Patient Presentation
A pediatrician had recently seen several college students who were going on various study abroad trips.
She then was sitting in an airport for an international flight next to two college men who obviously were traveling abroad for the first time for a 1 month trip.
Both were excited about the trip but one was noticeably more prepared. Their overheard conversation was:

Student 1: When are we going to sleep?
Student 2: On the plane.
Student 1: We’re not going to the hotel and sleeping? I was going to play a bunch of games and watch movies on the plane.
Student 2: No, we have a tour of the city, then dinner and then later to bed. You have to sleep on the plane.
Student 1: That’s crazy. I don’t think I can sleep on a plane.
Student 2: You have to try. Tomorrow is our first day. You don’t want to miss seeing the cathedral do you? Didn’t you read the itinerary?
Student 1: No, the prof will just tell us what to do anyways.
Student 2: You should read it so you kind of know what is going on. By the way, you’re supposed to wear your money belt under your clothes.
Student 1: Why? It’s easier to get this way.
Student 2: I have my credit card and extra cash in it and I don’t want someone to steal it. Don’t you remember they said we had to get them to stop pickpockets.
The pediatrician observed Student 1 getting up and putting his money belt under his clothes.

Discussion
Study abroad programs (SAP) are wonderful opportunities for students to learn languages, as cultural exchanges and to help students in general become a better global citizen. From a health care perspective, it is a combination of going off to college, short-term travel health, and long-term travel health. SAP programs vary immensely from 1 week trips to year-long intense cultural immersion experiences. They can involve college classes and/or volunteer experiences. Preparation before leaving also varies from specific curriculums for students to complete to little else than a list of suggested packing items and how to get a passport and visa. In country support also varies but usually the longer the program is the more support there is. Students are excited about the travel, classes and cultural opportunities. Parents are worried about safety, money and their student having fun but also being supported.

Tips for going off to college can be reviewed here.
Travel health can be reviewed here.

Learning Point
Tips for a student going on a SAP include:

• Expectations
  Have reasonable expectations about how your study abroad program will go. How will you do in your classes? How will the language learning go? How much time can you spend exploring the local city, or traveling farther afield? Remember that you likely won’t meet all your expectations. Some things will go smoother and other things just won’t happen. Realize that there will be many other opportunities and experiences that you will never expect such as going to the local festival, talking to the elderly man on the train, etc.

  Parents care about you. They are excited you are going but also are worried with 3 main concerns: safety, are you having a good time and money issues. Make sure to discuss expectations such as how often you will be communicating and how. A quick text once or twice a week to let them know that you are okay and explored the local market is great. Parents need general information such as your local address and SAP contact information in the US and the local country. Remember that life continues at home and they may need to contact you because of a life event.

  Budget also should be discussed so that you and your parents are clear about who will pay for what and how much. For short programs, using a credit/debit card that has no foreign fees is a good option. It can be difficult to establish a foreign bank account and/or obtain a foreign credit card even if you will be in the program for a longer time period. Alternatively, there are online banks which offer credit cards for the local country that can be obtained before leaving home. Make sure your bank/credit card knows that you will be using it internationally so they don’t put a hold on the card. Generally (but not always) it is less expensive to complete a credit card transaction in the local currency. Your bank and its credit card will generally offer a better currency conversation rate than the local shopkeeper. Consider how you will obtain cash. Some countries are mainly cash societies and others are cashless.

  Do all the before-you-go curriculum for the SAP as this will help you to understand your course and be prepared.

  Be responsible and stick to your plans for communicating and budget and do your pre-coursework.

• Safety
  Think ahead about potential scenarios and what you will do if something happens. What will you do if you are sick, lost your passport, your phone was stolen, are out later than usual and aren’t sure how to get back home? Make a plan and consider talking with your parents and/or SAP staff about options.

  SAP rules – Know what they are and follow them. Do you need to tell them if you are traveling? Can you drink alcohol? What happens if you miss class? There is a reason they usually have the rules they do even if you don’t understand them so it’s better to follow them.

  Just like at home your SAP will have class expectations, homework and assessments. They will also have support to help you with your classes. Follow the SAP instructions. Also know what is required to be able to transfer your credit back to your home school.

  Know the 911 emergency equivalent for your country to call the police, fire, ambulance. Also know the 988 equivalent for mental health support for your country. A list can be found here.

  Clothing and travel days. Travel clothing should be comfortable and functional. Deep pockets, hidden pockets with zippers etc. help keep valuables safe. Clothing should also consider the weather and be culturally appropriate. Remember that in some places modest clothing is expected such as in houses of worship, and specific clothing may be required (i.e. skirts, head coverings, etc.). Think about your itinerary and if specific clothing is needed such as visiting churches, hiking, and beach activities.

  Consider wearing “travel clothes” on days of heavy touring or traveling. This means clothing with hidden/zippered pockets to keep valuables safe and wearing a money belt. It will not stop a pickpocket but will make it harder for them. Use safety pins and/or cable ties on backpacks’ zippers and/or clothing. Again this deters pickpockets.

  It is also good to get into the habit of doing a WIPPLE check as you move from one activity to another to recheck you have everything and they haven’t been tampered with since the last time you checked.

  W – Wallet with money, credit cards
  IP – Important posessions, passport and papers like keys, tickets, directions etc.
  P – Phone and computer, including cords
  L – Luggage and backpack
  E – Extras or miscellaneous things for the activity or travel
  

• Valuables
  Money, credit cards, passports, tickets, etc. need to be safeguarded. There is always a balance between having them easily accessible and them being a target for pickpocketing. In general, have enough money for the day and 1 credit card available in a wallet (again placed into a deep pocket or zipped into a hidden pocket), and tickets for the day too. If not traveling, your valuables should be left at your local dorm/apartment (maybe in a travel safe – see below). If traveling, the rest of the valuables should be in a money belt under the clothing. The money belt should be comfortable such that you will wear it and it is a personal preference as to the type. There are belts which go around the waist and are tucked into pants/shirt, and pouches that hang from the neck under a shirt. The neck pouches are more convenient but the strap can easily be cut and the neck pouch potentially stolen. They also are more obvious when wearing them. The strap could be used as a weapon to try to strangle someone.

  Travel safes – these are small containers which are designed to keep valubles safe, just like a home, office or hotel safe. There are different styles and sizes, but most have tamper-resistant materials and locking devices that are designed to latch around an immovable object such as furniture (in a home), fence or picnic table (pool, recreation facility) etc. These are good for long-term deep storage of valuables (like your dorm room, apartment, or if you have to take them with you for a particular activity (i.e. beach activities). These can also be used to store documents and prescription medications.

  Phones – Phone and their use are ubiquitous, but they can be easily stolen and with it potentially lots of personal information. First, use the phone only when necessary and take care to make grabbing it harder to do (e.g. someone riding a bike grabs it at the bus stop). Use it away from people or go to a corner/side of building. Don’t leave it in a backpack that can easily be taken. Keep it on your person in a hidden pocket if possible. Put a lock on the phone for using it to make it harder for someone to get at your data. Have a plan to be able to “kill” the phone and remove the data remotely if needed. Some people want just the phone to re-sell it and others want your data. Have a backup of your phone available to reconstitute a new phone if needed. The same goes for a laptop computer.

  Many US phone providers have international travel plans that are at least convenient. For short term SAPs, these are often the easiest and most affordable. They also allow you to keep your US phone number. A local phone provider may be more affordable for a longer term program. This usually requires a different SIM card and phone number. Check on the cost, particularly if you will be going to several different countries. Does the local provider also allow roaming to another country? If you keep your US phone number, check if there is a different cost if someone from the US (like your parents) contacts you.

• Health
  Common sense and planning – Make a travel medicine appointment with your health provider at least a couple months in advance of travel, so that any vaccine series needed can be completed. Make a travel first aid kit and keep it with you. Follow the general instructions for food, water and environmental safety (see travel health). If the SAP is going to be a long program, have your routine appointments for medical, dental, ophthalmology, etc. completed before leaving.

  Keep yourself well hydrated, fueled with food and take rest breaks during the day. Have a consistent schedule to go to school, do homework, have fun and sleep. This will help with your physical and emotional health.

  Food and alcohol – Try the local food specialties and beverages but make sure you take reasonable care that they are prepared and given to you in a sanitary way. Following local customs is a great way to meet new people and have experiences but be careful of drinking alcohol. Only drink if you are legal age and your SAP allows it (some don’t even if you are of age – follow the SAP rules) . It is also fine to refuse a food or beverage even if it is “customary” if you don’t feel right about it. You don’t have to give a reason and most hosts will be fine with that.

  Medications Make sure it is legal to bring your prescription medication into the country, and if you need to apply for a permit to import the medication for your own use. Stimulant and anti-anxiety/depressant medications are common ones that may need permission to bring with you. Take enough prescription medication (in your hand luggage and always in the original bottle along with a paper prescription for the medication) for the entire time you will be abroad plus a little extra. Lock this up in your travel safe (see above) once you arrive.

  Homesickness and Emotional Health
  – Studying and traveling abroad is exciting. It is a culture shock. It takes a lot of cognitive energy to be aware of your new language and surroundings (and hopefully enjoying them). You add trying to study and make new friends and being away from your regular family, friends and location all can be stressful. It is really normal to feel some homesickness/sadness especially around the quiet times of the day. It is also normal to feel like you are overwhelmed with everything you are seeing/doing/class expectations, etc. SAPs know this and especially offer opportunities to meet other study abroad students, local students, faculty and let you know who you can go to for any assistance you might need. Some programs even do field trips to the grocery store, and places like the bus/train station to help you know the local area and practice your language with some local help around. If yours does not, consider doing some of these activities with another local or SAP student. Even having someone help you learn to do your laundry the first time can be a bonding experience between people.

  If you are feeling anxious or overwhelmed, experiencing more sadness than you think you ought to, or are avoiding people or experiences, then it is likely time to talk with a SAP staff member to help you. Also if you have in the past or are currently being treated for a mental health issue and your symptoms are getting worse in some way, you should contact the SAP for help.

  Countries offer mental health support. A list of resources can be found here.

  Coming home – People often don’t realize that there can be a culture shock of coming back to your home country. This occurs more often the longer you are away from your home country. Just like you gave yourself time to adapt to your SAP and new country, it may take some time to adapt back to your home country. This is very normal and again follow the ideas above about traveling to your program.

• Planning and Backup
  One of the most concerning issues is that something will happen and you don’t know the system and how to get help. Think ahead and plan for potential problems and have a backup plan.

  Health insurance – check your health insurance company before you leave and see what it may, or likely not, cover when you are abroad. Also realize that you likely will need to pay for any healthcare (including prescription medications) when it is provided and pay in cash. This cost can potentially be significant. You can later ask for reimbursement from your insurance company if they will cover the care. If your health insurance does not, or inadequately covers your healthcare when abroad, travel insurance with health coverage is strongly recommended. See below.

  Travel insurance – These policies have a broad range of coverage from covering lost luggage and tickets, to providing for medical evacuation. Health coverage especially for major illnesses and/or accidents is imperative. Travel assistance also usually comes with these policies and aids the student/travelers with big problems such as finding a health provider, what to do if their passport/valuable was stolen, transportation has been delayed for a significant amount of time and they are stuck, etc.

  Travel and/or international health insurance may be included in the SAP cost or it may need to be obtained separately. Also the included insurance may not cover additional days outside the SAP such as traveling before or after your SAP. Additional insurance to cover this gap may be needed. Also check to see what type of insurance is included in the SAP and if are you comfortable with this coverage or want to obtain more yourself.

  Some travel insurance also excludes certain activities such as high risk activities, traveling in places where there are trip advisories, etc. Driving or driving of certain types of vehicles or in particular conditions (such as off-paved roads) could also be an exclusion. Also when buying the travel insurance make sure that it covers the entire amount of time you expect to be in the foreign country and plan for additional time as well in case your plans change. In some situations you cannot buy additional travel insurance once you are in the foreign country to cover additional time out of country.

  The US State Department – The State Department (SD) offers a variety of services to help Americans abroad. Other countries have similar services for their citizens. Information for US students studying abroad can be found here. The SD cannot provide financial help for traveling home, healthcare costs, attorney fees, etc.

  The SD monitors foreign country safety and provides appropriate guidance. Note that the guidance can change at any time. You can register your trip with the State Department (STEP Program) and they can send safety messages tailored to your location and itinerary. The State Department also recommends to follow their social media accounts for information.

  Documents – Have a copy of your important documents. This includes passport (including the front cover), credit/debit cards, health and dental insurance cards and documents, travel insurance and assistance contacts, SD embassy and consulate listings, Study Abroad program contacts, emergency contacts at home/abroad. Having them available by the Internet is a good idea, but also having a paper copy is good as there can be problems with Internet service availability or your phone was stolen. Keep these in your money belt and/or travel safe. Similarly have a backup of the data on your phone so you can reconstitute it if it is stolen.

• What to do when there is a problem
  Something will happen. Know and plan for it.

  Most of the time it is irritating, annoying and inconvenient, but is not a safety or health issue. Don’t compound the problem by making another bad decision. Often it is fixed by taking a moment to think things out, asking for help, or being patient and waiting.

• Miscellaneous
  Transportation and Accommodations – Transportation costs (especially bus and train) are often decreased for students with appropriate identification. Transportation may be less expensive at particular times of the day or days of the week. Many countries have specific reduced cost student accommodations such as hostels (one example is the International Youth Hostel program). Appropriate identification can vary depending on the country.

  Student discounts are often given for cultural attractions and activities like museums. Many often have times when they are free too. Many big attractions can be booked online saving time standing in line. They may require identification when you enter the attraction. The appropriate identification can be your college or high school identification along with a passport to a special ID for the country. Sometimes the SAP needs to verify your student status. This may not be helpful for a short-term SAP, but likely is worth the time and effort for a longer program. Also be careful to safeguard your personal data and not just give it out to get a small discount.

  Electronics – Take the electronic devices you need but leave anything else at home. Remember that you likely will need both an electrical adapter (changes your device’s pins so you can physically plug into the electrical outlet) and a converter (changes the electrical voltage you get from the outlet into the appropriate voltage for your device). Using USB cords often make this much simpler because it is a universal standard. Take backups with you.

  Activities – Try different activities especially those you might not be able to do again because it is a local activity. Just be sure that you are physically and mentally ready for the activity and have the appropriate safety gear or documentation. For example, you may need an International Driver’s License (available only before you leave the US) to drive in particular countries even if you have a valid US driver’s license. Do you have hiking shoes and can you really climb that mountain?

  Luggage – Check your luggage especially before crossing a border -make sure you have packed it, there is not something inadvertently left from the last time it was used. Something that is legal in one country may not be legal in another and you don’t want to be detained and/or arrested. Examples include prescription medications, any potentially illegal substances (including marijuana/CBD) or firearms/ammunition/weapons. Even small knifes (like a Swiss army knife) or scissors could cause a problem. Do not carry anything for anyone else – only your own stuff that you pack yourself. Your new best travel buddy may not be what they seem.

Questions for Further Discussion
1. What counseling do you offer for students going on SAPs?
2. What resources do you use for traveler’s health?
3. What tips do you have for travel in general?

Related Cases

Disease: Study Abroad Programs | Traveler’s Health

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Adolescent Medicine | School | Travel Medicine

Age: Young Adult

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: Traveler’s Health and College Health.

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.

Sanford C. The Pretravel Consultation. American Family Physician. 2016;94(8).

Mahadevan SV, Strehlow MC. Preparing for International Travel and Global Medical Care. Emergency Medicine Clinics of North America. 2017;35(2):465-484. doi:10.1016/j.emc.2017.01.006

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

Patient Presentation
A 17-year-old female came to clinic with a history of genital itching for several weeks. She actually had noticed that there were some genital “bumps” that had also been present which had initially been small but had increased in size. These were now becoming pruritic and sometimes painful. She denied any systemic problems and also denied any rashes, vaginal discharge, and abdominal or pelvic pain. Her menstruations were monthly and had not altered over the past 2 years.

The past medical history showed she had initiated sexual intercourse at age 15 and had 3 lifetime male partners. The newest relationship had been 6 months. She had been screened for sexually transmitted infections (STIs) twice since age 15. She stated that she always used condoms and a spermicide but was not using other contraception. She was not immunized against human papilloma virus and some other routinely recommended vaccines.

The pertinent physical exam showed a healthy appearing female with normal vital signs and growth parameters. HEENT and skin exams were negative. Her genitourinary examination showed no vaginal discharge and normal labia. She had multiple skin-colored papular lesions from 1-10 mm in size along the perineum and around the anus, that showed some minor excoriations.

The diagnosis of genital warts was made. The physician explained the natural history and offered some options. The patient decided to try to use some emollients to the area and also use an antihistamine to try to help with the pruritis while waiting for possible spontaneous regression but was going to return if the lesions increased significantly or she had more pain or pruritis than she could tolerate. She also wanted to start using a more consistent form of contraception and was referred to a provider for a Nexplenon&reg: placement. She also wanted to have STI testing as she had not had this completed with her new partner. Confidentiality issues were discussed and as her parents were aware of her sexual health status, there were no issues with evaluation, treatment and followup.

Discussion
Condylomata acuminata or genital warts are caused by human papilloma virus (HPV) from the Papillomaviridae family. There are about 200 different types of HPV with ~30 of them causing genital infections. HPV serotype 6 and 11 are the most common causing condylomata (90% of infections). HPV serotypes 6, 11, 16 and 18 are the most common ones causing dysplastic changes and/or cancer. Types 16, 18, 31 and 45 are high risk oncogenic types. There are 2 different vaccines available. Data for the quadra-valent vaccine (for types 6, 11, 16 and 18, original Gardasil&reg:) has extremely high rates of effectiveness for condylomata prevention (~99%) and for cervical cancer prevention (~97%). There is also data supporting cross-reactivity with other serotypes and herd immunity. In the United States, Gardasil-9® (with the addition of serotypes 31, 33, 45, 52 and 58 from the original) can be given from 9-45 years for males and females, and requires a 2- or 3- dose series depending on age at vaccine initiation. A bivalent vaccine for serotypes 16 and 18 is also manufactured.

Learning Point
HPV causes epithelial cell proliferation producing skin-colored papules of 1-5 mm to large pedicaled or cauliflower type lesions . Transmission is usually via sexual contact but auto/heteroinnoculation and vertical transmission are also common. The incubation period is about 10-14 weeks and physical symptoms begin about 8-10 weeks after infection. Patients do not have to have clinical symptoms because the virus may be dormant but present within epithelial cells for long time periods. Children who present with condylomata may raise the suspicion of child abuse but like many sexually transmissive infections is not specific for it. Pediatric patients should have potential child abuse considered as part of the evaluation and treatment process.

Patients may need treatment but up to 30% have spontaneous regression within 4 months of symptoms, but many patients have recurrence within the following 3 months. In general watchful waiting is the best treatment, but if lesions are persistent > 2 years or are symptomatic then treatment is recommended.
Potential treatments include:

• Physical removal
  • Cryotherapy causes thermal destruction which also triggers an immunological response. This requires professional application usually with several treatments needed. Side effects are mainly local, and potential but less likely cutaneous and vascular damage. Success in adult population is ~60-80%
  • Electrocautery causes thermal destruction and cautery. It requires professional application. Side effects are local but more extensive tissue damage could occur. Effectiveness is cited at ~55-90% in adult populations.
  • CO2 laser therapy causes thermal damage and cautery. It requires professional application with specific training and unfortunately is also expensive. It is precisely applied with little to no scarring. Side effects are local. Environmental controls and virus-resistant masks for those in the procedure room are needed because of potential aerosolization of the viral particles during the procedure.
  • Pulsed light therapy is a 2 step process where a keratolytic agent is used along with phototherapy. It requires professional application with specific training and unfortunately is also expensive. Side effect include burning, itching and pain.
• Topical treatment
  • Imiquimod is an immunomodulator. It is self-applied. Side effects are mainly local with burning, erythema and erosions. Effectiveness is up to 75% in pediatric patients.
  • Podophyllotoxin is a anti-mitotic agent. It is self-applied. Side effects are mainly local with edema, erythema and erosions. Systemic effects mainly include the liver and neurological systems.
  • Trichloroacetic acid is a chemical cautery. It is usually requires professional application. Side effects are irritation, edema, erythema, and burn. Effectiveness is up to 80% with recurrence of 36%
  • Other keratolytic agents such as salicylic acid or 5-fluoracyl are also sometimes used.

Questions for Further Discussion
1. What are the immunization rates for HPV in your own practice and/or local environment?
2. What is your practice standard for the types of verrucae? Why?
3. How common are STIs in your location? A review can be found here
4. What is respiratory papillomatosis and how is it treated? A review can be found here

Related Cases

Disease: Genital Warts | HPV | Sexually Transmitted Diseases

Symptom/Presentation: Mass or Swelling | Papulosquamous Lesions

Specialty: Adolescent Medicine | Obstetrics / Gynecology

Age: Teenager

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: Genital Warts and HPV.

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.

Drolet M, Benard E, Boily MC, et al. Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2015;15(5):565-580. doi:10.1016/S1473-3099(14)71073-4

Costa-Silva M, Fernandes I, Rodrigues AG, Lisboa C. Anogenital warts in pediatric population. An Bras Dermatol. 2017;92(5):675-681. doi:10.1590/abd1806-4841.201756411

Yuan J, Ni G, Wang T, et al. Genital warts treatment: Beyond imiquimod. Hum Vaccin Immunother. 2018;14(7):1815-1819. doi:10.1080/21645515.2018.1445947

Kore VB, Anjankar A. A Comprehensive Review of Treatment Approaches for Cutaneous and Genital Warts. Cureus. 15(10):e47685. doi:10.7759/cureus.47685

Deak P. What I Tell Every Patient About the HPV Vaccine. ACOG. Accessed July 15, 2024. https://www.acog.org/womens-health/experts-and-stories/the-latest/what-i-tell-every-patient-about-the-hpv-vaccine

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

Patient Presentation
A 4-year-old female came to clinic for an initial health screening as she had been placed into foster care the day previously after the children had been removed from their home. The very experienced foster mother had been given little information, but said the reason for removal was parental substance abuse and neglect. Her school age sister was coming to a later appointment that day as well. The foster mother said when both arrived, the children and their clothing were dirty but she did not see any infestations. The child had said little since placement and seemed quite wary. The foster mother had been able to bathe her but she would not allow someone to brush her teeth, and she noted that she had bad breath. She also would not eat until the foster parents and other household children retreated away from her. Then she ate quickly and would keep her eyes averted. The foster mother said the older sibling was acting similarly but would answer direct questions for both of them.

The pertinent physical exam showed a very quiet child who would sit next to the foster mother with eyes averted. Over the interview and physical examination she would answer simple questions and would assist the pediatrician. Her vital signs were normal. She appeared thin and her weight was 3rd percentile, height was 25%. Skin examination had some bruises on her shins and dorsal surfaces of arms. She had a couple of healing cuts on her shins but no abnormal skin lesions. Her eyes were normal but she was unwilling or unable to complete the visual acuity examination. Her mouth had intact frenula, obvious brown spots on multiple dental surfaces and her gingiva appeared red and swollen in multiple places. She had obvious halitosis. Her nose was patent without obvious rhinorrhea. Her ears had thick cerumen. Her neck had multiple shotty anterior cervical nodes without other adenopathy. She did allow an inspection of her genitourinary area which appeared normal. The rest of her examination was normal.

The diagnosis of a neglected child who had been placed into foster care and who had dental caries and gingivitis was made. The Department of Health Services was working on providing additional medical information including immunization. The foster mother said that she felt she had the supports she needed to help the child at this point, but that she could use some help with her mouth. Quietly she remarked that this was the worse halitosis she had encountered with a newly placed child. The pediatrician suggested to get a very soft toothbrush and start to brush her teeth regularly with fluoride toothpaste. “I also have some toothettes which I can give you. They are small sponges on a stick that are softer. If the toothbrush is too much for her you can use these the same way. I also can talk with a dentist friend of mine to get her in to see someone relatively quickly,” the pediatrician offered. The mother said she was going to call her dentist when they got home and when she brought the older sibling in the afternoon she hoped to have more health information, both of their immunization records and she would let the doctor know if she needed the dental referral too. “I hope we can make a better plan this afternoon once we both have more information,” she said.

Discussion
Neglect is a form of child maltreatment. It is the chronic failure by the child’s caretaker to meet the child’s basic needs such as food, clothing, shelter and adequate safe-guarding. Failure to also meet medical/dental, emotional and educational needs are also included as neglect. Neglect can be one of the most difficult forms of child maltreatment to identify and/or prove. Presentations for child neglect include:

• No physical or sexual abuse signs
• Abnormal growth pattern or non-organic failure to thrive
• Chronic infections such as diaper dermatitis
• Cold injuries
• Delayed puberty
• Dirty clothes and/or body
• Dental caries
• Infestation such as lice
• Developmental delay or immaturity
• Behavior that is listless, distractable, attention-seeking
• Poor concentration
• Lack of self-esteem or confidence
• Truancy, problems with the law
• Alcohol or substance abuse
• Self-harm

A review of presentations for child maltreatment can be found here.

Learning Point
Oral health is important to overall health. Basic oral health including daily tooth brushing and flossing can prevent many dental problems. Regular, preventative, dental care for cleaning and examination is valuable. Many children may also receive dental sealants to help prevent caries.

Dental plaque is the sticky biofilm that coats the teeth. It is usually colorless and contains bacteria. It is the “fuzzy” feeling on the teeth. It is removed by regular daily dental care. This film is normal (is symbiotic) but can become dysbiotic causing dental disease.

Tartar or dental calculus is calcified dental plaque and is a more serious problem as it can extend under the gingival line. This requires professional dental treatment to remove.

Dental caries are one of the most common infections. They occur when the normal biofilm becomes more acidic and demineralizes the tooth structure. Caries are usually caused by Streptococcus viridans.

Dental abscesses are usually caused by poor oral hygiene but others are at risk because of malformations and deformation of the dental structure or underlying medical conditions. Dental abscess often contain poly-organisms with combinations of anaerobic and fastidious organisms. A review of caries and abscess can be found here

Gingivitis is the infection and swelling of the gingival tissues. Periodontitis is the infection and destruction of the gingival and other supporting tissues of the teeth (especially the periodontal ligament) including potentially bony erosion. Periodontitis also has various definitions depending on the extent, severity and age of patient, although these definitions are used less consistently. There are several different infections that are associated with severe periodontitis including Aggregatibacter actinomycetemcomitans, Polyromanas gingivalis, Tannerella forsythia and Selomonads.

Gingivitis and periodontitis are a continuum of the same inflammatory, infectious process. Depending on the patient “[m]icrobial dysbiosis, overgrowth of pathogenic bacteria, herpesvirus reactivation, immune-system disruption and acquired and/or genetic susceptibility factors are probably involved in disease progression from gingivitis to periodontitis.”

Gingivitis and periodontitis can be prevented and treated if needed. Limited access to professional care is partially associated with the prevalence of periodontal disease.

Treatment needs ongoing professional care including professional cleaning which may be extensive and require anesthetic (local and/or operative), treating active infections, and may need dental surgery for treatment of pocket disease and even bone grafting. Treatment of this gingivitis/periodontitis continuum not only treats the local disease, but also has been shown to have systemic health improvements especially in reduction of processes associated with systemic inflammation, cardiovascular disease and even premature births.

Symptoms of gingival/periodontal disease include:

• Guns that are red, swollen, and sore
• Easy bleeding while brushing or flossing
• Halitosis
• Receding gums (pulling away from the teeth
• Teeth that are loose or have changes in the tooth space (teeth may be separating)
• Loose or separating teeth that show greater than normal spacing
• Bite or tooth alignment changes
• Obvious purulence

Questions for Further Discussion
1. What problems should be considered and screened for in children entering foster care or being internationally adopted? A review can be found here
2. When can children brush their teeth unsupervised?
3. What are indications for dental referral?

Related Cases

Disease: Gum Disease | Child Dental Health | Child Abuse

Symptom/Presentation: Dental Problems | Child Abuse and Neglect and Sexual Abuse

Specialty: Dentistry / Orthodontia | Child Abuse and Neglect

Age: Preschooler

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: Gum Disease, Tooth Decay and Child Abuse

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.

Fine DH, Patil AG, Loos BG. Classification and Diagnosis of Aggressive Periodontitis. J Periodontology. 2018;89(Suppl 1: S103-119.

Botero JE, Rösing CK, Duque A, Jaramillo A, Contreras A. Periodontal disease in children and adolescents of Latin America. Periodontology 2000. 2015;67(1):34-57. doi:10.1111/prd.12072

Orlandi M, Muñoz Aguilera E, Marletta D, Petrie A, Suvan J, D’Aiuto F. Impact of the treatment of periodontitis on systemic health and quality of life: A systematic review. Journal of Clinical Periodontology. 2022;49(S24):314-327. doi:10.1111/jcpe.13554

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

Patient Presentation
A 16-year-old male came to clinic for his health supervision and sports physical visit. Overall he was doing well in school and was looking forward to his upcoming cross-country, basketball and baseball seasons. His mother was worried because his cousin, who attended the same high school, had just been released from inpatient psychiatric treatment for newly diagnosed schizophrenia. The past medical history was non-contributory. The family history was positive for his mother and aunt having anxiety. There was no known depression, but in his uncle’s family there was some unknown mental illness where the uncle’s brother had needed inpatient psychiatric treatment. The review of systems was negative.

The pertinent physical exam showed normal vital signs and normal growth. His weight was 15% and height was 75% consistent with his family.
His examination was normal.

The diagnosis of a healthy male was made. During the interview the mother voiced concern for the nephew, her sister and the family. The patient said that he didn’t know how to really talk with his cousin about this and what to say to other students at school. Options for handling these situations were discussed, and during this time the patient said, “He was just like me and then got weird over this last year. I’m worried it might happen to me. He started saying weird things, not all the time, but enough. He also got paranoid and would want to sit in the corner of the locker room where he could see his stuff. If you left him alone he was okay but would get really angry and physical if you went near him or his stuff. I could kind of handle this so my locker was next to his, but sometimes he would hit me.” The pediatrician said that he didn’t know a lot about schizophrenia but that it was treatable but could be difficult to treat. He also said that it can be inherited but noted that it was less likely as he was a cousin and not a brother. “I don’t know the exact numbers. This is a tough diagnosis because patients with it need long-term treatment and support. You both need support too. I can refer you to a therapist who can help with some of the questions you have as well as helping you sort out some of the feelings you have. You could do this now or sometime in the future if you want. Your school counselor could also be someone to talk to and also knows the school situation,” he offered. The patient said he was going to talk with the counselor. “I’m friends with his son ’cause we run together. He’s okay and I think I can ask him some questions,” the patient said. His mother was also offered mental health support for herself and 13 year old daughter, but declined at the time.

Discussion
“Psychosis [is] characterized by aberrant thinking, perceptions and behavior….”
Psychosis includes the presence of hallucinations and delusions without insight into them.

Psychosis can be seen in a mental health disorder such as schizophrenia spectrum disorders, autism spectrum disorders, mood disorders and also medical conditions.
Common medical conditions where psychosis can be a feature in the teen and young adult population includes:

• Substance abuse – most common
• Medication side effects or toxin
• Epilepsy
• Traumatic brain injury
• Brain tumor
• Stroke
• Metabolic diseases

In the adult population other medical conditions include dementia, adrenoleukodystrophy, Huntington disease, multiple sclerosis, Parkinson disease, and other metabolic abnormalities.

Psychosis-like experiences can be normative childhood experiences such as an overactive imagination or explaining egregious behavior done for secondary gain. They can also be common in various mood disorders such as anxiety or psychological trauma.

Characteristics of a potential psychotic state in a child or youth includes:

• Consciousness is clear. Patient is oriented to surroundings, time, and space
• Hallucinations and delusions
• Socially withdrawn
• Bizarre behavior including talking or responding to invisible objects or people
• Language is abnormal. Production can be minimal or patient can be mute. It may be repetitive or incoherent.
• Inappropriate emotional response – excessive emotional response (i.e. excessively giggling) or laughing over a serious matter
• Activity changes – often hypoactivity but may be hyperactivity

Learning Point
Childhood onset (<13 years old) or early onset (teens) schizophrenia is rare at about 1:10,000 prevalence but this increases to 4:1000 lifetime prevalence in the adult population. Males have an increased risk. Overall risk is about 0.7-1% but is higher in families. In twin studies there is ~60-80% risk. “…[T]he morbid schizophrenia risk for parents and siblings of [adult onset schizophrenia] probands was 6% and 9% respectively, compared to 1% in the general population.”

The genetics are very complex, and polygenetic involving possibly thousands of genes. Currently there appears to be some environmental risk factors as well including complications of pregnancy/delivery, older father, born in winter/spring, living in an urban setting and cannabis use. Antipsychotic medication can significantly decrease the symptoms and reduce the relapse risk. Schizophrenia is also a chronic illness that requires continued treatment and support for patients and families.

Schizophrenia usually doesn’t appear suddenly but there are cognitive and mood symptoms often before other symptoms. For the diagnosis of schizophrenia the symptoms must be occurring for longer than 1 month and need to include at least 2 of more of the following:

• Hallucinations – beliefs of sensory perception in the absence of a stimuli
• Delusions – wrong beliefs or thoughts that continue to be held even when contradictory evidence is presented or can be logically reasoned
• Disordered speech – i.e. incoherent or derailment (frequent interruptions, jumping from idea to idea)
• Disorganized or catatonic behavior
• Negative symptoms such as lack of motivation, speaking less, flat affect, reduced pleasure in life events

Questions for Further Discussion
1. What is included in the differential diagnosis of hallucinations? A review can be found here
2. How common is Bipolar Disorder? A review can be found here
3. What are the resources in your community for substance abuse?
4. What are some of the chronic mental and physical health issues that people with schizophrenia are at risk for?

Related Cases

Disease: Schizophrenia | Psychotic Disorders

Symptom/Presentation: Health Maintenance and Disease Prevention | Genetic Disorder

Specialty: Psychiatry and Psychology

Age: Teenager

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: Schizophrenia and Psychotic 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.

Arciniegas DB. Psychosis. Continuum (Minneap Minn). 2015;21(3 Behavioral Neurology and Neuropsychiatry):715-736. doi:10.1212/01.CON.0000466662.89908.e7

McClellan J. Psychosis in Children and Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 2018;57(5):308-312. doi:10.1016/j.jaac.2018.01.021

Forsyth JK, Asarnow RF. Genetics of Childhood-Onset Schizophrenia: 2019 Update. Child Adolesc Psychiatr Clin N Am. 2020;29(1):157-170. doi:10.1016/j.chc.2019.08.007

Tandon R, Nasrallah H, Akbarian S, et al. The schizophrenia syndrome, circa 2024: What we know and how that informs its nature. Schizophr Res. 2024;264:1-28. doi:10.1016/j.schres.2023.11.015

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