What is in the Differential Diagnosis for Red, Orange or Yellow Skin Conditions?

Patient Presentation
A 15 month-year-old female came to clinic with a history of fever for 2 days up to 101.7F° and a rash that the mother noticed on the toddler’s trunk the evening before. She had some rhinorrhea, but no cough, emesis, or emesis and did not seem to be in pain. She had no history of exposures to any new soaps, lotion, detergents, etc. She was not taking any medications. Her daycare had some children with fevers but the mother didn’t know if they also had rashes. She had been drinking and urinating well. She was otherwise well.

The pertinent physical exam showed a healthy appearing child who interacted and smiled. She was afebrile and her growth parameters were around the 75%. HEENT reveled clear rhinorrhea, with normal ears and pharynx. She had a few shotty anterior cervical nodes. Her trunk and proximal shoulders and legs had multiple 1-2 mm, uniformly diffuse macular lesions that were pink in color and blanched with pressure. The rest of her examination was normal.

The diagnosis of a viral exanthem was made and her mother was educated regarding symptomatic care and when she could return to daycare.

Discussion
This is the first in a short case series of differential diagnoses of colored skin conditions.
A differential diagnosis by distribution and common pattern can be found here.
For green, blue and violet conditions, a review can be found here.
For black and white conditions, a review can be found here.
For brown and grey conditions, a review can be found here.

Note that any color can be a normal variant for an individual or is physiologic for a given state.

The skin is the largest organ of the body. It can be easily examined but for many clinicians continues to be difficult to describe what they are seeing. Analogies and comparisons are often used such as “It sort of looks like XXX,” or “It looks like atopic dermatitis but also YYY.” Skin lesions are described in many terms including morphology, size (using standard measurements), demarcation (well- or not well- demarcated), location, distribution and color. Morphologically lesions may be uniform or not uniform.

Primary morphology terms include:

  • “Macule – flat lesion less than 1 cm, without elevation or depression
  • Patch – flat lesion greater than 1 cm, without elevation or depression
  • Plaque – flat, elevated lesion, usually greater than 1 cm
  • Papule – elevated, solid lesion less than 1 cm
  • Nodule – elevated, solid lesion greater than 1 cm
  • Vesicle – elevated, fluid-filled lesion, usually less than 1 cm
  • Pustule – elevated, pus-filled lesion, usually less than 1 cm
  • Bulla – elevated, fluid-filled lesion, usually greater than 1 cm”

Secondary morphology terms include: erosion, fissure, lichenification, scaling, ulceration, serum (dry crust).

Distribution patterns include generalized, dermatomal, extensor, and photodistribution.

Color can also be difficult for people to describe both for patients and clinicians. Skin coloration is not uniform over the body and the changes from one area to the other are often not well-demarcated and are subtle. Color changes with high contrast (i.e. vermilion border, areola) are often easier for people to appreciate and articulate more accurately. Intensity of the coloration makes a difference (i.e. newborn jaundice with fluorescent quality or barely perceptible over the nose/face). The underlying skin tone, predominant skin color and ambient lighting conditions also makes large differences in how color is perceived and articulated.
Even color has different definitions which are commonly used interchangeably.

  • Primary colors – red, yellow, blue
  • Secondary colors – orange, green, violet
  • Tertiary colors – red-orange, yellow-orange, yellow-green, blue-green, blue-violet, red-violet
  • Hues – pure colors
  • Tints – hue + white
  • Tones – hue + grey
  • Shades – hue + black

Because of these numerous issues, it can be helpful to describe the predominant color and then a secondary color. For example, red with some pink areas is different than pink with some red areas.

Learning Point
Red is in the visible spectrum of light with wavelengths ranging from 625 to 750 nm.
The differential diagnosis for red skin conditions includes:

  • Skin
    • Burns – including sunburn
    • Dermatitis
      • Allergic
      • Atopic
      • Contact
      • Rosacea
      • Seborrheic
    • Dermatomyositis
    • Drug eruptions including Red man syndrome due to vancomycin
    • Erythema nodosum
    • Erythroderma
    • Infectious
      • Abscess
      • Cellulitis
      • Erysipelas
      • Candidiasis
      • Dermatophytoses
      • Toxic erythema – Kawasaki disease, Scarlet fever, Staphylococcal scalded skin syndrome, Toxic shock syndrome
      • Viral exanthems
    • Inflammatory
    • Multiple causes and specific locations
    • Acne
    • Lupus erythematosus
    • Neoplasms
    • Phototoxic reactions
    • Post-inflammatory erythema
    • Pityriasis rosea
    • Specific areas – red hands or palms, red scrotum or vulva
    • Trauma
    • Vascular lesions and problems
      • Angiomas
      • Hemangiomas
      • Deep vein thrombosis
      • Stasis dermatitis
  • Hair
    • Red or “ginger” hair
    • Chemical-induced
  • Nails
    • Chemical-induced
    • Rubronychia
    • Red splinter lines in nails
  • Mucosa
    • Infection
    • Trauma

Orange is in the visible spectrum of light with wavelengths ranging from 590-625 nm.
The differential diagnosis for orange skin conditions includes:

  • Skin
    • Xanthoderma
      • Drug-induced
      • Carotenemia
      • Lycopenemia
      • Foreign body granuloma
    • Infections
      • Leishmaniasis
      • Lupus vulgaris
    • Neoplastic
      • Sebaceous lesions – adenoma, carcinoma, nevus sebaceum
      • Histiocytosis, non-Langerhans
        • Juvenile xanthogranloma
        • Xanthoma disseenatum
      • Mastocytoma
    • Sarcoidosis
    • Pityriasis rubra pilaris
  • Hair
    • Chemical-induced
  • Nails
    • Chemical-induced

Yellow is in the visible spectrum of light with wavelengths ranging from 565-590 nm.
The differential diagnosis for yellow skin conditions includes:

  • Skin
    • Acne
    • Adipose tissue such as fat herniation
    • Connective tissue nevus
    • Ecchymosis
    • Epidermal cysts
    • Elastoma
    • Fixed drug eruption
    • Infectious
      • Candidiasis
      • Dermatophytosis
      • Impetigo
      • Sloughing skin
      • Viral
    • Lichen aureus
    • Keratin
      • Actinic keratosis
      • Hyperkeratosis
      • Seborrheic keratosis
      • Viral
    • Metabolic
      • Biliary disease
      • Diabetes
      • Estrogen
      • Hyperbilirubinemia, neonatal
      • Hyperlipoproteinemia
      • Hypothryoidism
      • Obstructive liver disease
      • Phytolesteroemia
      • Pancreatitis
      • Renal failure
    • Neoplastic
      • Histiocytosis
      • Mastocytoma
      • Sebaceous lesions – adenoma, carcinoma, nevus sebaceum
      • Squamous cell carcinoma
    • Pustular lesions
      • Erythema toxicum neonatorum
      • Folliculitis
      • Pustular dermatotis
      • Pustular psoriasis
      • Transient neonatal pusular melanosis
    • Rosacea
    • Staining
      • Henna
      • Nicotine
      • Tattoo
      • Tumeric
    • Solar elastosis
    • Xanthomas and xanthadermatosis
      • Multiple variations including specific locations such as tendon xanthoma
      • Drug-induced
      • Carotenemia
      • Lycopenemia
  • Hair
    • Chemical-induced
  • Nails
    • Chemical-induced
    • Dystrophic nails
    • Onchomycosis
    • Pachyonychia congenita
    • Yellow nail syndrome

Questions for Further Discussion
1. What red skin conditions do you see often?
2. What orange skin conditions do you see often?
3. What yellow skin conditions do you see often?
4. What are indications for referral to a dermatologist?

Related Cases

    Symptom/Presentation: Rash

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: Rashes

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.

Elias M, Patel S, Schwartz RA, Lambert WC. The color of skin: red diseases of the skin, nails, and mucosa. Clinics in Dermatology. 2019;37(5):548-560. doi:10.1016/j.clindermatol.2019.07.017

Logan IT, Logan RA. The color of skin: yellow diseases of the skin, nails, and mucosa. Clinics in Dermatology. 2019;37(5):580-590. doi:10.1016/j.clindermatol.2019.07.019

Soundararajan V, Charny JW, Bain MA, Tsoukas MM. The color of skin: orange diseases of the skin, nails, and mucosa. Clinics in Dermatology. 2019;37(5):520-527. doi:10.1016/j.clindermatol.2019.07.014

Dermatology Exam: Learning the Language. Stanford Medicine 25. Accessed January 4, 2022. https://stanfordmedicine25.stanford.edu/the25/dermatology.html#serum

Visible spectrum. In: Wikipedia. ; 2021. Accessed January 4, 2022. https://en.wikipedia.org/w/index.php?title=Visible_spectrum&oldid=1062416030

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

What is Vocal Cord Dysfunction?

Patient Presentation
A 6-year-old male came to clinic for left ear pain during a respiratory illness, that had occurred for 2 days. The evening prior he had a fever to 101.2°F. The past medical history was positive for vocal cord dysfunction diagnosed after stridor, coughing and voice changes that would not improve after a previous viral illness.

The pertinent physical exam showed a current temperature of 100.8°F, respiratory rate of 26 and pulse of 96. He looked tired. HEENT showed erythematous bulging left tympanic membrane with distorted landmarks and dull right tympanic membrane. He had copious rhinorrhea and his throat was normal. Lungs were normal as was the rest of his examination.

The diagnosis of left otitis media was made. The patient was started on antibiotics. The medical student asked the attending physician to explain why the patient was seeing the speech therapist for the vocal cord dysfunction.

Discussion
Vocal cord function involves balancing muscular and neuronal functions. The superior laryngeal nerves (SLN) and recurrent laryngeal nerves (RLN) are the main nerves responsible for sensation and motor innervation. There are two sides to the larynx and they operate ipsilaterally, therefore one side can be affected while the other is not.

Vocal cord paresis or paralysis are “an impairment of the vocal fold motor function that is caused by nerve or neuromuscular abnormalit[ies].” Paresis involves some maintenance of vocal cord movement while paralysis does not. Paresis is also more of a continuum than an absolute movement or not. “Paresis is often considered idiopathic, but potentially any pathology present from skull base to mediastinum that compresses, tethers, stretches, or infiltrates contributing fibers to the SLN or RLN may cause abnormalities.” Common examples in children would be post-viral infections, Lyme disease, neoplasms, and cardiovascular defects and cardiovascular surgery, but many others causes occur. Paralysis is often caused by necessary surgical interventions such as patent ductus arteriosus surgery causing trauma to the RLN as it is a long nerve and traverses multiple body spaces.

Symptoms can include cough, choking, globus sensation, voice changes, dyspnea and feeding difficulties among others. The diagnostic standard is direct visualization while awake when the patient may be able to assist in producing various sounds or types of breathing. Treatment involves speech therapy but the smaller the vocal cord movement the more likely other interventions will be needed including various surgical procedures.

Learning Point
Vocal cord dysfunction (VCD) is a functional disorder and “… is the abnormal closing (adduction) of vocal cords during inspiration and/or expiration.” Patients or parents complain of dyspnea, air hunger, chest or air tightness, dysphonia, hoarseness and globus sensation. Patients (50%) with difficult to control asthma may also have concomitant asthma. Signs include stridor or expiratory stertor, but it may be difficult to trigger during physical examination.

Spirometry may show abnormal flow-loop curves during inspiration or during inspiration and expiration depending on when the abnormality occurs. Flow-loops may be normal between episodes and not show up during the examination. VCD can be exercise-induced (most common) or spontaneous. Exercise-induced is often easier to identify as it occurs more consistently with exercise, whereas spontaneous occurs intermittently and seemingly with or without disparate provokers.

Treatment is speech therapy to teach patients voluntary control of the vocal cords. This is helpful but can be a problem during exercise. Pre-exercise treatment with anticholinergic inhalers (such as Ipratropium) can be used as one option. Long-term data shows a high rate of spontaneous resolution of VCD.

Questions for Further Discussion
1. What causes coughing? A review can be found here
2. How do airway malacias present? A review can be found here
3. What is the difference between stertor and stridor? 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: Voice 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.

Ivey CM. Vocal Fold Paresis. Otolaryngol Clin N Am. 2019:637-648. Accessed December 21, 2021.

Graham ME, Smith ME. Unilateral Vocal Fold Immobility in Children. Otolaryngologic Clinics of North America. 2019;52(4):681-692. doi:10.1016/j.otc.2019.03.012

Kaplan A, Szefler SJ, Halpin DMG. Impact of comorbid conditions on asthmatic adults and children. NPJ Prim Care Respir Med. 2020;30:36. doi:10.1038/s41533-020-00194-9

Hurvitz M, Weinberger M. Functional Respiratory Disorders in Children. Pediatric Clinics of North America. 2021;68(1):223-237. doi:10.1016/j.pcl.2020.09.013

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

What Are the Genetics of Multiple Endocrine Neoplasia (MEN)?

Patient Presentation
A 4-month-old female came to the resident continuity clinic for her health maintenance appointment. The patient was well but one parent had multiple endocrine neoplasia type 1 (MEN1). The family had already seen the geneticist and molecular testing was pending. They had met the resident during the genetics appointment and wanted to transfer their primary care to the regional children’s hospital so that all of their care was in one place. The past medical history revealed a healthy term female who was the first baby for these parents. The family history was positive for MEN1, and also for diabetes and lymphoma.

The pertinent physical exam showed a happy baby with growth parameters around 50% and normal vital signs.
The physical examination was normal.
The diagnosis of a healthy female with risk of MEN syndrome was made. “We know that if she has MEN then we won’t need to do a lot until she is around school age, but we think it’s best to have all of her care in one place. That way if things change then all of you can work together,” the parents explained. The resident and staff pediatricians discussed with the family that they would oversee all of her regular primary care and would work to schedule any surveillance testing needed in the future. “The oncology group has a multidisciplinary group that follows patients at risk for various cancers and once we know about the baby we can talk about possibly referring you to that team as well,” the staff physician said.

Discussion
Primary care physicians often work as part of a health care team. Their job can be particularly important for helping oversee intermittent or ongoing surveillance for various diseases. Some of the challenges are changes in clinical guidelines or treatment for uncommon diseases, timelines for evaluation that are in the future (particularly several years), and communication between various health care providers especially across locations or health systems. It is not surprising that families with children with special health care needs may move closer to their providers and consolidate their care within one health care system.

Like many diseases, multiple endocrine neoplasias (MEN) have been a known entity for many years, but the understanding of their genetics has exploded in the past few years. Molecular diagnosis has made this diagnosis easier along with the important genetic counseling of family members as this is mainly an autosomal dominant disease with high penetrance. MEN requires a multidisciplinary team to monitor the patient (as well as the literature for changing practices) over many years. Some centers have clinical specialists who do cancer screening and monitoring for diagnoses which carry increased risks such as MEN, Beckwith-Widemann syndrome, etc.

Learning Point
One challenge of MEN is that there are multiple tumor types that can be observed. Below is an overview of the most common tumors and known genetics:

  • MEN Type 1
    • 2-20/100,000 persons affected
    • Genetics
      • Autosomal dominant on chromosome 11q13 with > 1000 germline mutations noted
      • Changes menin which is a cellular scaffolding and signaling protein
      • 90% are inherited and 10% sporadic
    • Penetrance
      • 0% at age 5 years
      • 50% by age 20 years
      • 95% by age 40 years
      • Onset is 5-81 years though
    • Diagnosis made with
      • > 2 MEN1 related tumor, or
      • 1 MEN related tumors and positive family history, or
      • Molecular diagnosis
    • Main tumors
      • Parathyroid – hyperparathyroidism is most commonly seen
      • Pituitary
      • Pancreatic neuroendocrine tumors
    • Treatment
      • Surveillance starts around age 5 with annual biochemical screening and scheduled imaging.
      • Tumor treatment is multi-disciplinary including oncologists, surgeons and endocrinologists
    • Outcomes poorer as tumors tend to be larger, multi-focal or more aggressive
  • MEN Type 2
    • 2.5/100,000 persons affected
    • Genetics
      • Autosomal dominant on chromosome 10q11.2 with multiple mutations
      • 95% are inherited and 5% sporadic
      • Changes RET pro-oncogene which is a transmembrane tyrosine kinase receptor
    • Penetrance
      • As early as age 3 years
    • Diagnosis made with multiple tumors, family history and molecular diagnosis
    • Main tumors
      • Medullary thyroid carcinoma – affects nearly all patients
      • MEN2A – pheochomocytoma and hyperparathyroidism (afffects 75% of all MEN2 patients)
      • MEN2B – pheochromocytoma, mucosal and gastrointestinal tumors
      • Familial – only medullary thyroid carcinoma
    • Treatment
      • Surveillance starts around age 5 with annual biochemical screening and scheduled imaging
      • Tumor treatment is multi-disciplinary including oncologists, surgeons and endocrinologists. This includes consideration of prophylactic thyroidectomy because of the high risk of medullary thyroid cancer.
    • Outcomes have improved with earlier detection especially in younger children. If detected later in adolescence, there is a decrease in survival.
  • MEN Type 4
    • Described in 2006
    • 9 pedigrees identified
    • MEN1 like tumors

Questions for Further Discussion
1. What other diseases have high potential cancer risks and patients which need monitoring?
2. What resources for genetic counseling are available locally?
3. How do you view your role on a multidisciplinary team?

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: Endocrine Diseases and Cancer in Children.

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.

Giri D, McKay V, Weber A, Blair J. Multiple endocrine neoplasia syndromes 1 and 2: manifestations and management in childhood and adolescence. Arch Dis Child. 2015;100(10):994-999. doi:10.1136/archdischild-2014-307028

Concolino P, Costella A, Capoluongo E. Multiple endocrine neoplasia type 1 (MEN1): An update of 208 new germline variants reported in the last nine years. Cancer Genetics. 2016;209(1-2):36-41. doi:10.1016/j.cancergen.2015.12.002

Wasserman JD, Tomlinson GE, Druker H, et al. Multiple Endocrine Neoplasia and Hyperparathyroid-Jaw Tumor Syndromes: Clinical Features, Genetics, and Surveillance Recommendations in Childhood. Clin Cancer Res. 2017;23(13):e123-e132. doi:10.1158/1078-0432.CCR-17-0548

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

Who’s Afraid of Needles?

Patient Presentation
A 7-year-old male came to clinic for treatment of possible needle phobia. He had received a vaccine at another facility and had required multiple providers to restrain him to complete the procedure. His mother described an escalation of a fear of needles over at least 2 years. He did not have other fears in other settings nor was he described as an anxious child. He said he didn’t like thunderstorms because of the noise but wasn’t worried about them. A chart review did not show any previous mental health or behavioral concerns, but he did have a laceration 2 years previously that needed stitches which the mother described as “not going well.” The child was obviously distressed by the vaccine incident and expressed remorse for the extreme acting out. He said, “I know it’s okay but I just couldn’t stop.” The family history was positive for an aunt with anxiety and depression who was treated with medication and therapy.

The pertinent physical exam revealed a child who was hyperalert. He was very concerned when the doctor cleaned his stethoscope with an alcohol pad, and had to be shown several times that the physician had nothing in his hands so he would move to the examination table. Otherwise he was a very cooperative, pleasant child who could be distracted during the examination which was also normal.

The diagnosis of a child with an extreme needle fear or possible phobia was made. The physician described the natural history where needle fears usually decrease with age. However, the mother and the boy expressed concern about escalating fears, and the need for additional vaccines soon. The pediatrician recommended a therapist to teach additional coping skills and if needed additional therapies, in addition to briefly discussing procedural pain options for the future.

Discussion
There are products that are valued highly because of their design and function are elegantly suited for their use. Books would be one example and the hypodermic needle is another. Medical hypodermic needles are used for accessing bodily spaces (e.g. vascular, peritoneal, subarachnoid, dermal, etc.), obtaining specimens (both solid tissue and liquid) and to deliver drugs, biologicals, fluids and other treatments to patients. Medical procedures involving some type of needle are the most common procedures taught to health care providers. A brief history of syringes and hypodermic needles can be found here. A variety of medical artifacts and online books can be found in the Wellcome Collection here.

The major con of hypodermic needles is pain. Physiological pain from the actual needle, the drug delivered or associated procedure. Psychological pain from anticipation or previous experience. Pain management can be divided into 5Ps:

  • Physical – provide techniques known to decrease pain such as application of cold or vibration near the injection site, or anesthetic skin cream prior to venipuncture
  • Pharmacological – adding a buffering or anesthetic solution to the drug to decrease burning sensation
  • Procedural – provide all procedures simultaneously if possible such as coordinating multiple surgeries and providing vaccination while under anesthesia
  • Psychological – provide education or distraction before, during and after the procedure, provide emotional support with a family member or favorite toy
  • Process – decrease drug delivery rate, use smallest needles possible including microneedles, or a non-needle option (e.g. jet injector, mucosal or oral administration)

Learning Point
Fears are unpleasant emotions with behavioral, cognitive and psychological components that are in response to a recognized source. They are often protective and keep people safe within their environment. These can but generally do not cause persistent problems with functioning. Phobias have a persistent dread and preoccupation with the source. They cause persistent problems with functioning.

Needle fear occurs almost 100% in young children and decreases with age. In a systematic review, they decreased to ~30% by age 20. Overall rate of fear of needles in the adult population is ~20% with phobia felt to be around 3.5-10%. While fear and phobia does decrease, the age of onset is thought to be between 5-10 years for adults with needle fear and phobia. Patients (~80%) with phobia have a first-degree relative with phobia. Needle fear and phobia prevalence is greater in girls and women than in boys and men and this was consistent regardless of country origin. Patients who require injections because of their disease have high rates of needle fear and phobia (i.e. cancer treatment 15-84%, diabetes 1-42% and routine dental procedures (2-91%).

Some people may also have fears which are related to the general procedure process rathen than the specific needle itself and this causes problems in needle-related settings. Examples include anticipation of possible hypoglycemia with insulin injection or worry about vasovagal syncope recurrence after a previous event with a needle-based procedure. Some people fear the need to be restrained too for suturing or a similar procedure.

Needle fear and phobia can cause patients to put-off or decline care especially vaccination preventative care. Even health care workers are not immune with a systematic analysis finding 27% of hospital workers and 18% of long-term care facility workers avoiding influenza vaccine because of this fear.

Treatment for excessive fear and phobia can include short acting benzodiazepines or nitrous oxide, education, coaching, relaxation techniques, distraction, hypnosis and exposure-based interventions.

Questions for Further Discussion
1. What is dry needling and how is it used? A review can be found here
2. How does acupuncture work?
3. What techniques do you employ in your setting to decrease needle fears?

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: Phobias and Anxiety.

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.

McMurtry CM, Pillai Riddell R, Taddio A, et al. Far From “Just a Poke.”” Clin J Pain. 2015;31(Suppl 10):S3-S11. doi:10.1097/AJP.0000000000000272

Luo L, Lai C. Needle Phobia: A Vasovagal Response During Acupuncture. AFP. 2016;94(12):1002-1002.

Susam V, Friedel M, Basile P, Ferri P, Bonetti L. Efficacy of the Buzzy System for pain relief during venipuncture in children: a randomized controlled trial. Acta Biomed. 2018;89(Suppl 6):6-16. doi:10.23750/abm.v89i6-S.7378

Orenius T, LicPsych, Saila H, Mikola K, Ristolainen L. Fear of Injections and Needle Phobia Among Children and Adolescents: An Overview of Psychological, Behavioral, and Contextual Factors. SAGE Open Nurs. 2018;4:2377960818759442. doi:10.1177/2377960818759442

McLenon J, Rogers MAM. The fear of needles: A systematic review and meta-analysis. J Adv Nurs. 2019;75(1):30-42. doi:10.1111/jan.13818

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