What Can Parents Do To Promote Literacy?

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

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

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

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

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

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

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

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

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

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

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Development and Learning Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

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

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

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

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

Summer Break

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

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

What Conditions is Erythema Nodosum Associated With?

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

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

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

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

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

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

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

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

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

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

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

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Skin Conditions and Skin Infections.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

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

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

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

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

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

How Common Are STIs?

Patient Presentation
An 18-year-old male came to clinic for his health supervision visit. His past medical history showed that he was generally healthy and had all of his immunizations. During the social history he denied using alcohol, drugs, tobacco or being sexually active. The pertinent physical exam showed a healthy male with normal vital signs and BMI of 22.2, He was Tanner stage V and the rest of his examination was negative.

The diagnosis of a healthy male was made. The pediatrician recommended for him to receive his second Group B Meningococcal vaccine along with an updated tetanus vaccine as he was going to be working in construction and gardening over the summer. He said, “We also are screening all adolescents for HIV at your age. I know that you said you have not been sexually active but it is still recommended. The most important part is two-fold. One, the best way wait to prevent sexual infections and pregnancy is not to have sexual relations. So I recommend that you continue your current lifestyle. Two, if you do decide to become sexually active, use condoms each and every time along with some type of spermicide. That is also another good option to help prevent pregnancy and infections.” The physician discussed and gave the teen a handout on how to properly use a condom and when to have sexually transmitted infection testing (STI). “I always think its best to have all the information. Besides you can also keep this information for later or give it to a friend who might need it,” he remarked.

Of the 30 different microbes which can be transmitted by sexual contact, 8 have the greatest incidence of transmitting disease. Four are curable (Chlamydia, Gonorrhea, Syphilis and Trichomoniasis) and 4 are incurable at present (Hepatitis B, Herpes simplex virus (HSV), Human immunodeficiency virus (HIV) and Human papillomavirus (HPV)).
Sexually transmitted infections (STIs) are important as they can cause:

  • Increased rates of acquisition of other STIs (ie HSV and syphilis increase the rate of HIV infection acquisition)
  • Pelvic inflammatory disease and infertility
  • Stillbirth and neonatal death
  • Neonatal morbidity including low-birth weight, prematurity, conjunctivitis, pneumonia, sepsis, and congenital abnormalities
  • Genital cancer

In high-income countries diagnosis usually includes laboratory testing and then treatment. Short-course antibiotic treatment for curable infections is effective. In low- and middle-income countries laboratory testing is often cost prohibitive and the diagnosis is made by syndromic management using symptoms and guidelines to direct care. Syndromic management is good as patients can be treated the same day, but the majority of STIs are not detected because patients are asymptomatic. Preventative vaccines for Hepatitis B and HPV have and are showing high prevention rates. Other vaccines are also being developed. Other interventions show that male circumcision decreases the risk of heterosexually transmitted HIV infection and may provide some protection against other STIs. A vaginal microbicide called Tenofovir may have some efficacy against HIV and HSV prevention.

STI screening guidelines from the Centers for Disease Control (CDC) can be found here. 2016 STI treatment guidelines from the CDC can be found here.

Learning Point
The World Health Organization estimates that more than 1 million STIs are acquired daily with 357 million new infections of one of the 4 curable STIs occurring each year. An additional 500 million people are living with HSV and another 290 million women have HPV.

The United States saw an increase in STIs in 2015. It is estimated that 20 million new STIs occurred in 2015 with more than 50% of them in the adolescent/young adult population (age 15-24 years). The large increase in Chlamydia and Gonorrhea were in this age group. There is also an increase in Syphilis reported among men, particularly those who are bisexual or gay.

Total STIs by World Region from the World Health Organization Reported in 2016

Location Total STIs
Americas 64 Million
Africa 60 Million
Eastern Mediterranean 31 Million
Europe 18 Million
South-East Asia 39 Million
West Pacific 142 Million

STIs by Age Range in the United States Reported to the Centers for Disease Control in 2015

Location Total STIs Chlamydia Gonorrhea Syphilis
Age 0-14 years N.A. 11,308 2,538 Primary and secondary 12, Congenital syphilis 487, increase 6%
Age 15-24 years N.A. 981,359 increase 2.5-4.2% 196,593 increase 5.2-7.2% Primary and secondary 5,966 increase 10.2-14.9%
Total 20 Million 1,526,658 increase 6% 395,216 increase 13% Primary and secondary 23,872 increase 19%

Increased rates are from 2014 to 2015, ranges are given if more than 1 age group is included. N.A. is not available

Questions for Further Discussion
1. What are the 5P’s of screening in a sexual health history?
2. How is teenage confidentiality handled in your practice regarding sexual health?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sexually Transmitted Diseases.
To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

CDC Fact Sheet. Reported STDs in the United States. 2015 National Data for Chlamydia, Gonorrhea, and Syphilis.Available from the Internet at https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/std-trends-508.pdf (rev. October 2016, cited 5/2/17).
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016.

World Health Organization. Sexually Transmitted Infections (STIs) Fact Sheet. Available from the Internet at http://www.who.int/mediacentre/factsheets/fs110/en/ (rev. 8/2016 cited 5/2/17).
World Health Organization. Global Health Sector Strategy Sexually Transmitted Infections 2016-2021. Available from the Internet at http://apps.who.int/iris/bitstream/10665/246296/1/WHO-RHR-16.09-eng.pdf?ua=1 (rev. 6/2016, cited 5/2/17).

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