Our next post will be March 25th. In the meantime, why don’t you take a look at the more than 125 differential diagnosis available. They are located in the navigation bar on the right.

Respectfully,
Donna D’Alessandro, MD

Patient Presentation
A 3-year-old male came to clinic for his health supervision visit. The mother described that the 3-year-old was always bothering his 5-year-old brother and they would have lots of verbal fights which were becoming more physical. The mother says a typical situation was one where the 3-year-old wanted to play with his brother, but the brother was doing something else. He usually tried to convince his brother to play, then slowly moved into the 5-year-olds personal space, then took the 5-year-old’s possessions. The 5-year-old’s usual response was to ignore the brother’s negotiating, verbally warn the brother to leave his space, and then yell loudly for a parent or hit the brother when the possessions were taken. The mother wasn’t sure what to do and was worried because the 3-year-old seemed to be getting more aggressive. The social history was negative including mental illness and domestic violence.

The pertinent physical exam showed a healthy male with growth parameters in the 10-50%. His examination was normal. The diagnosis of normal sibling rivalry but with recent escalation was made. The mother was counseled in understanding that it is normal for the younger sibling to want to play with the older sibling but both have different developmental needs with the 3-year-old just learning cooperative play and the 5-year-old’s being very good at it. The mother was encouraged to help the older son find ways they could play together (“You play with the horses and I’ll play with the other animals on the farm”), to continue to ignore when appropriate and to walk away or find an adult when needed to help with the conflict. For the younger child, she was encouraged to monitor him and to redirect him earlier in the process if possible. For example, once the 3-year-old starts to enter the 5-year-olds physical space she could verbally redirect him to another activity in the same area. Also helping both children understand their physical boundaries and possessions, such as “Those are your brother’s toys and he is playing with them now. You can play with your toys.”

Discussion
Sibling rivalry is a common problem. It often occurs around the time of birth of a second child. There can be aggression towards the sibling and/or developmental regression in the child.
Older children can “…regularly wage war, physically and psychologically, within the home.” While this can worry and irritate parents, the inter-sibling confrontations also offer the opportunity to learn conflict resolution, adaption, sharing and can also evolve the relationship “…into one of extraordinary closeness and depth.”

Factors that can help in understanding the problem include:

• Temperament – how does the child react in general to the world
• Development – what is the child’s cognitive understanding of the world
• Parental favoritism/descriptions of the child – while there may not be overt favoritism, the words a parents uses to describe a child are important including typecasting or stereotyping. There may also be special needs that a sibling necessarily has that must be met by the parents and therefore are seen as favoritism such as a child with special health care needs.
• Perception – how the child views the other sibling(s) and parents
• Privacy – is there private space for the child to go, to store belongings or to have private time with parents?
• Analysis of typical fights – a “blow-by-blow” description of the last event may bring insight into provocations, conflict resolution strategies used, parental interventions, etc. which may identify typical enhancing and mitigating factors in the conflicts.

Learning Point
Help for sibling rivalry includes:

• Encourage parental understanding of the situation
• Encourage child understanding of the situation – having children begin to understand that fair is not necessarily equal in a family as everyone needs something different
• Teach conflict resolution – including sharing and taking turns, ignoring the behavior, talking it out, walking away from the situation, or getting an adult (or someone else) to help are excellent strategies.
• Parental modeling of what they would like the child to do is powerful. Advising parents to talk and not hit (e.g. talk it out) or to put themselves in time out (e.g. walking away).
• It is also helpful for a parent to tell the child what behaviors are appropriate. For example it is okay to be angry with their sibling and they could hit a pillow or bounce a ball, but not hit the sibling or throw the pillow or ball at the sibling.
• Praise that is truthful – Praise for behavior that the parent wants to encourage can be good. “I thought the way you ignored your sister who kept asking you about XXX was good. She finally got bored and walked away.”

For most families these treatments can help them through many sibling rivalry conflicts. However, there are many situations that persist beyond the normal time frame, or are intensified beyond the normal circumstances. For example, a 2 year old who bites a younger sibling once would probably be considered normal sibling rivalry. But a 10 year old who continually bites a sibling probably is not. This may be a child who is physically abusing his or her sibling and is perpetrating sibling violence. Sibling violence can be physical, psychological, emotional or sexual, as is other types of domestic violence. Many health care providers and family members do not recognize such acts as sibling violence because they are perpetrated between children and youth. But if perpetrated between adults such acts would be considered illegal. Such acts are often dismissed as “just being kids,” “roughhousing,” or “boys will be boys.” Behavioral and psychological treatment is needed to help these children and families and stop the violence.

Questions for Further Discussion
1. What history questions would help you to determine if interpersonal conflict is normal sibling rivalry or sibling violence?
2. What local resources are available to help treat sibling violence?

Related Cases

Disease: Sibling Rivalry | Adoption | Family Issue

Symptom/Presentation: Behavior Problems

Specialty: Child Abuse and Neglect | General Pediatrics | Psychiatry and Psychology

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the 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: Family Issues.

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

To view images related to this topic check Google Images.

Phillips DA, Phillips KH, Grupp K, Trigg LJ. Sibling Violence Silenced, Rivalry, Competition, Wrestling, Playing, Roughhousing, Benign. Advances in Nursing Science. 2009:32;e1-e16.

Needlman A. Sibling Rivalry in Behavioral and Developmental Pediatrics. Park and Zuckerman eds. Little Brown and Co. Boston, MA. 1995:384-86.

ACGME Competencies Highlighted by Case

Patient Presentation
A 13 month-old female came to clinic with dry itchy skin that has been worsening over 3 days. The mother noticed that it is worse on her arms, legs and face, and she has had dry skin before that she treated with some lotion occasionally. She has been scratching quite a bit and the areas are becoming redder. The family history shows that mother has dry skin also.

The pertinent physical exam reveals a healthy female with generalized dry skin that is mainly papular and red. Excoriation is seen on the cheeks, behind the ears, and in the flexural areas of the elbows and knees. These areas are also more pink-red in color than the surrounding skin. There are no areas that appear infected. The diagnosis of atopic dermatitis was made. Her mother was educated as to the natural history of the disease. She was told to use “thick” emollients such as petrolatum to protect her skin and use them every couple of hours to keep her skin moist. She was also told to use thinner emollients, such as a cream or lotion, if she was going to be in a warm place so she wouldn’t sweat under the emollients and irritate her skin. After bathing with a mild “beauty bar” such as Dove® or a non-soap alternative such as Cetaphil® she could pat her dry and apply the emollients.

Discussion
Atopic dermatitis or eczema is a common dermatological skin problem which characteristically is a pruritic, papular eruption with erythema. Like most papulosquamous eruptions it often occurs in intertrigenous areas in people with allergic constitutions or with a family history of atopy. It does not have scale which occur in other papulosquamous eruptions such as psoriasis or tinea. Sometimes atopic dermatitis is described as the “itch that rashes.” Rubbing and scratching can lead to excoriation and, over time, lichenification. There can also be secondary infections or changes to the skin pigmentation (hyper- or hypo-) in affected areas. Emollients for skin rehydration are a mainstay of treatment. Topical steroids are commonly used to decrease inflammation in affected areas. Immunosuppressants such as tacrolimus are also used in some cases.

Complications includes secondary bacterial infections with Group A Beta-hemolytic Streptococcus or Staphlococcal species. Oral or intravenous treatment of bacterial infections is common with appropriate agents. Eczema herpeticum is another complication which has an umbilicated appearance of papular, vesicular and pustular lesions. Luckily, eczema vaccinatum (caused by smallpox virus) does not occur anymore because of no circulating virus in most parts of the world.

Learning Point
The differential diagnosis of atopic dermatitis includes:

• Xeroderma
  • Variants include
    • Dishydrotic eczema
    • Ichthyosis vulgaris
    • Keratosis pilaris
    • Nummular eczema
    • Perioral dermatitis
    • Pitaryiasis alba
• Contact dermatitis
  • Allergic- papular or papulovesicular that is pruritic
  • Irritant contact dermatitis – usually milder, less pruritic, often seen on cheeks/chin because of saliva or areas that are rubbed
• Seborrheic dermatitis – greasy yellow or pink-colored scale with little pruritis. See also this case.
• Scabies – highly pruritic, may or may not see linear burrows. See also this case.
• Tinea corporis – pink papular round lesions with small scale on the edge
• Acrodermatitis enteropathica – papular, vesicular and bullous lesions, has failure to thrive, alopecia, diarrhea and nail changes, associated with zinc deficiency
• Drug eruptions
• Histiocytosis
• Ichythiosis and other keratin disorders
• Impetigo
• Lymphoma, cutaneous
• Phenylketonuria – usually diagnosed because of screening, but may have diffuse hypopigmentation, eczema, photosensitivity as dermatological changes.
• Psoriasis – more on extensor surfaces with mica-like scale, has delinated border
• Wiskott-Aldrich syndrome – X-linked recessive, severe eczema with thrombocytopenic purpura and immune deficiencies

Questions for Further Discussion
1. What is the difference between atopic dermatitis and ichythosis?
2. How have immunomodulators changed the treatment of atopic dermatitis?

Related Cases

Disease
Eczema

Symptom/Presentation

Papulosquamous Lesions
Urticaria and Pruritis

Specialty
Dermatology

Age
Infant

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: Eczema

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

To view images related to this topic check Google Images.

“>Google Images.

Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics. 2008 Oct;122(4):812-24.

Hebert AA. Atopic Dermatitis. ePocrates.
Available from the Internet at https://online.epocrates.com/u/293587/A. (rev. 1/18/2013, cited 1/28/13).

ACGME Competencies Highlighted by Case

Patient Presentation
A 4-year-old female came to clinic with a history of not passing stools for 6 days. She had been traveling and her mother said she refused to use the toilet because she was afraid she was going to fall into it. Her appetite had decreased in the past 48 hours and she complained of more generalized abdominal pain. Her mother had tried to give her a suppository, but said, “That didn’t go very well.” The past medical history was positive for intermittent constipation that normally resolved with increased fluids and prunes. The family history was non-contributory.

The pertinent physical exam showed a healthy appearing female with normal vital signs and growth parameters.
Her abdominal examination revealed a moderately distended abdomen with increased abdominal sounds and palpable stool. Her genitourinary, spine and neurological examinations were normal. The diagnosis of constipation was made. As the child and parent were reluctant to use any rectal medication, Miralax^TM at ~2 mg/kg/day was ordered for 3-4 days to produce diarrhea. Then the mother was instructed to decrease the amount to ~ 1 mg/kg/day for the next 3 days and further instructions to titrate the medication off. One week later the patient returned to clinic for upper respiratory symptoms and the mother said the Miralax had resolved the constipation.

Discussion
Constipation generally is defined as infrequent or painful defecation. Constipation can be very disturbing to the patient and family who believe the stools are too infrequent, too hard or too difficult to pass. Most children develop constipation after the child begins to associate pain (e.g. a hard bowel movement) with defecation. The child then begins to withhold the stools trying to decrease the defecation discomfort. As stool withholding continues, the rectum dilates and gradually accommodates with the normal defecation urge disappearing. Passing large hard stools infrequently reinforces the defecation pain. The cycle continues. If the cycling is severe enough, worsening stool retention and more abnormal defecation dynamics occurs. Chronic rectal distension results in both loss of rectal sensitivity, and loss of urge to defecate, which can lead to encopresis.

Treatment basics include:

• Evacuate the colon – a clean out by enemas or oral medication
• Stop painful defecation – by using laxatives in a maintenance regimen so patients have a soft stool daily
• Establish regular bowel habits – through toilet sitting

A balanced diet is important and increasing dietary fiber may also help.
Medications include osmotic laxatives, stimulant laxatives, stool softeners and lubricants.
MiraLax^TM is polyethylene glycol, is an osmotic laxative, and pool research studies show that it may be superior to placebo, milk of magnesia or lactulose. It is usually used as a maintenance medication in a dose of 0.5 -1 gram/kg/day divided BID. The dose can be titrated to have one soft stool per day.

Usually primary care providers can successfully treat constipation.
A pediatric gastroenterology consultation may be considered for treatment failure, complex disease management or concerns for organic disease as the etiology.

Learning Point
The differential diagnosis of constipation includes:

• Nonorganic (most common)
  • Situational – poor toilet training techniques (coercive, excessive, etc.), toilet phobia, school/public bathroom avoidance including travel,
    sexual abuse

  • Abnormal stool dryness and/or volume – dehydration, decreased dietary fiber, eating disorders, malnutrition or underfeeding,
  • Constitutional – colonic inertia, genetic predisposition
  • Depression or other psychiatric conditions
  • Developmental – attention or cognitive disorders
• Organic
  • Anatomic malformations – anal abnormalities (i.e. stenosis, imperforate, anteriorly displaced)
  • Gastrointestinal or metabolic problems – hypothyroidism, hypercalcemia, hypokalemia, Crohn’s disease, cystic fibrosis, diabetes mellitus, multiple endocrine neoplasia, gluten enteropathy
  • Central nervous system – spinal cord (i.e. anomalies, trauma, and tethered cord), encephalopathy, Hirschsprung disease, intestinal neuronal dysplasias, neurofibromatosis, visceral myopathies or neuropathies
  • Abdominal musculature abnormalities – Down syndrome, gastroschisis, prune belly
  • Connective tissue disease – Ehlers-Danlos syndrome, scleroderma, systemic lupus erythematosus
  • Drugs – opiates, antacids, anticholinergics, antidepressants, antihypertensives, phenobarbital, sucralfate, sympatomimetics
  • Skin abnormalities – Group A streptococcus perianal skin infection, Lichen sclerosis et atrophicus
  • Tumor – pelvic or other abdominal tumor
  • Other – Botulism, Cow’s mild protein intolerance, lead and heavy metal toxicity, Vitamin D intoxication

Questions for Further Discussion
1. What physical examination findings should be highlighted during an evaluation for constipation?
2. What history questions should be highlighted during an evaluation for constipation?
3. What are indications for surgical consultation in a child with constipation?

Related Cases

Disease
Abdominal Pain
Constipation

Symptom/Presentation
Abdominal Pain
Constipation and Encopresis

Specialty
Gastroenterology
General Pediatrics
Pharmacology / Toxicology

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, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Constipation.

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

To view images related to this topic check Google Images.

Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e1-e13.

Burgers R, Di Lorenzo C. Diagnostic testing in constipation: is it necessary? J Pediatr Gastroenterol Nutr. 2011 Dec;53 Suppl 2:S49-51.

Gordon M, Naidoo K, Akobeng AK, Thomas AG. Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev. 2012 Jul 11;7:CD009118.

ACGME Competencies Highlighted by Case