What is Prolonged Grief Disorder?

Patient Presentation
A 10-year-old female came to clinic for her health supervision visit. She was doing well in school and her dance and swimming classes. She and her mother said she continued to be very sad about her father’s sudden death from a heart attack 9 months previously. She said that she felt happy at school and with her friends and mother and thought they were helping her, but “I just will suddenly cry and feel so sad. I just can’t stop it.” Her mother said that friend’s, family, school and work had been supporting them and she felt grateful for the support, but she too felt like this often. “Her friend’s mother has been really helpful, but she is worried about her too. Her teacher said at conferences that she thinks the patient is doing okay but notices that she still seems sad.” She and her mother denied any self-harm thoughts. Her mother also stated that she personally was also struggling with her own grief.

The review of systems showed no weight loss, with good appetite. There was improving sleep but still she had at least 2 nights/week where she would have sleep initiation or interruption issues.

The pertinent physical exam revealed normal growth parameters and vital signs. Her physical examination was normal. During the examination she talked about many things she liked to do by herself or with friends and hopes that she had for the future.

The diagnosis of a grief reaction were made. The pediatrician said, “It sounds like you are both trying to figure out what his death means for you and your future. You’ve been doing a pretty good job of surviving and I’d say some thriving too. But it sounds like you both could use some more help with processing his death so you can feel a little better. Many people struggle some and need some extra help. I have some counseling resources. Let’s talk about what might work best for you, and her and your mom too.”

Discussion
Grief is the process of experiencing different emotions, expressions and action in response to the death of someone the person cares about. This is a personal and private process. Grief can occur for other significant losses such as a divorce, job, or health. People may overlook loss of routine and special activities, presumed safety, and autonomy that can also cause loss and grief. Additional traumas of these loss types have been magnified especially in the past couple of years as the world lives with Covid. Mourning is a public process of showing grief. This often involves religious beliefs and customs, and cultural customs. Bereavement is the time period of grief and mourning.

The deceased’s relationship with the survivor, the circumstances around the death or loss, previous experiences with death or loss and the supports the person has or can gather are key factors in shaping how the survivor experiences their grief. Often today people use a framework of a 5 stages approach to understanding the grieving process for adults. People may have components of these at any time and some are shorter or longer but generally people experience these stages including:

  • Denial – that the death or loss has occurred or will occur as this can happen even before the death. People may experience fear, shock, numbness, distress, and may avoid reminders of the deceased.
  • Anger – this can last for days to months and people may experience anger, frustration, loneliness, uncertainty, intense pain, agitation, and preoccupation with thoughts.
  • Bargaining – this tends to be shorter and the person is trying to find meaning in the death or loss. People may want to tell their story and as they do it, they make meaning of the death or loss for themselves.
  • Depression – this can be short or long. People feel sadness, may be overwhelmed or feel helpless as the reality of the death or loss sets in. They may withdraw or be aggressive or hostile and extreme emotions may come intermittently like waves.
  • Acceptance – this usually occurs over a few months to a year or more. The person comes to accept the death or loss. This last phase of grief happens when people find ways to come to terms with and accept the loss, adjusting to their new life without the person or other loss.

Children may not experience death or loss this same way but they do experience the death. Developmentally children will process the death or loss differently. Parents can help their children by allowing children to express their own emotions verbally, behaviorally, or creatively.
Providing consistency and being there to meet their needs not only helps the child as they are coming to terms with the new reality, but can also help parents with their own grief and loss.
Consistency of daily routine, meals, activity and sleep supports the physical and emotional healing for all. As children ask questions about what has occurred and what will happen in the future, adults can provide clear, consistent and supportive answers. Children often ask the same questions over and over and questions about death and loss are no different.
These reminders can be distressing to a grieving parent and they offer an opportunity to support the child, and as well as parents can be reasonably honest about their own feelings. For example, “Mommy is crying because I am sad that grandma has died, but I am crying because I love her so much too just like I love you. It makes me happy when you talk about her but sometimes I cry.”
Modeling emotional honesty in a way that is supportive of the child and meets the child’s needs, can also help the parent with their own grief.

“When griefs are too many, last too long, occur too close on the heels of each other, are too grievous and lacerating in nature and call a halt to too many aspects of our lives, we call this morbid or complicated grief.” People usually need additional support and help to process this type of grief. Grief that is complicated can include other mental health issues such as major depression, separation anxiety, post-traumatic stress disorder, and bereavement disorder.

Learning Point
Prolonged grief disorder (PGD) was recently added to the Diagnostic and Statistical Manual of Mental Disorders. This occurs when there are more consistent or extreme reactions to the death or loss over a prolonged period of time. It can be diagnosed after 6 months of symptoms in children and 12 months in adults. From the American Psychological Association, PGD symptoms include:

  • “Identity disruption (e.g., feeling as though part of oneself has died).
  • Marked sense of disbelief about the death.
  • Avoidance of reminders that the person is dead.
  • Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.
  • Difficulty with reintegration (e.g., problems engaging with friends, pursuing interests, planning for the future).
  • Emotional numbness.
  • Feeling that life is meaningless.
  • Intense loneliness (i.e., feeling alone or detached from others).

In the case of prolonged grief disorder, the duration of the person’s bereavement exceeds expected social, cultural or religious norms and the symptoms are not better explained by another mental disorder.”

Cognitive behavioral therapy has been shown to be effective for children and adolescents experiencing PGD due to a parental death.

Questions for Further Discussion
1. What are some behavioral expressions of grief?
2. What mental health resources are available for grief in your community?

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: Bereavement and Child Mental 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.

Melhem NM, Porta G, Walker Payne M, Brent DA. Identifying prolonged grief reactions in children: dimensional and diagnostic approaches. J Am Acad Child Adolesc Psychiatry. 2013;52(6):599-607.e7. doi:10.1016/j.jaac.2013.02.015

Boelen PA, Lenferink LIM, Spuij M. CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial. Am J Psychiatry. 2021;178(4):294-304. doi:10.1176/appi.ajp.2020.20050548

APA Offers Tips for Understanding Prolonged Grief Disorder. Accessed April 5, 2022. https://www.psychiatry.org/newsroom/news-releases/apa-offers-tips-for-understanding-prolonged-grief-disorder

Fitzgerald DA, Nunn K, Isaacs D. What we have learnt about trauma, loss and grief for children in response to COVID-19. Paediatr Respir Rev. 2021;39:16-21. doi:10.1016/j.prrv.2021.05.009

Grief and Bereavement. Accessed April 5, 2022. https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/grieving-process.html

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

How to Remove Foreign Bodies?

Patient Presentation
A 4-year-old female came to clinic after putting some small styrofoam balls into her ears at daycare. They had been part of an art project and she had told the teachers she had done it. They had tried washing her ears with running water but could still see some in her ears so called her mother. She was otherwise well and was not having pain.

The pertinent physical exam showed a happy preschooler with normal vital signs.
Her examination was non-contributory except for her ears. Both ears had styrofoam in them with direct visualization.

The diagnosis of bilateral foreign bodies in the ears was made. Some were removed with a curette easily, but there were several which were closer to the tympanic membrane. During water irrigation several more intact styrofoam balls floated out of the ear with the effluent, and repeat visualization found no retained foreign bodies. There did not appear to be any irritation to the canals and so no additional treatment was recommended. At her next visit she proudly told the doctor, “Nothing in my ears!”

Discussion
Living in the world makes the human body susceptible to foreign bodies. Orifices are particularly inviting for children to explore and see how it feels if the opening is touched by their hands or an object. Small objects are easily inserted or even just retained (such as toilet tissue in the genital area, or tissue in the nose). The mouth is particularly inviting to explore objects with as oral sensations are paramount to survival even at birth. Food can be considered a foreign body and often acts like one when stuck in the respiratory or gastrointestinal tract but is necessary to sustain life.

When someone says foreign body often thoughts of harmful objects predominate. Usually these involve some type of trauma or accident from splinters and retained bee stingers to bullets and schrapnel. Accidents predominate but some can be self-inflicted when mental health problems are concurrently present. Some foreign bodies are intentionally inserted such as jewelry, contraceptives, surgical implants, catheters, etc. These are designed with removal methods in mind. However the objects can be defective, become damaged or migrate making usual removal methods not an option. Most health care personnel have stories of various foreign bodies they have encountered, the circumstances they occurred under, and how they were managed.

Learning Point
Foreign body treatment principles vary according to the organ systems involved.

  • Management principles
    • Assess if this is a life-threatening or non-emergency issue and treat accordingly. Removal should be planned and common problems planned for so additional equipment and/or emergency treatment is available if needed.
    • Foreign bodies need to be identified including their type and position (which can change even during the treatment) – direct visualization, wound probing, plain radiographs for radiopaque objects (a review can be found here), ultrasound and computed tomography can be used. Magnetic resonance imaging often cannot or should not be used as a metal foreign body could be dislodged causing additional trauma. Metal detectors have been used but are not very specific for location or identification.
    • Pain and anxiety need to be identified and treated. Immobilization of the area is also needed for removal. For patients of any age this may require anesthesia.
    • Adequate visualization is needed which includes a strong light source, and a means to see the area such as a speculum or even surgical incision to open up the area. Ice sometimes can be used to decrease swelling and help visualization and removal.
    • Removed objects should be inspected to make sure the entire object has been removed. Fragments are common especially for compressible objects.
    • Tetanus prophylaxis requirement should be assessed.
  • Removal techniques
    • Foreign bodies usually should be removed to decrease infection risk, improve healing and avoid additional trauma to tissues. The area should be irrigated and debrided and definitively treated. Sometimes foreign bodies need to be left in place because the risk of removal is higher than the risk of the object such as a bullet lodged near a major vessel. Irregularly shaped or sharp objects almost always need to be removed (i.e. glass)
    • The track where the object was inserted or entered is often the best to follow to find the object, remove it and treat it.
    • Common options for removal are:
      • Forceps – non-compressible foreign bodies such as beads, rocks, food, jewelry etc. Special forceps have been developed for common foreign bodies such as rounded forceps to remove beads and other small round objects.
      • Suction – compressible foreign bodies such as sponges, styrofoam, paper
      • Irrigation or lubrication – non-compressible foreign bodies or in a location that is amenable such as an eye or ear
      • Medical adhesive on a stick (less common) – attach to the object and wait before removing being careful to not displace the foreign body.
      • Enblock excision (less common) – uncommon but can be used for old foreign bodies or many small foreign bodies in a discrete area
  • Special considerations
    • Airway foreign bodies often need special treatment to manage the airway and prevent dislodging the object or pushing it farther into the respiratory tract.
    • Swallowed foreign bodies depending on their characteristics often pass through the gastrointestinal system without problems once they pass through the lower esophageal sphincter and pylorus. Those that are too large need to be removed usually by endoscopy.
    • Certain objects always need to be removed such as button batteries (can erode the surrounding tissue), and small magnets (they can trap tissue between them and erode or necrose the intervening tissue).
    • Hair, styrofoam and cyanoacrylate glue can be dissolved with acetone but should have intact skin around them.
    • Live insects should be euthanized before removal – lidocaine is one option
    • Nasal foreign bodies can be expelled using a short burst of positive pressure such as parent blowing into mouth with the unaffected nare closed
    • Metallic objects possibly can be removed with a magnet in the right circumstances

Questions for Further Discussion
1. What is your favorite foreign body story?
2. What other techniques have you used for foreign body removal?
3. How do foreign bodies present? 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: Foreign Bodies

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.

Saps M, Rosen JM, Ecanow J. X-ray detection of ingested non-metallic foreign bodies. World J Clin Pediatr. 2014;3(2):14-18. doi:10.5409/wjcp.v3.i2.14

Oyama LC. Foreign Bodies of the Ear, Nose and Throat. Emerg Med Clin North Am. 2019;37(1):121-130. doi:10.1016/j.emc.2018.09.009

Couper K, Abu Hassan A, Ohri V, et al. Removal of foreign body airway obstruction: A systematic review of interventions. Resuscitation. 2020;156:174-181. doi:10.1016/j.resuscitation.2020.09.007

Del Cura JL, Aza I, Zabala RM, Sarabia M, Korta I. US-guided Localization and Removal of Soft-Tissue Foreign Bodies. Radiographics. 2020;40(4):1188-1195. doi:10.1148/rg.2020200001

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

What are Potential Problems with Placental Abnormalities?

Patient Presentation
A 2-week-old male came to clinic for his health supervision visit. He was a 36 week gestation infant born by planned cesarean section to a 32 year old, G2 now P2 mother. The pregnancy was complicated with placenta accreta along with a low-lying placenta that was identified on second trimester ultrasound examination. The father had no concerns and was very comfortable feeding and caring for the infant in the office. The baby had been delivered and the mother had undergone hysterectomy.

The pertinent physical exam showed a well appearing male whose weight was 48 grams past birthweight. He was 25% for all growth parameters. His examination was normal with a almost completely well-healing circumcision.

The diagnosis of a healthy male was made. The father said that they were a little overwhelmed, “We made the decision to have him and then she had a planned hysterectomy. My wife has done well but it’s really hard taking care of her, my other 2 year old and this one. Thank heavens that my in-laws are here and helping. That way we have one adult to help take care of each of them. I’m supposed to go back to work in a couple of days, but my work is really understanding and I have at least another week off and my mother-in-law is going to stay until my wife is better. She wanted to breastfeed this one like she did the first, but it’s too much right now. Formula is just fine. I’m just so thankful he is growing and that my wife is safe and healthy too.”

Discussion
“The placenta is a unique organ that sits at the interface of, and facilitates nearly all interactions between, maternal and fetal physiology. It is the sole source of oxygen and nutrition for the fetus, and provides a protective barrier against external insults. The placenta is also a highly adaptable organ that is capable of showing a wide range of pathological changes in response to various maternal and fetal factors and stressors.” The placenta has 3 layers: the amnion (fetal side), the chorion, and decidua (maternal side). In addition to making observations about the maternal and fetal sides, cord variations (i.e. size, length, twists, number of vessels, insertion location) can be observed. Even with these these possible variations, most placentas are normal.

Learning Point
There are some important placental abnormalities which are clinically, and potentially critically important for maternal and fetal outcomes.

  • Location problems
    • Placenta previa is a placenta that overlies the cervical os to some extent. Those that are near but do not overlie are termed low-lying placentas.
      • Incidence 1:200
      • Diagnosis: found on routine ultrasound or painless vaginal bleeding usually in 3rd trimester
      • Treatment: cesarean section prior to labor, often before term
      • Maternal problems: hemorrhage which has its own risks such as blood transfusions, septicemia, thrombophlebitis, admission to intensive care unit, hysterectomy, maternal death
      • Neonatal problems: prematurity – up to ~45% delivered before 37 weeks gestation
    • Vasa previa are fetal blood vessels that are attached but unprotected which traverse the fetal membranes near or over the cervical os
      • Incidence 1:2500-5000
      • Diagnosis: found on ultrasound
      • Treatment: cesarean section prior to labor and before rupture of membranes
      • Maternal problems: emergency care and its attendant complications including surgical complications
      • Neonatal problems: severe fetal blood loss and ensuing mortality, compromised umbilical blood flow and its attendent risks, prematurity
    • Placenta accreta is the placenta attaching to the myometrium without decidua in between. If the placenta invades the myometrium it is termed placenta increta, and if it extends outside the uterus it is termed placental percreta. Placenta accreta is also used sometimes to refer to this entire spectrum.
      • Incidence 1:300-2500
      • Diagnosis: found on ultrasound and more common with subsequent births after cesarean section or any procedure where the endometrium would be instrumented
      • Treatment: various, but planned intervention before labor is important
      • Maternal problems: severe maternal hemorrhage and potential mortality, and risks from hemorrhage
      • Neonatal problems: prematurity
  • Vascular problems
    • Maternal vascular malperfusion
      • Vascular problems on the maternal side of the placenta. This can anffect the entire or part of the placenta and the placenta is small.
      • Maternal problems: preeclampia, antiphospholipid syndrome, autoimmune disease, pregestational diabetes
      • Neonatal problems: fetal growth restriction
    • Fetal vascular malperfusion
      • Vascular problems on the fetal side of the placenta.
      • Neonatal problems: fetal distress, fetal demise, intrauterine growth restriction, cardiac abnormalities and coagulopathies
  • Infection
    • Acute chorioamnionitis
      • Usually microorganisms invade via the ascending route from the vagina, breech the placenta into the amniotic fluid. There is a fetal and maternal inflammatory response. It is a clinical diagnosis but laboratory testing may be helpful.
      • Maternal problems: endometritis, sepsis
      • Neonatal problems: sepsis, respiratory problems, neurodisability, necrotizing enterocolitis
    • Chronic villitis also known as Villitis of Unknown Etiology
      • Affects the chorionic villi but there is no identifiable organism
      • Neonatal problems: intrauterine growth restriction
    • Villitis
      • Affects the chorionic villi with an identifiable organism
      • There are many, but common examples are:
        • TORCH infections – Toxoplasmosis, Other agents including Syphilis, Rubella, Cytomegalovirus, Herpes simplex
        • Listeria
        • Zika
      • Miscellaneous
        • COVID-19 intrauterine transmission has been documented but is considered rare. Most cases of neonatal COVID are from infected caregivers.
          For breastfeeding, “Replication- competent SARS-CoV-2 has not been detected in breastmilk, although breastmilk samples are occasionally polymerase chain reaction positive.” Given the current information available and weighting risks and benefits “Most guidelines support the rooming in of the newborn with an infected mother, particularly when the mother is afebrile and asymptomatic.”

Questions for Further Discussion
1. What other maternal complications can cause problems for the fetus and newborn?
2. What resources to you use to answer your question about maternal or fetal medicine?
3. What are indications for consultation with a neonatologist?

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.

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.

Silver RM. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet Gynecol. 2015;126(3):654-668. doi:10.1097/AOG.0000000000001005

Ravishankar S, Redline RW. What Obstetricians Need to Know About Placental Pathology. Obstet Gynecol Clin North Am. 2020;47(1):29-48. doi:10.1016/j.ogc.2019.10.007

Komine-Aizawa S, Takada K, Hayakawa S. Placental barrier against COVID-19. Placenta. 2020;99:45-49. doi:10.1016/j.placenta.2020.07.022

Jamieson DJ, Rasmussen SA. An update on COVID-19 and pregnancy. Am J Obstet Gynecol. 2022;226(2):177-186. doi:10.1016/j.ajog.2021.08.054

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

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