What Should Parents Teach Their Children About Stranger Safety?

Patient Presentation
A 5-year-old female came to clinic with her mother for her health supervision visit. She was starting kindergarten in the fall and had not been in a childcare or an educational setting before. Her mother described her as a sociable child whom other children and adults liked. She was a very trusting child and therefore her mother was concerned that she would be vulnerable to a stranger abduction. The pertinent physical exam showed a well-developed child with normal vital signs and growth parameters in the 90-95%. Her pertinent physical examination was normal. She was quite gregarious with advanced speech content. Her other development was on track for her age.

The diagnosis of a healthy female was made. The pediatrician talked with the girl about a couple of potential scenarios for when a child should be wary of strangers. It was obvious that she needed some more information and practice regarding stranger safety. The pediatrician gave the mother some ideas about how to practice stranger safety with her daughter over the next few months in addition to information about developmental readiness for kindergarten.

Fortunately, when a child goes missing it is usually for short periods of time and is often because of miscommunication or expectations. Familiar examples are a child wandering away, or not returning at the proper time. Unfortunately, child abduction does occur.

Data from the U.S. Department of Justice’s Office of Juvenile Justice and Delinquency Prevention provides the statistics below. Problems with definitions and reporting make these statistics more difficult to gather.

  • ~340,500 children (43%) reported in 1999 as missing, were because of benign causes and no harm occurred to the child. Most were because of communications problems such as failing to come home or coming home later than expected.
  • ~43,700 missing children in 1999 were injured but only 10,200 were reported to authorities to help locate the child.
  • There were ~58,200 child victims of non-family abductions in 2002.
  • ~ 105 children in 2002 were victims of stereotypical kidnapping in 2011. Most of these were teenage, white females and most ended with recovering the child alive.
  • Cellphone, Internet and other technologies helped law enforcement solve ~2/3 of these crimes.

A missing child, emergency reference guide is available here.

Tips for getting ready to go to Kindergarten can be reviewed

Learning Point
Parents can help their child be safe from strangers by:

  • What is a stranger?
    • Stranger are people that the child or your family doesn’t know or doesn’t know well.
    • Strangers can look like anyone. Nice looking strangers can be as dangerous and strangers who look “bad” or “mean” can be safe strangers.
    • Remind the child that if they need help, most strangers are not bad. It is just that they are strangers and the child needs to decide whether or not to trust them.
    • Most strangers actually can be trusted to help a child.
  • What is a safe stranger? Where can you find a safe stranger?
    • Safe strangers are people that can be asked for help if needed.
    • Police and firefighters are common, recognizable safe strangers.
    • Other common safe strangers would be teachers, librarians, and spiritual advisors.
    • Public places are good places to teach children to find safe help. During your usual day, point out places you would choose as a safe place to find help such as a local store, restaurant, recreation center, school or house of worship.
    • Point out that the workers in stores or restaurants usually have a uniform – all wearing a similar shirt and have a name tag.
    • Point out homes of family friends in the neighborhood that children could go for help too.
    • Make sure the child knows their name, parents first and last name, and street they live on. This information can help the safe stranger contact the parent or local police.
  • How do you recognize potentially dangerous situations?
    • Children should be taught to be wary of potentially dangerous situations and strangers. That doesn’t mean that they need to be scared of every stranger or situation but need to be taught to be cautious.
    • Children should learn to recognize suspicious behavior. Examples include an adult who:
      • Asks the child to do something the child knows is wrong to do
      • Asks the child for help (adults ask other adults for help)
      • Makes the child feel uncomfortable
  • The child should be taught how to handle these situations – one way is “No, Yell, Go, Tell”
    • No – in a dangerous situation the child should say No. Even better if they describe what they are saying No to. For example, “No. You are not my father” Or “No, I do not want any candy from you.”
    • Yell – Yell very loudly to get others attention – Yell “Help” or “Fire” to attract attention.
    • Go – Run away from the situation and go to a place that they feel is safe
    • Tell – tell a trusted adult as soon as possible
    • For example, a stranger asks for directions on your child’s way home from school. The child can say No – “No I’m not going with you, ” continue to yell while running back toward the school. Then finding a teacher and telling about the incident.
    • A child should be taught they can do this inside (ex. a mall or hospital) or outside (ex. park, street, etc.)
    • If they are grabbed, teach children to resist, kick, bite or hit to try to get away.
  • Practice makes perfect
    • Parents can talk about and model appropriate behavior with their children. When you get lost, how do you get directions from a safe stranger?
    • Talk about different situations that could come up and practice what a child should do.
      • Ask “If you got lost now in the grocery store, what would you do?” and tell, “That’s right, the safe strangers in our grocery store have a uniform with white shirts and a black name badge.”
      • Ask “If that woman over there wanted to give you candy, or go outside to pet her dog, what would you do?” and tell, “Never take candy from a stranger or go with a stranger. You can just say No, yell real loud and run away until you can find a safe stranger.”
      • Point out safe places and safe strangers in your community.
    • Teach children to trust their instincts. If they feel uncomfortable they should “No, Yell, Go, Tell”
      • If they are wrong about the situation, that is okay. Better to “No, Yell, Go, Tell” than to have a problem.
    • Teach children play with other children and to have trusted adults around.
      • Remind children that if they cannot see the trusted adult then the trusted adult cannot see them. They are too far away and need to come back to the trusted adult.
    • Teach children to never accept any item from a stranger or go any place or accept a ride from a stranger.
  • When can a child be left alone?
    • That depends on many factors which can be reviewed here.
    • Parents should know where their child is at all times.
      • The child should know how to contact the parent.
      • The parent should have a way to contact the child and check in with them such as a cellphone.
      • Teach children how and when to dial 911 and how to use a cellphone or regular phone.
      • Teach children about online/Internet safety – some recommendations can be reviewed here.

Questions for Further Discussion
1. What are safety tips for online/Internet safety?

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: Child Safety

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.

Finkelhor D, Hammer H, Sedlak AJ. Nonfamily Abducted Children: National Estimates and Characteristics. U.S. Department of Justice. Office of Juvenile Justice and Delinquency Prevention. Available from the Internet at https://www.ncjrs.gov/pdffiles1/ojjdp/196467.pdf (rev. 10/2002, cited 6/1/17)

Sedlak AJ Finkelhor D, Hammer H. National Estimates of Children Missing Involuntarily or for Benign Reasons. U.S. Department of Justice. Office of Juvenile Justice and Delinquency Prevention. Available from the Internet at https://www.ncjrs.gov/pdffiles1/ojjdp/206180.pdf (rev. 7/2005, cited 6/1/17)

Wolak J, Finkelhor D, Sedlak AJ. Child Victims of Stereotypical Kidnappings Known to Law Enforcement in 2011. U.S. Department of Justice . Office of Juvenile Justice and Delinquency Prevention. Available from the Internet at https://www.ojjdp.gov/pubs/249249.pdf (rev. 6/2016, cited 6/1/17)

National Crime Prevention Council. What to Teach Kids About Strangers.
Available from the Internet at http://www.ncpc.org/topics/violent-crime-and-personal-safety/strangers (rev. 2017, cited 6/1/17).

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

What Can Parents Do To Promote Literacy?

Patient Presentation
A 12-month-old male came to clinic with his mother for a health maintenance examination. When the pediatrician walked into the room, the infant was trying to give his mother a book, but she did not notice as she was playing a game on her cellphone. She stopped the game appropriately and did not use it again during the visit. The mother said she was only concerned that he didn’t talk as much as she thought he should. He had 3 words and made a dog sound. He would appropriately point and would try to follow 1-step commands. The past medical history showed a normal hearing test as an infant. The pertinent physical exam showed a healthy male with growth parameters in the 10-25%. His physical examination was normal.

The diagnosis of a normal infant was made. During the examination, the pediatrician noted that he would say many different sounds and would turn-take when interacted with. She also noted that he tried to bring a book to his mother on two other occasions and she did not react to him. The pediatrician offered, “He seems to be on track for talking. He says several words, and the other things he is saying and you don’t understand will become words. He takes turns saying things just like we are doing now too. A couple of things you can do is to talk with him alot. Talk all the time about what you are doing like, “We’re walking down the hallway. Now we are stopping at the check out counter.” It seems funny but it really helps. Another important thing you can do is to read with him. I noticed that he seems really interested in books and has tried to bring you several during our visit. Do you read with him?” The mother answered, “I don’t read with him because I thought he was too little. He also doesn’t sit still very long so I didn’t thing he could do it. I tell him stories and sing with him.” The pediatrician said, “That’s great that you tell stories and sing. That’s great for his language. He’s never too young to read with though. Even a few minutes a day can really be a nice time to spend together and he will learn about books and stories. I forgot to bring a book for him, so let me get it and I’ll show you a few ways you can use the book with him.”

Positive parenting has been shown to improve the overall health and well-being of children. Positive parenting includes:

  • Respecting the individuality of the child and the adult in the relationship – accept the child for their strengths and weaknesses, encourage children to take risks, encourage their confidence in themselves
  • Respecting that the individuals are part of a family and community – help children understand that they cannot have everything their way, that other people and the world they live in must be considered too.
    Even in a resource poor environment, data shows that positive parenting can help ameliorate the effects of poverty in children.

  • Working together – doing things together – reading, coloring, singing, cleaning up and household tasks, etc. Family meals are great ways to spend time together. For more information Click here.
  • Respecting others creativity and individuality – thank children for their actions as one would another adult, allowing children to do things by themselves even if it isn’t the way the parent would do it, allow them to fail and support them in the failure
  • Positive communication – listening more than talking, be encouraging, appreciating when the person may not be able to find the words well, model respectful discussions and show children how to disagree in a respectful way. Hold emotions in check and say “I’m sorry” when one doesn’t do this as well.
    Say “Please” and “Thank you,” be honest but positive

  • Setting limits – every child (and adult) wants to know what the rules are – be clear about them. For more information about discipline Click here.

Learning Point
Reading is one positive parent activity that parents and children can do together. It is usually a happy activity, time-limited and low cost. Adults can help children learn about reading and literacy from the day they are born. It takes a little time each (or most) days and is a great time to spend together. For specific ideas about how to read to your young child Click here.

  • Read with your child every day
    • 20 minutes daily is recommended. The 20 minutes doesn’t have to be at one time. You can split it up over the day. Especially if your child is young as they only have a short attention span.
    • Some days this may seem too long, but even 1 book read together is a special time together. It can help both parent and child be calmer, closer and enjoy the experience.
  • Even when your children can read, spend time reading to them or with them. It continues to be a nice time to spend together and you can share and discuss the stories.
  • Have a book box
    • Have a box to put books in your child can easily use. Your child can read to himself and choose books to read with you. They also know where the books go when it is time to clean up.
    • Having a blanket, mat or towel next to the books encourages your child to sit and read in a cozy place.
  • Get your child a library card
    • Most libraries encourage children, even babies, to have their own library card.
    • Picking their own books and having their own card is special for children.
  • What should children read?
    • In general – EVERYTHING. Children should learn about fiction, non-fiction and reference books even at young ages. They should learn about all book types. Importantly, books should have appropriate content for your child’s age. Books are usually grouped by section based on age such as:
      • Board books: Newborn to age 3
      • Picture books: Ages 3-8
      • Coloring and activity books: Ages 3-8
      • Novelty books: Ages 3 and up but this depends on the content
      • Early, leveled readers: Ages 5-9 (these usually have the level listed on the cover or inside of book)
      • First chapter books: Ages 6-9 or 7-10
      • Middle-grade books: Ages 8-12
      • Young adult book: Ages 12 and up or 14 and up
  • Not sure the book’s content is right for your child?
    • Read the book (or sections of it) and see what you think.
    • A children’s librarian can also help.
    • Booklists can be found at any library. They usually are for different ages, or categories such as holiday books or biographies. Winners of children’s book awards are good places to start too.
      The Association of Library Service to Children notable book lists can be found here.

      • Caldecott Medal for most distinguished picture books Click here.
      • Newberry Medal for contributions to American literature for children Click here.
      • Coretta Scott King Book Awards for outstanding African American children’s authors and illustrators Click here.
      • Pura Belpre Award for outstanding Latino/Latina children’s author and illustrators Click here.
      • Geisel Award for most distinguished American book for beginning readers. Click here.
      • Other book award winner lists can be found at the Association for Library Service to Children Click here.
  • Librarians can help you
    • Librarians are specially trained to help children and parents find information and choose appropriate books.
    • They can help with choosing books that:
      • Match the child’s reading skills
      • Match the child’s interests
      • Find books similar to one the child already likes
      • Help dual language learners who may have different reading skills in each language
      • Find foreign language books
      • Help gifted children who may have advanced reading skills but still need age-appropriate content
      • Help encourage slower readers to enjoy reading and improve their reading skills
  • I’m not a good reader myself so how can I help my child?
    • It’s okay if you are not a good reader. Parents cannot be perfect. You can still read to your child whatever books you are comfortable with. It is about encouraging your child.
    • Modeling something you are also not as good at is also important for your child to see. They learn to keep trying even when it may be hard to do.
    • Maybe you can take some classes to improve your reading. These are often available free or low-cost at your local schools, community center, churches, and community colleges.
  • What about audiobooks or eReaders?
    • These also are fine as part of reading regular paper books. Listening to audiobooks can bring different stories to life while traveling in a car for example. You can discuss the book together.
    • Using an eReader with your child can also be another way to share books together.
  • Special opportunities
    • Bookmobile – some communities have books in a van or bus that will move around the community and distribute books.
    • Children’s reading programs in parks, recreation centers or other places.
    • Summer reading programs – these encourage children, teens and adults to read during the summer time by offering small incentive items for reading activities. For example, children would read 5 books, use their library card, attend a library program and then would receive a free ice cream cone donated by a local business.
    • Free Little Library – There are many communities that have “Free Little Libraries” where books are free to take and use. Small houses (like a birdhouse) are placed around the community. People donate books to the little libraries and the books are free to read and share. Click here.

Questions for Further Discussion
1. What other ways can early literacy be promoted in the office setting?
2. What are signs of a language disorder?
3. When should a child be referred for a language or learning disorder?

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: Child Development and Learning 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.

Brody GH, Gray JC, Yu T, et.al. Protective Prevention Effects on the Association of Poverty With Brain Development. JAMA Pediatr. 2017 Jan 1;171(1):46-52.

Association for Library Service to Children. Available from the Internet at http://www.ala.org/alsc/ (cited 5/22/17).

Reach Out and Read. Available from the Internet at http://www.reachoutandread.org (cited 5/22/17).

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

Summer Break

PediatricEducation.org is taking a summer break. The next case will be published in on August 7th. In the meantime, please take a look at the different Archives and Curriculum Maps listed at the top of the page.

We appreciate your patronage,
Donna D’Alessandro and Michael D’Alessandro, curators.

What Conditions is Erythema Nodosum Associated With?

Patient Presentation
A 12-year-old male came to clinic with a history of 3-4 days of painful bruising on his shin and lower arms. He had Streptocococcal pharyngitis diagnosed by rapid strep testing approximately 4 weeks previously and had taken all of his amoxicillin antibiotic per his parents. He had recovered without any problems until 3-4 days ago when his legs and arms started to have painful bruises along the shins and lower arms. They were raised, red/purple and painful mainly in the center of the lesions. He denied pain elsewhere nor any fever (Tmax was 99.5F), chills, sweats, weight loss, joint stiffness, abdominal pain, vision or eye changes, or mucous membrane changes. He had normal bowel and bladder habits without hematuria. The family had traveled to visit relatives in Central America 3 months previously but denied any tuberculosis risks. The past medical history was non-contributory. The family history was positive for heart disease and osteoarthritis in an older grandmother. The review of systems was otherwise negative.

The pertinent physical exam had normal vital signs including weight that was 75% and consistent with previous weights. HEENT, heart, lung and abdomen examination were negative. He had some shotty nodes in the anterior cervical, posterior cervical and groin. He had 1-2 cm nodular purple/red lesions over the extensor surfaces of the bilateral anterior tibia and ulnar areas. They were painful to the touch but the bones were not painful otherwise. No pain could be elicited in the adjacent muscle groups. His extremities had full range of motion without pain and had no swelling or erythema.

The diagnosis of of erythema nodosum probably due Streptocococcus was made. The evaluation included a complete blood count, complete metabolic panel, urinalysis, chest radiograph, throat culture, and QuantiFERON-TB GOLD® were negative. His Anti-streptolysin O titre was positive, as were his erythrocyte sedimentation rate (= 42 mm/hr, normal 1-25 mm/hr) and C-reactive protein were 8 mg/L (normal < 3 mg/dL). The patient was started on ibuprofen and rest, along with clindamycin to make sure that his streptococcal infection was treated. It was felt that this was not a drug reaction but a penicillin was avoided. The patient’s clinical course over the next week was that he had no new lesions and his other lesions were slightly less painful. Over the next 3 weeks he had almost complete resolution of the lesions and they were completely gone by 6 weeks. Repeated labs were negative.

Erythema nodosum (EN) is a common dermatological eruption characterized by inflammatory nodules of the subcutaneous fat (panniculitis) on the extensor surfaces of the extremities especially the shins, thighs, and forearms. They are usually painful, nodular, bilateral and multiple. They can be found on other areas and be unilateral. They can be red, purple or blackish. They usually resolve without problems in 3-6 weeks.

Diagnosis is usually clinical but biopsy may be needed if there is atypical presentation or history, physical examination or laboratory testing reveals potential underlying diseases. Treatment is usually conservative with rest and non-steroidal anti-inflammatory drugs. Identified underlying causes of the EN should be treated but in some studies more than 50% of the causes remain unidentified. Other treatments include steroid medication and even potassium iodide has been used.

Learning Point
A study of 39 Turkish children in 2014 found the following causes of EN (some had two infections):

  • Idiopathic = 43.5%
  • Streptococcal infection = 23%
  • Mycoplasma pneumonia = 7.7%
  • Tularemia = 10.2%
  • Tuberculosis, latent = 5%, pulmonary = 2.5%
  • Behçet disease = 2.5%
  • Cytomegalovirus = 2.5%
  • Giardia lamblia infection 2.5%
  • Sarcoidosis = 2.5%

EN has been associated with a variety of other causes including:

  • Drugs – Bromides and iodides, Oral contraceptives, Penicillin, Sulfonamides
  • Infections
    • Bacteria – Brucellosis, Campylobacter, Chlamydia trachomatis, Leprosy(*), Leptospirosis, Salmonella, Yersinia
    • Fungus – Blastomycosis, Coccidioidomycosis, Histoplasmosis
    • Viral – Bartonella henselae, Epstein Barr virus, Hepatitis B, Lymphogranuloma venereum, Paravaccinia, Psittacosis
    • Gastrointestinal – Crohn’s disease, Ulcerative colitis
  • Malignancy – Carcinosis, Leukemia, Lymphoma,
  • Other – Pregnancy, Sweet Syndrome, Whipple disease

*EN should not be confused with erythema nodosum leprosum (ENL) which is a rare immune-mediated systemic disease associated with Leprosy.

Questions for Further Discussion
1. How do you diagnosis inflammatory diseases such as Behçet disease, Crohn’s disease, or Ulcerative colitis?
2. What is the role of a consultants in the evaluation and treatment of EN?

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: Skin Conditions and Skin Infections.

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.

Aydın-Teke T, Tanır G, Bayhan GI, Metin O, Oz N. Erythema nodosum in children: evaluation of 39 patients. Turk J Pediatr. 2014 Mar-Apr;56(2):144-9.

Jones M, de Keyser P. Rash on the arms and legs. BMJ. 2015 Aug 3;351:h4131.

Walker SL, Balagon M, Darlong J, et.al.
ENLIST 1: An International Multi-centre Cross-sectional Study of the Clinical Features of Erythema Nodosum Leprosum. PLoS Negl Trop Dis. 2015 Sep 9;9(9):e0004065.

Kroshinsky D. Erythema nodosum. UpToDate. (rev. 11/30/2016, cited 5/16/17).

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