How Good is Cholecystectomy For Biliary Dyskinesia in Pediatric Patients?

Patient Presentation
A 17-year-old female came to clinic for her health maintenance visit. She had a history of multiple gastrointestinal complaints throughout her lifetime including slow-transit constipation and gastroesophageal reflux disease. For the past 2 years she had increased right upper quadrant and epigastric pain that would occur at random intervals and was severe enough to disrupt her activities and which precipitated emergency room evaluation one time. Her gastroenterologist also evaluated her for gallbladder disease which had shown no gallstones, but had a slow gallbladder ejection fraction. She had been referred to a surgeon who agreed with the diagnosis of biliary dyskinesia and had performed a cholecystectomy 5 months previously. She reported that most of her symptoms had abated but that she still had intermittent similar pain but much less frequently and with less intensity.

The pertinent physical exam revealed normal vital signs and she had a BMI of 31.2. Her abdomen examination had well-healed laparoscopic incisions and was otherwise normal. The diagnosis of a healthy female with obesity who was status-post laparoscopic cholecystectomy was made. She was encouraged to followup with her gastroenterologist as planned.

Discussion
Biliary disease includes gallstones, cholecystitis (inflammation of the gallbladder), cholangiopathy and cholangitis (pathology of the bile ducts), biliary dyskinesia, gangrene, and cancer. Some are often overlapping as gallstones often contributing to cholecystitis and cholangitis.

Biliary dyskinesia (BD) is well-recognized in adults. Adult criteria include: “abdominal pain located in the epigastrium and/or right upper quadrant along with; buildup of pain to a steady level and lasting 30 minutes or longer, pain occurring at different intervals and not daily, severe enough to interrupt activities or lead to an emergency department visit, the pain is not significantly (<20%) related to bowel movements, and not significantly (<20%) relieved by postural change or acid suppression.” There is not a similar BD definition for the pediatric population, making research to improve outcomes and treatment decisions more difficult. According to the US National Library of Medicine BD is “[a] motility disorder characterized by biliary [colic], absence of [gallstones], and an abnormal [gallbladder] ejection fraction. It is caused by gallbladder dyskinesia and/or [sphincter of Oddi dysfunction].” Criteria often used in the pediatric population includes “chronic or recurrent epigastric or right upper quadrant pain or other discomfort, absent gallstones and abnormal [gallbladder ejection fraction]…” on cholecystokinin-cholescintigraphy.

Learning Point
Most cholecystectomies (~95%) are performed laparoscopically as opposed to an open procedure. Overall there has been an increase in cholecystectomies in the US for all indications and also for BD. Approximately 10% of all pediatric cholecystectomies were for BD and ~73% were for calculous cholecystitis between 2002-2011. Cholecystectomy increases are related at least partly to increasing gallstone disease in children mainly due to the pediatric obesity epidemic. Cholecystectomies overall and for BD occur more often in teenagers, females and those that are obese.

In a pediatric systematic review, outcomes after cholecystectomy for BD showed 34-100% (average ~66%) symptomatic symptom success in the short term, but longer term (1-2 years) many symptoms recurred. There are probably many reasons for this including the actual definition of BD used, individual patient symptoms, placebo effect of surgery and alternative diagnoses. One example is delayed emptying of the gallbladder (as noted above is used for BD diagnosis) can be caused by other problems including obesity, constipation, gastroesophageal reflux, allergies and parasitic infection in children. Alternative diagnoses are possible as some patients (adults and pediatric) have other functional gastrointestinal disease or other disease diagnosed often within 1-2 years after cholecystectomy. Functional dyspepsia is one example with many symptoms that overlap with BD including “post-prandial fullness, early satiety, [and] epigastric pain or burning not associated with defecation.” Other alternatives include Crohn’s syndrome, cyclic vomiting syndrome, hiatal hernia and irritable bowel syndrome. One author concluded, “…almost 34% of patients will have persistent symptoms, whereas 50% will be diagnosed with another disorder soon after cholecystectomy, making the BD diagnosis doubtful.” There is other data supporting improved long term cholecystectomy outcomes for patients with pre-operative post-prandial pain and those with lower gallbladder ejection fractions (i.e. <15%).

Questions for Further Discussion
1. What are the common gallstones made of? A review can be found here
2. What are the functions of the liver? A review can be found here
3. How is a cholecystokinin-cholescintigraphy test performed?

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: Gallbladder Diseases and Bile Duct Diseases.

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.

Biliary Dyskinesia. MeSH Browser. Accessed November 8, 2022. https://meshb-prev.nlm.nih.gov/record/ui?ui=D001657

Santucci NR, Hyman PE, Harmon CM, Schiavo JH, Hussain SZ. Biliary Dyskinesia in Children: A Systematic Review. J Pediatr Gastroenterol Nutr. 2017;64(2):186-193. doi:10.1097/MPG.0000000000001357

Matta SR, Kovacic K, Yan K, Simpson P, Sood MR. Trends of Cholecystectomies for Presumed Biliary Dyskinesia in Children in the United States. J Pediatr Gastroenterol Nutr. 2018;66(5):808-810. doi:10.1097/MPG.0000000000001777

Liebe HL, Phillips R, Handley M, Gastanaduy M, Burton JH, Roybal J. A pediatric surgeon’s dilemma: does cholecystectomy improve symptoms of biliary dyskinesia? Pediatr Surg Int. 2021;37(9):1251-1257. doi:10.1007/s00383-021-04922-1

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

What Are Potential Treatments for Hyperacusis?

Patient Presentation
A 3 year-old male came to clinic for his health supervision visit. His mother complained that he was very sensitive to loud noises. “He’s almost toilet trained now but every time we go into a public bathroom his eyes get big. I actually put my hands over his ears so he can do his business and he won’t be scared if a toilet flushes,” she reported. “He also likes planes so we took along some ear protectors to the airshow at the airport. He still didn’t like the loud noises but he had fun seeing all the planes. Anything surprising like an alarm going off makes him really upset,” she continued. He usually calmed down quickly after the noise and didn’t seem to avoid activities. His mother had no concerns about his hearing, language development, or problems with other sensations. She and his daycare providers had no concerns about his development. The past medical history was non-contributory and he had 1 ear infection around 2 years of age.

The pertinent physical exam showed a chatty male with growth parameters in the 10-25%, and normal vital signs. His examination was normal.

The diagnosis of a healthy male was made who was sensitive to loud noises. The doctor explained that this was common and that the mother was right to try to help him when he had to be in settings where they could occur. “Putting your hands over his ears is a good option and as he gets more used to public toilets and gets a bit older, this should improve. If this seems to be getting worse, or it is causing him more stress or anxiety or even avoiding places or activities, that may need more help. Just let me know and we can talk about it again,” she said. At his 4 year-old checkup, his mother reported that he still didn’t like the public restrooms, but would use them without her help now. He also still doesn’t like the dogs or sirens but said he realizes that they just happen and stop pretty quickly too.

Discussion
Hearing is functional in human fetuses at approximately 25-27 weeks gestation.. The aural anatomical structures are developed by ~32 weeks gestation.

Hyperacusis does not have a specific definition but in general is an increased sensitivity to sounds (either intensity or loudness). Some authors describe it as “…decreased sound tolerance where there is a negative reaction to the physical characteristics of the sound,” and other authors use “…increased sensitivity to sound in levels that would not trouble a normal individual.” Phonophobia is a true fear of sounds with anticipation causing anxiety at the sight or thought of the object generating the sound. Misophonia is distress caused by certain sounds or patterns of sounds (e.g. chewing, scratching of chalkboards) rather than the sound loudness. Tinnitus can be a ringing or buzzing sound and in general practice means any perceived sound that is not generated externally. Tinnitus usually does not arise to the level of distress but could. A tinnitus review can be found here.

Hyperacusis has a reported prevalence of 3.2-17.1% in the general population but is markedly increased in other populations. For example children with autism spectrum disorder and William’s syndrome have an 18-63% and 95% prevalence rate respectively. In one study the commonest age of presentation was 3-4 years but ranged from 1-15 years. It is not uncommon for young children to be sensitive to sounds but over time to become tolerant.

Possible mechanisms for hyperacusis include:

  • Normally developing but immature auditory system – example is normally developing children who are sensitive for a period of time
  • Auditory deprivation that is temporary – example is child with persistent middle ear fluid may habituate to needing louder sounds, but when fluid diminishes the brain does not appropriately recalibrate and the patient perceives these sounds as “too loud” or distressing in some manner
  • Auditory system disorder – example are patients with neurodevelopmental problems such as autism spectrum disorder, etc, but can also be acquired such as traumatic brain injury
  • Sensory processing disorder – example is children with “…difficulty in regulating or integrating sensory information (visual, touch, sounds, smells, proprioception) which can lead to patterns of hyper-sensitivity to sensory stimuli or a ‘sensory overload’ effect.”

Learning Point
Common troublesome noises triggering hyperacusis include:

  • Household appliance – vacuum cleaner, hair dryers, blender, washing machines, radio or television, lawn mowers
  • Community sounds – toilets, hand dryers, doorbells, telephones, airplanes, sirens
  • Gathering noises – classroom, lunchroom and playground noise, music class, restaurants, sports events
  • Unexpected noises – school bell, balloon popping, dog barking, clapping, sneezing, laughing, babies crying

Also remember that a child is often closer to the sound generator (e.g. toilet, vacuuum, dog, etc.) than an adult and therefore the sound can be louder for them. Also some of these objects also have additional potential threats such as a dog could bite, or a child could be splashed with toilet water which can lead to additional wariness of the object.

Hyperacusis for most children is developmental with improved tolerance with maturation and/or habituation, but other patients may need additional assistance.
Possible treatments include:

  • Reassurance, support, watch and wait
  • Avoidance – doing the vacuuming when patient is not around
  • Allowing control – patients often are more comfortable with sounds they generate or have control over. Child can do the vacuuming, using ear protection to decrease sounds, or sit in different location to mitigate the sound or be able to escape it temporarily
  • Focus on the good part of the activity – help child to focus on playing games with friends rather than the loud sounds the children are making
  • Various specific therapies
    • Desensitization
    • Sensory integration therapy – clinic-based intervention where activities increase the child’s ability to integrate sensory information
    • Sensory based intervention therapy – adult-directed activities to help improve behaviors associated with the sensation, such as using a white noise generator

Questions for Further Discussion
1. How can portable listening devices affect hearing? A review can be found here
2. What are the current recommendations for hearing screening?
3. What are potential choices for hearing amplification?

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: Hearing Disorders and Deafness and Child Development.

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.

Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism. 2015;19(2):133-148. doi:10.1177/1362361313517762

Clark-Gambelunghe MB, Clark DA. Sensory Development. Pediatric Clinics of North America. 2015;62(2):367-384. doi:10.1016/j.pcl.2014.11.003

Myne S, Kennedy V. Hyperacusis in children: A clinical profile. International Journal of Pediatric Otorhinolaryngology. 2018;107:80-85. doi:10.1016/j.ijporl.2018.01.004

Rosing SN, Schmidt JH, Wedderkopp N, Baguley DM. Prevalence of tinnitus and hyperacusis in children and adolescents: a systematic review. BMJ Open. 2016;6(6):e010596. doi:10.1136/bmjopen-2015-010596

Potgieter I, Fackrell K, Kennedy V, Crunkhorn R, Hoare DJ. Hyperacusis in children: a scoping review. BMC Pediatrics. 2020;20(1):319. doi:10.1186/s12887-020-02223-5

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

What Are Common Dietary Fermentable Carbohydrates?

Patient Presentation
A 2-month-old female came to clinic for her well child examination. She was a term infant and the parents complained that she was “gassy.” They said she would cry briefly around the time she had a bowel movement and would turn very red. They also would hear bowel sounds occasionally around the time she was breastfeeding or stooling. The stool had a soft, toothpaste-like quality and she had 1-2 stools/day without blood or mucous. The family was using simethicone drops to help with the “gas.” The parents said that the baby herself didn’t seem distressed but it worried them.

The pertinent physical exam showed a smiley infant with growth parameters around the 75%. Her examination was normal. The diagnosis of a healthy baby was made. The pediatrician explained the natural history of how infants’ stools changed from birth over time, as well as normal bowel movement patterns. “It’s not uncommon for babies’ faces to turn red as they are stooling or to make sounds. Remember for babies they often don’t have gravity to help them to pass stools and also aren’t as active as older children and adults. When we are passing stools it also isn’t uncommon for us to make sounds, plus we aren’t being watched. Our faces probably change color if we looked in a mirror,” she pointed out. “What you can do if she seems to be having a problem is to bicycle her legs and the movement may help the gut to move the stool along. Also gently rubbing the abdomen may also help. Remember don’t push, just gently rub. The simethicone probably isn’t doing much but shouldn’t hurt her,” she commented.

Discussion
Parents may often come to the pediatrician for concerns about crying and colic, increased belching, abdominal distention, increased flatulence, abdominal pain or stool changes. They complain of increased “gassiness,” which could mean any or a combination of these problems, or something different that they believe is referred to the abdomen. In newborns parents’ intolerance for crying and normal changes in the abdomen (e.g. appearing larger or smaller) may have them complain of “gassiness” but they do not mean actual belching or flatulence. In older children, parents may state that the child has abdominal pain and again is “gassy,” and may or may not mean increased belching or flatulence. Of course other common problems such as constipation or infectious diarrhea need to be considered and teased out when parents bring their children for these complaints.

Gases within the intestinal tract are normal. They are a combination of swallowed air and fermentation processes within the tract. Fermentation is usually thought of as sugar digestion but fat and protein can also produce gases. Through these processes a variety of substrates are created and can be used by the body. Gases include hydrogen, oxygen, nitrogen, carbon dioxide, methane and the rotten egg smell to flatulence is due to hydrogen sulfide.

Learning Point
Dietary carbohydrates can be a culprit in “gassiness” and other abdominal complaints. Malabsorbed carbohydrates are osmotically active and are quickly fermented by colonic bacteria. They can cause rapid increase in luminal distention leading to abdominal symptoms such as increased gas, bloating, pain and/or loose or more frequent stools or frank diarrhea. Specifically this occurs by increasing the fermentable substrate which then increases gas production leading to luminal distention, and by increasing the luminal osmotic load which increases the luminal fluid leading to luminal distention. There are a variety of factors which may promulgate or mitigate symptoms including amount of carbohydrate ingested, ingestion with other substances (i.e. eating a meal or the substance individually), gastric emptying rate, transit time of the small intestine, concomitantly ingested bacteria able to break down the carbohydrate, “colonic bacteria adaption to one’s diet,” and other host factors.

Common dietary fermentable carbohydrates include:

  • Glucose, a monosaccharide, found in honey, fruits, some vegetables (e.g. sweet corn)
  • Maltose, a disaccharide of glucose and glucose, found in barley, wheat, cornmeal and fruits (e.g. pears, peaches)
  • Starch, polymers of glucose, found in staple foods such as potatoes, corn, wheat and also fruits
  • Fructose, a monosaccharide, found in honey and fruits (e.g. pears, apples)
  • Lactose, a disaccharide of glucose and galactose, found in dairy products
  • Sucrose, a disaccharide of glucose and fructose, found in sugar cane, sugar beets, and other fruits and vegetables
  • Fructans, fructose polymers, found in wheat, rye and onions
  • Galactans, galactose polymers, found in legumes and beans
  • Polyols, sugar alcohols, found in fruits (e.g. cheeries, pears, and apricots) and sweetener substitutes (e.g. sorbitol, xylitol)

Glucose, maltose, starch and sucrose are usually easily digested by small intestine enzymes and absorbed, but enzyme deficiencies can cause problems. Lactose is a unique disaccaride as it is only found in mammalian milk. Lactase the enzyme that breaks it down into glucose and galactose is found in the small intestinal villi tips and its highest concentration is found in infants. The lactase concentration decreases with age and only about 30% of the population has persistence into adulthood and this persistence is mainly in people of northern European descent. Glucose and galactose are absorbed by the small intestine. Fructose uses the glucose transporter in the small intestine for absorption. Fructans, galactans and polyols are complex carbohydrates which enter the colon intact and are metabolized by gut bacteria.

Dietary fiber is commonly used in older children as an intervention to help with abdominal complaints. Dietary fiber are plant components which cannot be completely broken down by the body. They are found in whole grains, cereals, legumes, fruits, vegetables and nuts. They can be soluble or insoluble. Soluble fiber maintains the stool hydration by absorbing water and provides bulk to the stool. Psyllium is a common soluble fiber. Insoluble fiber mechanically stimulates the gut mucosa to secrete mucous and water and decrease the colonic transit time.

Probiotics theoretically work by colonizing the bowel, secreting antibacterial substances, competing with other organisms for nutrients and preventing adhesion to the intestinal epithelium and regulation of the immune system. The data on effectiveness can sometimes be conflicting. Two other potential interventions marketed to parents of infants are simethicone and gripe water. Simethicone is an antifoaming agent that purportedly works by creating larger gas bubbles that are more easily passed through the digestive system. Gripe water may have a variety of components including sodium bicarbonate acting as an antacid, ginger, fennel and possible other components. Ginger and fennel have some studies which support their use as digestive aids.

Questions for Further Discussion
1. What parent advice to you recommend for infant crying and/or colic? A review can be found here
2. What is in the differential diagnosis of acute abdominal pain? A review can be found here
3. What is in the differential diagnosis of recurrent abdominal pain? A review can be found here
4. What is irritable bowel syndrome? 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 this topic: Gas

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.

Skinmore-Roth L. Mosby’s Handbook of Herbs & Natural Supplements. 4th ed.St. Lois, MO: Mosby/Elsevier; 2010.

Chumpitazi BP, Shulman RJ. Dietary Carbohydrates and Childhood Functional Abdominal Pain. Ann Nutr Metab. 2016;68(Suppl. 1):7-17. doi:10.1159/000445390

Chumpitazi BP, Weidler EM, Shulman RJ. Lactulose Breath Test Gas Production in Childhood IBS Is Associated With Intestinal Transit and Bowel Movement Frequency. Journal of Pediatric Gastroenterology & Nutrition. 2017;64(4):541-545. doi:10.1097/MPG.0000000000001295

Williams BA, Grant LJ, Gidley MJ, Mikkelsen D. Gut Fermentation of Dietary Fibres: Physico-Chemistry of Plant Cell Walls and Implications for Health. International Journal of Molecular Sciences. 2017;18(10). doi:10.3390/ijms18102203

Simethicone. MedLinePlus. https://medlineplus.gov/druginfo/meds/a682683.html Last revised 2/15/18.

Probiotics: What You Need To Know. National Center for Complimentary and Integrative Health. https://www.nccih.nih.gov/health/probiotics-what-you-need-to-know. Last revised 8/2019.

Ouald Chaib A, Levy EI, Ouald Chaib M, Vandenplas Y. The influence of the gastrointestinal microbiome on infant colic. Expert Rev Gastroenterol Hepatol. 2020 Oct;14(10):919-932. doi: 10.1080/17474124.2020.1791702. Epub 2020 Jul 21.

Ginger. National Center for Complimentary and Integrative Health. https://www.nccih.nih.gov/health/ginger. Last revised 12/2020

Pi X, Hua H, Wu Q, Wang X, Wang X, Li J. Effects of Different Feeding Methods on the Structure, Metabolism, and Gas Production of Infant and Toddler Intestinal Flora and Their Mechanisms. Nutrients. 2022;14(8):1568. doi:10.3390/nu14081568

What is An Emotional Support Animal?

Patient Presentation
Two primary care pediatricians were discussing how they both had had requests for certification of an emotional support animal for their college-aged patients. Both patients were moving out of the dorms and were requesting an animal to live with them in their apartment.

“I haven’t seen her for almost 2 years and in looking through her chart, I don’t see any medical disability nor any mental health problems, so I told wrote back through the electronic medical record that she would need to contact her mental health provider. She hasn’t contacted me since,” he recounted. “I know my patient but I haven’t treated him for his mental health disability. The last time I saw him he was doing better. I also referred him back to his psychiatrist who has been treating him, but also told him that if he was having a problem to contact me again or come in,” she remarked. “We write lots of letters certifying disabilities, but I’ve been seeing more of these in the past couple of years,” he said. “Yeah, these must be more common for adult providers but still have to be difficult if you don’t really know the patient or you aren’t treating them for the particular disability,” she replied.

Discussion
Humans have had animals in their lives for millennia. Domesticated animals have been used for work, food, protection, and companionship among other activities. Dogs are a common species that are trained for a myriad of tasks including providing therapeutic benefits to persons with permanent or temporary disabilities including persons with psychiatric problems. The utilization of animals in medical/psychiatric therapeutic treatment programs is known as animal assisted activities (AAA) and animal assisted therapy (AAT). These programs have at least a 225-year history of being used. AAA tend to focus on recreation and quality of life activities, education, and motivation. AAT programs are used as part of a person’s overall therapeutic treatment plan for their disability. AAT programs are generally not stand-alone therapies.

These programs are used in “… numerous venues including schools, hospitals, mental health facilities, nursing homes, prisons, courtrooms, businesses, and physician’s offices.” They have been used successfully for anxiety, depression, behavioral problems, post-trauma including physical and mental health problems, substance abuse, grief, autism spectrum disorder, blindness, seizures, pain, and other problems. They can help “…encourage independence, self-esteem, psychology well-being, empathy and trust.”

Potential problems for using animals include:

  • Allergic reaction
  • Injuries such as bites
  • Zoonoses
  • Financial cost of training and maintaining an animal
  • Household disruption – sleeping problems, sanitation

Obviously the animal’s welfare must be appropriately attended to as well.

Learning Point
In the United States, there are certain legal statutes that are more influential regarding people with disabilities to utilize and be accompanied by an animal.

  • The Americans with Disabilities Act (ADA) allows disabled individuals to bring a service animal into local government building and public venues and is overseen by the Department of Justice. Workplace regulations are provided through the Equal Employment Opportunity Commission who provide “interpretive guidance” for employees and employers for reasonable accommodation requests for disability-related assistance animals.
  • The Fair Housing Act (FHA) has “adapted a more expansive view of what animals might act as a reasonable accommodation.” Animals are not pets but can be emotional support animals. It is overseen by the Department of Housing and Urban Development.
  • The Air Carrier Access Act uses the term service animal but with broader meaning that can include emotional support animals. However airlines are not required “…to permit an animal aboard if doing so would be unduly burdensome,…” and can deny certain types of unusual animals such as reptiles, spiders, rodents, etc.
    It is administered through the Department of Transportation.

Definitions of animals includes:

  • Service animal –
    “As defined by the ADA, a dog or miniature horse that has been individually trained to perform specific tasks that mitigate a person’s disability.”
  • Psychiatric service animal –
    “As defined by the ADA, a subset of service animal that has been individually trained to perform specific tasks, which do not include the provision of “emotional support,” that mitigate a person’s disability from psychiatric illness.”
  • Emotional support animal (ESA) –
    “An animal of any species, which does not qualify as a service animal under the ADA, that a medical provider has certified can mitigate a person’s psychiatric disability through companionship rather than by any specifically trained task(s).”
  • Therapy animal –
    “Any species of animal utilized by a trained handler, either through the animal’s presence or a guided interaction as a part of a structured animal-assisted therapy, to provide therapeutic benefit for persons with illness and suffering.”
  • Pet –
    “An animal kept for companionship or pleasure that is not clinically certified for therapeutic use in any illness or disability and is not afforded any special accommodations under the law.”

The Iowa Civil Rights Commission has sample policies and request forms here.
Letters asking for accommodations and/or certification of animal use include questions such as what reasonable accommodations the person is asking for, are these accommodations related to a disability, is the animal required because of the disability, is the animal trained and performs specific tasks, type of animal and animal health, etc.

Questions for Further Discussion
1. What types of disabilities do you write certifying letters for?
2. What types of problems do you you write similar letters for?
3. What types of AATs are available in your area?

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: Pet Health and Rehabilitation.

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.

Endenburg N, van Lith HA. The influence of animals on the development of children. The Veterinary Journal. 2011;190(2):208-214. doi:10.1016/j.tvjl.2010.11.020

Mims D, Waddell R. Animal Assisted Therapy and Trauma Survivors. J Evid Inf Soc Work. 2016;13(5):452-457. doi:10.1080/23761407.2016.1166841

Hill J, Ziviani J, Driscoll C, Teoh AL, Chua JM, Cawdell-Smith J. Canine Assisted Occupational Therapy for Children on the Autism Spectrum: A Pilot Randomised Control Trial. Journal of Autism & Developmental Disorders. 2020;50(11):4106-4120. doi:10.1007/s10803-020-04483-7

Carroll JD, Mohlenhoff BS, Kersten CM, McNiel DE. Laws and Ethics Related to Emotional Support Animals. The Journal of the American Academy of Psychiatry and the Law. 2020;48(4):10.

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