What Should You Do About Head Banging?

Patient Presentation
A 2-year-old male came to clinic for his health supervision visit.
His father was very proud that he could run, climb, eat by himself and was putting a couple of words together when speaking. When asked if he had any concerns, he noted that the boy would bang his head on pillows. This occurred when he was going to sleep in his bed, on a couch, or even in a stroller when he would turn his head to one side lightly striking the stroller frame. “He does it sometimes too when he gets upset,” the father described. These instances were always short-lived, occurred occasionally and the child had never hurt himself. The past medical history was non-contributory.

The pertinent physical exam showed a smiley boy, who was exploring the room and responded to his father easily. His vital signs were normal and his growth parameters were in the 10% for weight and 25% for length and head circumference. His physical examination was normal including his neurological examination.

The diagnosis of of a healthy boy was made. The pediatrician discussed that head banging or body rocking were normal behaviors for a child of this age, and that they usually improved with more time. “I’d just recommend that you just ignore it and it should go away as he gets older,” the pediatrician said.

Head banging and body rocking are common habits that young children exhibit that can be worrisome or frustrating for parents but that do not cause harm to the child. In a normally developing child they occur around 6-9 months age, and generally resolve around 2-3 years with most behaviors gone by 6-8 years. Children usually do not cause harm to themselves, but it can cause furniture to move causing noise, or potentially the child could lose balance and fall off a bed, or strike an object unintentionally and hurt themself (hit edge of a bed just right in a way that causes a small bruise). The behaviors appear to be a self-soothing behavior, that helps the child to get to sleep or to calm-down in some way. The behaviors commonly occur while going to sleep and may reoccur at night if the child awakens and then is trying to return to sleep. With body rocking the child often will be in a curled up position and may rock so vigorously that the bed shakes and even hits the room walls. Other child may just sit up and rock front-to-back or side-to-side.

While the above are normal habits, other repetitive movements can signal problems. Movement disorders can be divided into two major categories:

  • Dyskinesias or hyperkinetic movement disorders, which are repetitive abnormal involuntary movements which includes chorea, dystonia, myoclonus, tremors, tics and stereotypies.
  • Akinetic/rigid disorders or hypokinetic movement disorders which are relatively uncommon in children. The classic example is Parkinson’s disease.

Tics are usually single, repetitive, non-rhythmic, non-purposeful movements or utterances. They are usually most severe around 10-12 years of age. Motor tics usually appear 2-3 years before vocal tics but vary with the individual. Tics can last for a few weeks, months or be chronic (> 1 year of symptoms). Simple tic or provisional tics last less than 1 year. Treatment for tics can be watchful waiting and/or medication or some behavior modifications. More information about tics can be found here.

Stereotypies are “…patterned, repetitive, purposeless, involuntary movements that are also rhythmic and continual and tend to change little over time.” Examples can include finger wriggling, hand flapping or clapping, facial grimacing, walking in circles, body rocking or head nodding. Stereotypies more often occur in children with developmental disabilities, sensory impairments (e.g. blindness) or social deprivation. They can be seen in ~7% of normally developing children too. They occur at all times of the day, and can get worse with stress or heightened emotions including happiness. Their onset is before age 3 and tend to improve over years, but can persist into adulthood. Treatment includes behavior modifications and pharmacological therapy.

Learning Point
Head banging and body rocking habits are usually only a problem if they result in a non-simple injury, interfere with sleep, cause lots of household disruption, are associated with developmental delays, or are associated with other sleep issues such as obstructive sleep apnea.

As with most habits, treatment is ignoring the behavior as it generally regresses with time. Additional attention may cause the child to then seek more attention or increase tension. Punishment for the behavior can actually increase the tension that the child is trying to relieve with the habit. Parents should check that the bed is safe (check that the bolts and screws are tight, mattress is tight against railing) and the bed can be placed away from walls. If in a crib, the rail should always be up when a child is sleeping. If in a bed, a guardrail often can be placed to not have the child roll out of the bed. A child who head bangs usually does not hit with great force, or chooses soft objects to hit their head against. A child can be directed to an appropriate object such as a stuffed animal.

Questions for Further Discussion
1. How are other dyskinesias treated?
2. What are indications for referral to a developmental pediatrician or neurologist?
3. What are other sleep related movement disorders?

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 and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Mental Health, Child Behavior Disorder, and Sleep Disorders.

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.

Zinner SH, Mink JW. Movement disorders I: tics and stereotypies. Pediatr Rev. 2010 Jun;31(6):223-33.

Gwyther ARM, Walters AS, Hill CM. Rhythmic movement disorder in childhood: An integrative review. Sleep Med Rev. 2017 Oct;35:62-75.

Mackenzie K. Stereotypic Movement Disorders. Semin Pediatr Neurol. 2018 Apr;25:19-24.

Cleveland Clinic. Head Banging and Body Rocking.
Available from the Internet at https://my.clevelandclinic.org/health/articles/14305-head-banging-and-body-rocking (cited 11/15/18).

American Academy of Pediatrics. Common Childhood Habits. HealthyChildren.org.
Available from the Internet at https://www.healthychildren.org/English/family-life/family-dynamics/communication-discipline/Pages/Common-Childhood-Habits.aspx (rev. 11/21/2015, cited 11/15/18).

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

How Common is Dyscalculia?

Patient Presentation
An 11-year-old male came to clinic for his health supervision visit. He was doing well playing soccer, reading books and occasionally playing some videogames with his siblings and friends. His mother brought up that he had always struggled with math and was slower in reading. They had gotten him a tutor but last academic year he was falling farther behind. They had him evaluated by a private psychologist who diagnosed him with a specific learning disability in math and with a weakness in reading. He was doing well socially and was well-liked by friends and teachers. The mother stated, “We have gotten him a different tutor now and are going back to basics. Lots of repetition about things, using a calculator, and trying to figure out work arounds. He can remember his street address but always messes it up when he has to write it. We just put his address on a card in his backpack and he can use if he needs it.” The past medical history was non-contributory. The family history was positive for his father who also had “problems with math and reading.”

The pertinent physical exam showed a well-mannered talkative boy with normal growth patterns and vital signs. His examination was normal. The diagnosis of a healthy boy with a specific learning disability in math was made. The pediatrician asked if the mother had already contacted the school about the problem. “Oh yeah, they know and are being pretty good about helping. He already is getting help specifically in math but his teacher understands it’s a bigger problem and so is helping him during the rest of the day. He has a hard time understanding time. For example, she knows that he doesn’t understand that he might have to stop at 3:00 o’clock and will make sure he knows that is about 10 minutes time or half of recess time.”

Numerical understanding is imperative in everyday life. Even making coffee in the morning, a person considers whether she is making 1 cup or 2, and how much fluid will be in each cup. How many more days can she go without buying more coffee with the ground coffee left in the container? Other numerical skills such as telephone numbers, street addresses and locations, time and dates, and buying and selling of products and services occur all day long in people’s lives. What happens when those skills are not automatic?

Dyscalculia or developmental dyscalculia (DD) is “a heterogeneous learning impairment affecting numerical and/or arithmetic functioning at behavioral, psychological and neuronal levels.” It can also be defined as a “…domain-specific learning disorder that emerges at an early stage of development and cannot be explained by inappropriate schooling or deficient learning opportunities.” It can also be defined as a specific learning disorder. Specific learning disorders such as dyscalculia, reading or writing are “… a neurodevelopmental disorder of biological origin manifested in learning difficulties and problems in acquiring academic skills markedly below age level and manifested in the early school years, lasting for at least six months, not attributed to intellectual disabilities, developmental disorders, or neurological or motor disorders.” DD is not a term to be used for all forms of mathematical difficulties and is used for those who are severely impaired. Other terms for DD are math learning disability, acalculia, math anxiety, numerical impairment, and non-verbal learning disorder.

DD is a very heterogeneous disorder and this makes the definition and the research studies more difficult. DD is persistent into adulthood and females may be more affected than males but the studies are inconsistent. DD co-morbidities are common and include attention problems, anxiety, dyslexia, depression, spatial working memory problems and visual-spatial impairments for example.

Some examples of the development of numerical processing skills includes:

  • Basic skills include innate number sense (e.g. discerning between small quantities with greater distance), quantity discrimination skills (larger quantities, smaller distances) and subitizing. Subitizing is a basic numeric capacity where the person is able to perceive and conceptualize small quantities. In preschool children this is up to three in adults this is usually around five. People with DD have problems in 1 or more areas.

  • Number skills include mapping different numerical representations (e.g. actual quantity (***), number words (three), Arabic digits (3)), counting, place-value systems and mental number line representations (e.g. linear functions < logarithmic function). People with DD have problems such as inaccurately transferring information from one context to another. For example, the patient sees *** and write two or 2.
    Or is told 762 and writes down 700602.
    They also have problems with understanding place-value system. For example, the number is 65 but patient does not understand that the number 6 represents 6 groupings of 10.

  • Calculation skills include math by counting (i.e. 1,2,3,4,…), retrieval (e.g. math facts 2×2=4), decomposition (e.g. representing same idea in different ways (5*8 = 4*10 = 36 + 4 = 40), and learning different calculation procedures and concepts.
    For people with DD, they may have no way to recall math facts and thus may need to work each problem individually which can be very tiring and time consuming.
    For example, patients may not know 3*3 = 9, but can say to themselves, “This means 3 groups of 3, so if I add 3 plus 3 plus 3 this is 9.” Calculations and procedures can be especially troublesome.

Interestingly, functional brain imaging shows a complex fronto-parietal neuronal network at work with mathematical concepts. With development there is more focal recruitment of brain areas (more towards the parietal lobes) and less on supporting general brain function (more in the frontal lobes). In people with DD, the patterns are less precise and there is recruitment of other brain areas such as those involved with attention, working memory and monitoring.

Current interventions include individual training, repetition, and working on curricular and non-curricular numerical topics. Help for co-morbidities is important. Some other daily life interventions include use of calculators for routine math facts, using graph paper to help with organization of the numbers into columns, or separating money into different piles (so someone doesn’t confuse a $1 with a $10 which look alike). Street addresses can be programmed into cellphones with driving instructions given verbally when someone is actually driving. Calendars, timers, and automatic alarms are often helpful to remind people about time issues. Working with others to double-check someone’s math, is helpful for almost everyone and especially helpful for someone with DD. Using people’s strengths to support their weakness is also important. For example, someone with better verbal or memory skills may rehearse an address over and over.

Learning Point
It is estimated in a United Kingdom study that 22% of adults have some type of mathematical difficulty that causes occupational or practical problems.
DD with its more restrictive definition has a prevalence rate of 3-6%.

Questions for Further Discussion
1. What is the definition of dyslexia and how common is it?
2. What is an individualized education plan?
3. What is a 504 plan?

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 and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Learning Disabilities

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.

Kaufmann L, Mazzocco MM, Dowker A, von Aster M, Gobel SM, Grabner RH, Henik A, Jordan NC, Karmiloff-Smith AD, Kucian K, Rubinsten O, Szucs D, Shalev R, Nuerk HC.
Dyscalculia from a developmental and differential perspective. Front Psychol. 2013 Aug 21;4:516.

Kucian K, von Aster M. Developmental dyscalculia. Eur J Pediatr. 2015 Jan;174(1):1-13.

Dyscalculia.org. Available from the Internet at Dyscalculia.org (cited 11/13/18).

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

What Are Common Causes of Blindness in Children?

Patient Presentation
An 8-year-old male came to clinic because of increased fussiness, fever to 102°F and coughing for 2 days. He had increased respiratory secretions but it was difficult to tell if he had any sputum production, as he had global cognitive delays and was cortically blind after non-accidental trauma as an 8 month old. His adoptive mother stated that he usually had increased secretions but they had become thicker and yellowish. He also had been intermittently breathing faster. The past medical history included several ear infections when he was younger, and one viral pneumonia.

The pertinent physical exam showed he was non-communicative and was doing eye-rolling which was his normal state of health. His vital signs showed 32 respirations/minute, a temperature of 101.6°F and an oxygen saturation of 97% on room air. HEENT had increased oral and nasal secretions that were pale yellow. His lungs had coarse breath sounds throughout with crackles bilaterally at the bases. His heart, abdomen and skin examinations were normal.

The diagnosis of clinical pneumonia was made and was confirmed by the radiologic evaluation of a chest radiograph which showed bilateral consolidations at the bases consistent with bacterial pneumonia. The patient was started on oral antibiotics with instructions to call if he worsened. One week later at his health supervision visit he was markedly improved with decreased secretions and improved air exchange.

According to the World Health Organization, about 1.3 billion people have some form of visual impairment. Most people with visual impairments are >50 years old, more are female than male, and more live in resource-limited areas than resource-rich areas. Most visual impairments are avoidable (80%) in all age groups with the leading causes globally and across ages being uncorrected refractive errors and cataracts.

The most common causes of blindness are:

  • Refractive errors, uncorrected
  • Cataract
  • Age-related macular degeneration
  • Glaucoma
  • Diabetic retinopathy
  • Corneal opacity
  • Trachoma

The exact numbers vary by region and country. In general there has been an improvement in the percentage of those with visual impairments but because the global population has increased, especially the older population, the actual numbers of patients have remained steady or possibly increased over the past few years.

Visual impairment for distance vision is considered mild if worse than 6/12 in meters = 20/40 in feet or 0.3 LogMAR and for moderate impairment is 6/18 meters = ~20/60 = ~0.6 LogMAR. LogMAR stands for the Logarithm of the Minimum Angle of Resolution and is considered more accurate than other charts. Near vision is considered impaired if acuity is worse than N6 or N8 at 40 cm with existing correction. N numbers are the size of the letters on the handheld card.

Normal visual acuity development occurs over the first year of life with the average neonate being > 6/60 = 20/200 = 1.0 LogMAR at birth.

Examples of some visual acuity scale equivalents

Foot 20/16 20/20 20/32 20/40 20/63 20/80 20/100
Meter 6/4.8 6/6 6/9.5 6/12 6/19 6/24 5/30
LogMAR -0.1 0.0 0.2 0.3 0.5 0.6 0.7

Learning Point

For children it is estimated that ~ 14 million are blind. Prevalence is estimated to be 3-4/10,000 children in affluent global areas and 12-15/10,000 children in very poor areas. Children that are blind have more disordered or delayed development, more likely to have other health impairments (particularly neurological) including a dramatic increased risk of death, and poorer overall socioeconomic status. Most children with blindness are diagnosed in the first year of life and especially with signs consistent with poor vision.

For children the common causes of blindness are:

  • Cerebral and optic nerve visual impairments
  • Cataract
  • Corneal opacity due to Vitamin A deficiency
  • Glaucoma
  • Infectious – Meningitis, TORCH, Measles, Rubella, Zika
  • Retinopathy of prematurity
  • Retinal disorders, inherited
  • Trauma

*Note that almost all are avoidable or treatable causes.

Questions for Further Discussion
1. What causes color blindness? A review can be found here
2. What are presentations of child abuse/child maltreatment/non-accidental trauma? A review can be found here
3. What are potential complications of pneumonia? A review can be found here

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 and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Pneumonia and Vision Impairment and Blindness</a.

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.

Stevens GA, et.al; Vision Loss Expert Group. Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990-2010. Ophthalmology. 2013 Dec;120(12):2377-2384.

Solebo AL, Teoh L, Rahi J. Epidemiology of blindness in children. Arch Dis Child. 2017 Sep;102(9):853-857.

Gudlavalleti VSM. Magnitude and Temporal Trends in Avoidable Blindness in Children (ABC) in India. Indian J Pediatr. 2017 Dec;84(12):924-929.

World Health Organization. Blindness Fact Sheet. Available from the Internet at http://www.who.int/en/news-room/fact-sheets/detail/blindness-and-visual-impairment(rev. 10/11/18,cited 11/5/18)

World Health Organization. Causes of Blindness and Visual Impairment. Available from the Internet at https://www.who.int/blindness/causes/en/ (cited 11/5/18)

LogMAR Chart. Wikipedia. Available from the Internet at https://en.wikipedia.org/wiki/LogMAR_chart (cited 11/6/18).

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

What Complications Can Gastrostomy Tubes Have?

Patient Presentation
A 2-year-old female came to clinic because of increasing rhinitis, coughing and fussiness for 2 days. Her cough was wet and was worse when she was lying down. She was afebrile, was tolerating her gastrostomy tube feedings and was urinating well. She was stooling normally and had no rashes. Her older brother and father had similar symptoms. The past medical history was positive for cognitive delay and cerebral palsy.

The pertinent physical exam showed a thin female with a respiratory rate of 36 per minute, oxygen saturation of 96% on room air and otherwise normal vital signs. HEENT showed copious clear-white rhinorrhea. Her tympanic membranes looked dull but were in a normal position without fluid. Her mouth was normal. She had a few shotty anterior cervical nodes. Her abdomen was soft, but her gastrostomy tube button (GT) site looked irritated. Neurologically she was non-communicative with spasticity throughout.

The diagnosis of a child with cognitive delay, cerebral palsy, upper respiratory tract infection and an irritated GT site was made. The mother had been worried that she had an ear infection or pneumonia as she had had these problems in the past. “The GT started to leak a couple of days ago. Usually, just drying it more often works, but I started the triamcinolone cream this morning. She has an appointment with the GI doctors in 2 days so I haven’t called them about it,” the mother stated. “I think that is fine but if it gets worse you probably should call them. Probably coughing isn’t helping because then the button top can irritate the skin more too,” the pediatrician replied.

Gastrostomy tubes (GT or GTubes) have been used to support patients for about a century. They are placed between the abdominal skin and the stomach either percutaneously or surgically. The tubes can be a standard long tube with either a bumper or inflatable balloon internally and externally they have a retention piece to hold the GT in place. A button or low profile tube are similar but extend just beyond the skin.

Reasons for GT placement include:

  • Nutritional support
  • Hydration maintenance
  • Medication management
  • Aspiration avoidance
  • Gastric stasis decompression
  • Obstruction bypass
  • Quality of life improvement for caregivers

They are very effective tools but do not always improve the quality of life for all individuals and the cost of care for a child with a GT significantly increases.

Fundoplication may be performed at the same time as GT placement to try to decrease gastroesophageal reflux and aspiration. It takes approximately 8 weeks for the GT site to heal. If the GT falls out before this, it should be replaced by the inserting specialist. After 8 weeks and with the opening visible, it is possible for other trained individuals to replace the tube. This is for most patients, but will depend on the actual individual. While healing, the site should be cleaned and monitored per the inserting specialist’s instructions. After healing, GTs should be cleaned daily with soap and water and dried thoroughly. Patients can be bathed and can swim with the GT following the instructions of the inserting specialist after the appropriate amount of time for healing.

Common problems include:

  • Leaks are relatively common and can be treated by using a gauze dressing, but if very irritated then triamcinolone cream may be helpful to decrease the inflammation. Persistent leaks may indicate a broken internal balloon or that the GT needs to be replaced.
  • Granulation tissue that can build up near the GT is also usually treated with triamcinolone cream but other options include stomahesive power, silver nitrate, cryotherapy and if recalcitrant, surgical debridement.
  • Cellulitis should be treated with topical or oral antibiotics as appropriate. Methicillin-resistant Staphlococcus aureus is the most common cause.
  • GTs can become blocked also. Small amounts of saline or water can be instilled and after a period of time (~30 minutes) flushing can be attempted. If it cannot be cleared then it needs to be replaced. There usually are two lumens – one for nutrition and one for medications. Liquid medication is preferred to be used in the GT. After using a lumen, 5-10 cc should be flushed to try to keep the lumen open.
  • Buried bumper can result from pulling on the GTs, so attention should made to not put traction on the GT. Surgery is usually needed to fix this problem.
  • Abdominal distention can result from too much air and can be easily fixed by connecting the extension tubing and allowing air to escape. Buttons usually have a valve that must be opened to allow venting.

Learning Point
GT Complications include:

  • Intra-procedural
    • Bleeding
    • Bowel perforation
    • Cardiorespiratory arrest
    • Collapsed lung
    • Death
    • Esophageal tear
    • Hemoperitoneum
    • Intraoperative laceration
    • Pneumoperitoneum
  • Post-procedural
    • Abscess
    • Bleeding
    • Death – related or unrelated to GT
    • Diaphragmatic dysfunction
    • Fever
    • Fundoplication wrap failure
    • Gastric prolapse
    • Gastric pseudopolyp
    • Gastric residue
    • Gastric separation
    • Gastroesophageal reflux
    • Gastrointestinal blockage
    • GT problems
      • Buried bumper
      • Dislodged
      • Leakage
      • Migration
      • Obstruction
      • Pulled out, intentional
      • Removal, re-operation or relocation
      • Malfunction – clogging, breaking
    • Hernia
    • Hospital admission
    • Intussuception
    • Megacolon
    • Nasogastric tube obstruction
    • Obesity
    • Pain
    • Pancreatitis
    • Perforation of stomach wall
    • Pneumonia
    • Prolonged oxygen use
    • Pseudotumoral proliferative gastric mucosa
    • Rectus sheath hematoma
    • Respiratory insufficiency
    • Sepsis
    • Stomach flu
    • Tract dehiscence
    • Ulcer
    • Unstated infection including chest
    • Urinary tract infection
    • Volvulus
    • Viscus rupture
    • Wound dehiscence
  • Stoma-related
    • Abscess
    • Cellulitis
    • Delayed closure of site after GT removal
    • Fistula
    • Granuloma
    • Pain
    • Skin
      • Infection
      • Irritation
      • Necrosis
    • Stomal herniation
  • Patient feeding
    • Abdominal distention
    • Aspiration
    • Aspiration pneumonia
    • Bloating
    • Constipation
    • Cramping
    • Delayed gastric emptying
    • Delayed feeding
    • Diarrhea
    • Electrolyte imbalance
    • Emesis
    • Ileus
    • Gastroparesis
    • Problems with feeding/medication administration
    • Malnutrition
    • Nausea
    • Retching

Questions for Further Discussion
1. What are the pros and cons of percutaneous versus surgical placement of a GT?
2. If a GT is dislodged, how long before the site can start to close up?

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 and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Nutritional Support

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.

McSweeney ME, Smithers CJ. Advances in Pediatric Gastrostomy Placement. Gastrointest Endosc Clin N Am. 2016 Jan;26(1):169-85.

Kapadia MZ, Joachim KC, Balasingham C, Cohen E, Mahant S, Nelson K, Maguire JL, Guttmann A, Offringa M. A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review. Pediatrics. 2016 Jul;138(1). pii: e20153967.

Fuchs S. Gastrostomy Tubes: Care and Feeding. Pediatr Emerg Care. 2017 Dec;33(12):787-791.

Yap BK, Nah SA, Chen Y, Low Y. Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications. Pediatr Surg Int. 2017 Feb;33(2):217-228.

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