
      • Apricot
      • Cantaloupe
      • Mango
      • Papaya
    • Vegetable
      • Asparagus
      • Brassica – broccoli, brussel sprouts, kale
      • Cassava
      • Carrots
      • Eggplant
      • Green beans
      • Greens – beet, collard, spinach, swiss chard, many other plant leaves
      • Okra
      • Peas
      • Sweet potatoes
      • Squash including pumpkin
      • Tamarind
    • Other
      • Butter
      • Egg yolks
      • Milk
      • Palm oil
      • Coloring additives

    There are many other foods depending on the region in the world.

    Questions for Further Discussion
    1. What other foods contain beta-carotene that are indigenous to your location?
    2. What else can be included in a differential diagnoses of yellowed skin?

    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: Jaundice and Skin Conditions.

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Sale TA, Stratman E. Carotenemia associated with green bean ingestion. Pediatr Dermatol. 2004 Nov-Dec;21(6):657-9.

    Serrano J, Goni I, Saura-Calixto F. Determination of beta-carotene and lutein available from green leafy vegetables by an in vitro digestion and colonic fermentation method. J Agric Food Chem. 2005 Apr 20;53(8):2936-40.

    Karthik SV, Campbell-Davidson D, Isherwood D. Carotenemia in infancy and its association with prevalent feeding practices. Pediatr Dermatol. 2006 Nov-Dec;23(6):571-3.

    Djuikwo1 VN, Ejoh RA, Gouado I, Mbofung CM, Tanumihardjo SA. Determination of Major Carotenoids in Processed Tropical Leafy Vegetables Indigenous to Africa. Food and Nutrition Sciences, 2011, 2, 793-802 793.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

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

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author

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

  • What Evaluation Should Be Considered for Heavy Menstrual Bleeding?

    Patient Presentation
    A 15-year-old female came to clinic for her health supervision visit. During the visit she said that although her periods were regular she had heavy bleeding that was interfering with running and swimming. She said that she would soak a pad and tampon every hour during the first 1-2 days then for the next 1-2 days she would soak a pad and tampon every 2-3 hours. On days 5-6 she would soak a pad or tampon every 6 hours. She said she had some cramping on day 1 of her periods but ibuprofen usually took care of the pain. Her menses lasted 5-6 days and occurred every 28-29 days almost since menarche at almost 12 years of age. She denied sexual activity or any bleeding problems. She said that sometimes she was more tired but attributed it to increased sports activities and staying up late to finish homework. Her exercise program included working out with her teammates during and just before the competitive seasons. She ran and swam for fun otherwise. She denied any eating disorders. The past medical history was non-contributory. The family history was negative for bleeding disorders, cancer or gynecological problems. The review of systems was negative including changes in hair or skin, heat or cold intolerance, epistaxis, easy bruising or bleeding.

    The pertinent physical exam showed a well-developed female with a weight at the 10-25%, height at the 75% with a BMI of 16.4. These were consistent with previous measurements and she was appropriately gaining weight. HEENT was negative including normal hair texture, thyroid and teeth. She was Tanner V for breast and pubic hair and her external genital examination showed no clitoromegaly and normal introitus. The diagnosis of heavy menstrual bleeding was made. The physician explained that the most likely reason was still anovulatory cycles, however other possibilities existed such as hypothyroidism or a bleeding problem. She also explained that usually this was treated with hormonal therapy, most often with contraceptive pills, but that there were other options such as an intrauterine device or vaginal contraceptive ring. After more discussion the teen and her mother decided that they wanted to discuss the issue with a gynecologist and do the appropriate evaluation at one time with the gynecologist. A referral was made. The physician did suggest that the teen eat an iron-rich diet or take a general multivitamin with iron in it. She also recommended that the girl use ibuprofen throughout her periods to possibly help decrease the bleeding.

    Discussion
    Heavy menstrual bleeding is a common problem. The rates depend on the population and underlying cause, but can occur 30% of adolescent females who go to a gynecologist. Average menstrual blood loss is 30-40 ml. Hypermenorrhea or menorrhagia are regular menstrual cycles that last too long (>7 days) or are too heavy (> 80 ml blood loss). Metrorrhagia is irregular menstrual bleeding. Menometrorrhagia is abnormally heavy bleeding that occurs with an irregular timing. Dysfunctional uterine bleeding is a more generic term describing prolonged, excessive or frequent, unpatterned uterine bleeding that is not related to an anatomical uterine abnormality or systemic cause.

    Adolescents can have a very difficult time accurately describing their menses but abnormal bleeding is considered pathologic if “…menstrual loss requiring pad or tampon changes every 1-2 h, with anything longer resulting in ‘flooding’ or ‘accidents’….” Problems associated with heavy menstrual bleeding include anemia, fatigue, missed school and difficulties participating in social and sporting activities. For young women with various disabilities it may offer the additional challenge of difficulty with managing menstrual hygiene.

    Causes of heavy menstrual bleeding include:

    • Anovulation – most common cause and is normal in the first 2-3 years after menarche due to the immature hypothalamic-pituitary-ovarian axis
    • Pregnancy and pregnancy related complications
    • Genitourinary infections especially chlamydia and gonorrhea
    • Bleeding disorders
      • von Willebrands disease
      • Thrombcytopenia
    • Drugs
      • Contraceptives including intrauterine devices
      • Anticoagulants
      • Androgens
      • Antipsychotics
    • Endocrine
      • Hypothyroid
      • Hyperthyroid
      • Hyperprolactinemia
      • Adrenal disease
      • Ovarian problems such as polycystic ovary syndrome (PCOS) or ovarian failure
    • Systemic disease
      • Diabetes
      • Renal disease
      • Systemic lupus erythematosus
    • Trauma
    • Tumors of the GU tract- uncommon but can occur

    Treatment depends on the acuity and severity. Some patients need to be hospitalized and aggressively managed. In addition iron rich foods are recommended for all adolescents but especially those with heavy menstrual bleeding. Non-steroidal anti-inflammatory medications (600-1200 mg/day) have been shown to improve the bleeding too. For patients with chronic heavy menstrual bleeding hormonal treatment is usually prescribed. Combined contraceptives in the form of pills, patches or contraceptive ring are used. Progesterone only treatment is also a potential option in the form of progestin only pills, levonorgestrel intrauterine devices and implants.

    For other information see What is the Treatment for Dysfunctional Uterine Bleeding? and
    What Are Indications for IUD Use in Teens?.

    Learning Point
    The initial evaluation for menorrhagia depends on the history and physical examination but often includes:

    • Pregnancy test
    • Sexually transmitted infection screening for chlamydia and gonorrhea
    • Complete blood count
    • Prothrombin time (PT)
    • Partial thromboplastin time (PTT)
    • Fibrinogen
    • von Willebrand Factor panel
    • Thyroid stimulating hormone
    • Prolactin

    Some clinicians will do iron studies during the initial evaluation. Also additional bleeding disorder studies may be ordered if a disorder is suspected such as ristocetin cofactor activity and Factor VIII. If PCOS is initially suspected then testosterone and dehydroepiandrosterone sulfate should also be considered. Pelvic ultrasound is also an initial consideration depending on the circumstances.

    Questions for Further Discussion
    1. At what age is normal menarche?
    2. At what age should an evaluation for late menarche begin?
    3. What are treatment options for menstrual cramps?

    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: Menstruation

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Gray SH, Emans SJ. Abnormal vaginal bleeding in adolescents. Pediatr Rev. 2007 May;28(5):175-82.

    Grover S. Bleeding disorders and heavy menses in adolescents. Curr Opin Obstet Gynecol. 2007 Oct;19(5):415-9.

    Sokkary N, Dietrich JE. Management of heavy menstrual bleeding in adolescents. Curr Opin Obstet Gynecol. 2012 Oct;24(5):275-80.

    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.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    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.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

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

  • How Do You Treat Pinworms?

    Patient Presentation
    A 5-year-old male came to clinic with a history of constipation and anal itching. The anal itching had been occurring for over 1 month and was worse at night. He would wake his mother because of the itching and scratching. His mother said he had scratches on his bottom that then became so sore that the patient began to retain his bowel movements because of the irritation and soreness. This had been happening for about 2 weeks. “His cousin had pinworms a few months back, so I tried that pinworm medicine from the store, but it didn’t seem to help,” she noted. The past medical history was non-contributory. The pertinent physical exam showed a small but healthy appearing male with normal vital signs and growth parameter in the 10-25%. His perianal area had multiple excoriations. The diagnosis of presumed pinworm infection and secondary constipation was made. Because the cousin and several other extended family members frequently visited the home for extensive time periods, the patient and all the household and extended family members were treated with mebendazole. Hand hygiene and environmental control measures were discussed with the family. The clinical course 3 months later showed that although he was not reinfected, a female cousin had also developed pinworms. Everyone had been retreated and no one else had developed pinworms since.

    Discussion
    Pinworm infection is a parasitic infection caused by the roundworm, Enterobius vermicularis. A person is directly infected by fecal-oral transmission of eggs or indirectly such as through contaminated clothing or bedding. It is frequently seen in children and can easily pass to family members especially in crowded conditions. People can become easily reinfected. It is endemic worldwide. Incubation period is usually 1-2 months and eggs can survive outside humans for 2-3 weeks. Humans are the only known reservoir.

    Adult worms migrate at night from the anus to the perianal skin and vulvar areas causing anal or vulvar itching. The itching can cause sleep problems and scratching can cause secondary bacterial infection. The worms can exist in alternative locations such as the vagina, Bartholin’s glands and the urethra. Other distant sites such as the appendix have also been cited in the literature.

    Diagnosis is by direct visualization of the adult worms about 2-3 hours after sleep or by the “scotch-tape test” where upon wakening the patient has clear cellophane tape applied to the perianal skin. The tape is then reviewed under a microscope to identify the adult worms. See To Learn More below for images of pinworms. In many cases pinworms are treated presumptively because of the difficulty of obtaining specimens.

    Learning Point
    Treatment for pinworms is by antihelminthic agents such as mebendazole, albendazole, and pyrantel pamoate. Pyrantel pamoate is available over the counter in the US. Medications are given at diagnosis and 2 weeks later because all the eggs may not have been killed with the first dose. In high risk situations, all household or similar members should be treated concurrently. As reinfection is high, subsequent infections are treated the same way.

    Hand-washing is imperative for infection control. Hygiene including daily bathing, frequent clothes changing and laundering along with avoidance of long fingernails or nail biting is helpful.

    Items to be laundered should not be shaken to decrease the risk of transmitting eggs into the environment and should be placed directly into a washer. Items should be washed in hot water and dried in a hot dryer to kill any eggs. Underclothes and bedlinens should be changed first thing in the morning to decrease the risk of environmental transmission.

    Questions for Further Discussion
    1. What is the most common parasite in your location?
    2. What is the most common helminth in your location?
    3. What causes intense pruritis?

    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: Pinworms

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Maki AC, Combs B, McClure B, Slack P, Matheson P, Wiesenauer C. Enterobius vermicularis: a cause of acute appendicitis in children. Am Surg. 2012 Dec;78(12):E523-4.

    Huh S, Cunha, BA. Pinworm Treatment and Management. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/225652-treatment (rev. 10/26/2012, cited 11/12/13).

    Centers for Disease Control. Pinworm (Enterobiasis, Oxyuriasis, Threadworm). Available from the Internet at http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/pinworm-enterobiasis-oxyuriasis-threadworm (rev. 8/1/2013, cited 11/12/13).

    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.
    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.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • 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