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PediatricsinReview姞 Vol.32 No.5 May 2011
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Articles
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179 Infant Formulas
J. Andres Martinez, Martha P. Ballew
kbernard@aap.org
Editorial Board
Addressing Environmental Contaminants in
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190 Pediatric Practice
Catherine Karr
Brian Carter, Nashville, TN Jennifer Miller, Gainesville, FL
Joseph Croffie, Indianapolis, IN Blaise Nemeth, Madison, WI
B. Anne Eberhard, New Hyde Park, NY Renata Sanders, Baltimore, MD
Complementary, Holistic, and Integrative
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201 Medicine: Mind-Body Medicine
Hilary McClafferty
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218 Histiocytosis
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Abstract appears on page 208.
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e53 The Preparticipation Sports Evaluation

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 Infant Formulas
J. Andres Martinez and Martha P. Ballew
Pediatr. Rev. 2011;32;179-189
DOI: 10.1542/pir.32-5-179

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/cgi/content/full/32/5/179

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 Article nutrition

Infant Formulas
J. Andres Martinez, MD,*
Objectives After completing this article, readers should be able to:
Martha P. Ballew, MEd,
RD, CNSC, LDN† 1. Describe the macronutrient content of formulas used as substitutes for human milk for
term and preterm infants.
2. Identify appropriate clinical applications of infant formulas that have altered nutrient
Author Disclosure contents based on the physiologic significance of specific changes in formula
Dr Martinez and Ms composition.
Ballew have disclosed 3. Discuss the physiologic role and potential health benefits associated with four compo-
no financial nents added to infant formulas in the past decade.
relationships relevant 4. Delineate current regulatory guidelines that define standards for composition and
to this article. This performance and safety criteria for commercial infant formulas.
commentary does not
contain a discussion Historical Background
of an unapproved/ Development of infant formulas can be traced to the late 19th century. In 1867, Liebig
investigative use of a developed and marketed a product for infant feeding that contained cow milk, wheat flour,
commercial product/ malt flour, and potassium bicarbonate. In 1915, Gerstenberger reported a 3-year experi-
ence using “synthetic milk, adapted” that contained nonfat cow milk, lactose, oleo oils,
device.
and vegetable oils. This product represented early understanding that cow milk required
alteration to improve its acceptability for human consumption and is considered the
precursor to modern infant formulas. (1)
Government regulation of infant formula composition in the United States began in
1941 and underwent significant expansion with passage of the Infant Formula Act of
1980, a direct and prompt response to an epidemic of a Bartterlike syndrome (hypochlo-
remic, hypokalemic metabolic alkalosis). Most cases were later attributed to consumption
of a chloride-deficient soy infant formula. The Infant Formula Act of 1980 and its
amendments in 1986 defined minimum concentrations of 29 nutrients and established
quality control standards for commercial production of infant formulas. Current standards
are summarized in the Electronic Code of Federal Regulations: Title 21:107—Infant
Formula. (2) Organic infant formulas must also meet all
standards required for United States Department of
Agriculture Organic certification.
Abbreviations The addition of nucleotides to infant formulas in 1999 and
AAP: American Academy of Pediatrics long-chain polyunsaturated fatty acids (LCPUFAs) in 2002
ARA: arachidonic acid marked a new era in infant formula development. In 2004,
CMPA: cow milk protein allergy anticipating continued competition among infant formula
DHA: docosahexaenoic acid manufacturers to develop products that mimic the com-
EHF: extensively hydrolyzed formula plexities and performance of human milk, a special commit-
GERD: gastroesophageal reflux disease tee of the Food and Nutrition Board of the Institute of
Ig: immunoglobulin Medicine proposed enhanced regulatory and research proce-
LCPUFA: long-chain polyunsaturated fatty acid dures to assess the safety of potential new ingredients in
MCT: medium-chain triglyceride infant formulas. (1)
NEC: necrotizing enterocolitis Challenges continue in ensuring the quality and safety of
PHF: partially hydrolyzed formula commercial infant formulas. Within the past 5 years, pow-
VLBW: very low birthweight dered infant formulas have been recognized as potential
carriers of food-borne illness after the death of an infant due

*Assistant Professor, Director Pediatric Nutrition Support Program, Department of Pediatrics, Division of Gastroenterology,
Hepatology and Nutrition, Vanderbilt University School of Medicine, Nashville, TN.
†
Pediatric Nutrition Support Dietitian, Department of Nutrition Services, Monroe Carell Jr Children’s Hospital at Vanderbilt,
Nashville, TN.

Pediatrics in Review Vol.32 No.5 May 2011 179

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nutrition infant formulas
to Enterobacter sakazakii meningitis in the United States
and a case of infantile botulism in the United Kingdom.
These incidents led to stricter safety guidelines for home
and institutional preparation and handling of commercial
infant formulas. (3) The Table offers a comparison of
currently available formulas.
Cow Milk-based Formulas for Term Infants
Often referred to as “standard” infant formulas, these prod-
ucts are the most commonly used substitutes for human
milk. They are available as ready-to-use liquids (20 kcal/oz
or 67 kcal/100 mL) and as powder or liquid concentrates
that may be mixed with specific quantities of water to yield
caloric densities between 20 and 30 kcal/oz.
Protein
Differences in the serum amino acid profiles of breastfed
and formula-fed infants are due to variations in the specific
protein content of human and bovine milk. Human milk
has a higher whey-to-casein ratio (70:30) than bovine milk
(18:82). Unlike casein, which forms large curds on expo-
sure to gastric acid, whey protein is resistant to precipitation
and undergoes more rapid gastric emptying. These charac-
teristics are the primary reason for continued modification
of the whey:casein ratio of cow milk-based formulas. It is
important to note that the whey proteins in human and
bovine milk are vastly different from both compositional
and functional standpoints. In an effort to match the pro-
tein quality of human milk, cow milk-based formulas cur-
rently contain almost 50% higher total protein content (2.1
to 2.2 g/100 kcal) than human milk. Most infant formulas
also contain supplemental taurine. The physiologic signifi-
cance of differences in serum amino acid profiles of infants
fed cow milk-based formulas versus human milk remains
unclear. More importantly, casein-predominant (20:80),
whey-predominant (60:40), and 100% whey formulas have
all been shown to support normal growth patterns in both
term and preterm infants.
Carbohydrate
Lactose is the predominant carbohydrate in most cow
milk-based formulas and human milk. The lactase en-
zyme in the brush border of the small intestine reaches
maximum concentrations late in fetal development, but
some unsplit lactose usually reaches the distal bowel,
where its fermentation permits proliferation of acido-
philic bacteria, namely, Lactobacillus. Lactose has also
been shown to enhance absorption of calcium in term
infants between 8 and 12 weeks of age. The significance
of this benefit in term infants is unclear because adequate
calcium absorption has been demonstrated in infants
consuming lactose-free formulas.
180 Pediatrics in Review Vol.32 No.5 May 2011
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Fat
Approximately 50% of the caloric content of human milk
is contained in its lipid component, which is rich in
palmitic, oleic, linoleic, and linolenic fatty acids. Current
formulas contain specific blends of vegetable oils de-
signed to mimic the ratios of saturated, monounsatu-
rated, and polyunsaturated fatty acids in human milk;
increase the essential fatty acid content; and reduce gas-
trointestinal symptoms previously associated with infant
feeding of whole cow milk.
Docohexaenoic acid (DHA) and arachidonic acid
(ARA) are LCPUFAs present in human milk (mean
content of DHA 0.32% and ARA 0.47% of total fatty
acids) and have been found to accumulate rapidly in the
fetal retina and brain during the last trimester of preg-
nancy, continuing until 2 years of age. DHA and ARA
can be synthesized from precursor essential fatty acids
and before 2002 were not added to infant formulas.
Studies have shown that breastfed infants have a higher
content of DHA in the brain cortex compared with
infants consuming nonsupplemented formulas. Fur-
thermore, numerous studies have observed improved
visual and neurodevelopmental outcomes in children
who had been supplemented with DHA or DHA plus
ARA as infants. In 2008, two Cochrane meta-analyses of
randomized, controlled trials found that milks supple-
mented with these LCPUFAs did not improve growth,
visual acuity, or neurodevelopment in either preterm or
term infants, which called their standard supplementa-
tion into question. (4)(5) However, recent studies that
have focused on higher doses of DHA (between 0.3%
and 0.5% of total fatty acids) and at least equal amounts
of ARA have consistently reported significant benefits.
Preterm infants may have a higher requirement, based on
calculated accretion rates in the last trimester of preg-
nancy. No negative effects have been observed with
DHA and ARA supplementation, and both are presently
added to all formulas in a dose range of 0.15% to 0.32%
DHA and 0.4% to 0.64% ARA (% total fatty acids).
More studies are needed to define better the benefits and
the correct dose needed for supplementation. (6)
Vitamins and Minerals
Iron fortification was implemented in 1959 in response
to recognition of a high prevalence of iron deficiency
anemia among formula-fed infants. Iron from human
milk is absorbed at a higher rate (20% to 50%) compared
with cow milk (4% to 7%). To compensate for lower
bioavailability, all fortified formulas contain 1.8 mg/
100 kcal of iron as compared with 0.45 to 0.9 mg/
100 kcal in human milk. It is strongly recommended that
 Table. Infant Formula Comparison Chart1,2
Primary Protein Source Carbohydrate Fat Features
Added
Rice
100% Glucose Starch
Whey: Soy Free Reduced Polymers/ (⻫) or DHA/ARA
Casein Protein Partially Casein Amino Full Lactose (% Lactose- Glucose Sucrose Soy Fiber LCT/MCT (% total
Ratio Isolate Hydrolyzed Hydrolysate Acids Lactose Carbohydrate) free Polymers Blend (x) (%) fat) Osmolality Nucleotides Prebiotics Probiotics

Cow Milk-based
Formulas
(Intact Protein)
Enfamil® Premium™ 60:40 ⻫ 100/0 0.32/0.64 300 ⻫ ⻫
Similac Advance® 60:40 ⻫ 100/0 0.15/0.4 310 ⻫ ⻫
Parent’s Choice® 60:40 ⻫ ⻫ 100/0 0.32/0.64 280 ⻫ ⻫
Advantage
Soy Protein-based
Formulas
(Intact Protein)
Enfamil® Prosobee® ⻫ ⻫ ⻫ 100/0 0.32/0.64 180
Similac Sensitive ⻫ ⻫ ⻫ 100/0 0.15/0.4 200 ⻫
Isomil Soy™
Parent’s Choice® ⻫ ⻫ ⻫ 100/0 0.32/0.64 164
Soy Based
Modified Cow- or
Soy Milk-based for
Term Infants
Enfamil AR® 20:80 59% ⻫ ⻫ 100/0 0.32/0.64 230
Enfamil® Gentlease® 60:40 ⻫ *20% ⻫ 100/0 0.32/0.64 230
Enfamil® RestFull™ 20:80 59% ⻫ ⻫ 100/0 0.32/0.64 230
Good Start® Gentle 100:0 ⻫ 70% ⻫ 100/0 0.32/0.64 250 ⻫
Plus™
Good Start® Protect 100:0 ⻫ 70% ⻫ 100/0 0.32/0.64 250 ⻫ ⻫
Plus®
Good Start® Soy ⻫ ⻫ ⻫ ⻫ 100/0 0.32/0.64 180
Plus™
Similac Sensitive® 20:80 *trace ⻫ 100/0 0.15/0.40 200 ⻫ ⻫
Similac Sensitive 20:80 *trace ⻫ ⻫ 100/0 0.15/0.4 180 ⻫
for Spit-Up™
Similac Expert ⻫ ⻫ ⻫ x 100/0 240
Care™ for Diarrhea
(RTU; 20 kcal/oz)
Parent’s Choice® 60:40 ⻫ *25% ⻫ 100/0 0.32/0.64 189
Gentle
Parent’s Choice® 20:80 ⻫ ⻫ 100/0 0.32/0.64 198 ⻫
Sensitivity
Parent’s Choice® 20:80 ⻫ ⻫ ⻫ 100/0 0.32/0.64 206
Added Rice Starch
Extensively
Hydrolyzed
Formulas
nutrition

Nutramigen® (liquid ⻫ ⻫ ⻫ 100/0 0.32/0.64 260

concentrate)

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Nutramigen® with ⻫ ⻫ ⻫ 100/0 0.32/0.64 300 ⻫
Enflora™ LGG®
Pregestimil® ⻫ ⻫ ⻫ 45/55 0.32/0.64 320
Similac Expert ⻫ ⻫ ⻫ 66/33 0.15/0.4 370
Care™ Alimentum®
(Continued)
infant formulas

Pediatrics in Review Vol.32 No.5 May 2011 181

 Table. Infant Formula Comparison Chart1,2—continued
nutrition

Primary Protein Source Carbohydrate Fat Features

Added
Rice
100% Glucose Starch
Whey: Soy Free Reduced Polymers/ (⻫) or DHA/ARA
Casein Protein Partially Casein Amino Full Lactose (% Lactose- Glucose Sucrose Soy Fiber LCT/MCT (% total
Ratio Isolate Hydrolyzed Hydrolysate Acids Lactose Carbohydrate) free Polymers Blend (x) (%) fat) Osmolality Nucleotides Prebiotics Probiotics
infant formulas

Amino Acid-based
Formulas
Elecare® ⻫ ⻫ ⻫ 67/33 0.15/0.40 350
(unflavored)
Neocate® Infant ⻫ ⻫ ⻫ 67/33 0.2/0.35 375

182 Pediatrics in Review Vol.32 No.5 May 2011

Nutramigen® AA™ ⻫ ⻫ ⻫ 100/0 0.32/0.64 350
Milk-based Formulas
for Preterm/LBW
Infants (RTU
24 kcal/oz liquid)
Enfamil® Premature 60:40 40% ⻫ 60/40 0.32/0.64 300 ⻫
Good Start® 100:0 ⻫ 50% ⻫ 60/40 0.32/0.64 275 ⻫
Premature 24
Similac Special Care 60:40 50% ⻫ 50/50 0.25/0.4 280 ⻫
24 Advance™
Transitional Formulas
for Preterm/LBW
Infants (RTU
22 kcal/oz liquid)
Enfamil® EnfaCare® 60:40 70% ⻫ 80/20 0.32/0.64 250 ⻫
Similac Expert 60:40 50% ⻫ 75/25 0.15/0.40 250 ⻫
Care™
NeoSure®
Cow Milk-based for
Specific Medical
Needs
Enfaport® (RTU; 0:100 ⻫ ⻫ 16/84 0.32/0.64 280
30 kcal/oz)
(for chylothorax;
LCHAD)
Similac® PM 60/40 60:40 ⻫ 100/0 280
Low Iron
(for calcium/
phosphorus
disorders)
Cow Milk-based
Follow-Up
Formulas
(Intact Protein)
Enfagrow™ 20:80 55% ⻫ 100/0 0.32/0.64 270
Premium™
Next Step®
Similac Go and 60:40 ⻫ 100/0 0.15/0.4 300 ⻫ ⻫
Grow™
Parent’s Choice® 20:80 71% ⻫ 100/0 0.32/0.64 282

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Older Infants
(Continued)
 Table. Infant Formula Comparison Chart1,2—continued
Primary Protein Source Carbohydrate Fat Features
Added
Rice
100% Glucose Starch
Whey: Soy Free Reduced Polymers/ (⻫) or DHA/ARA
Casein Protein Partially Casein Amino Full Lactose (% Lactose- Glucose Sucrose Soy Fiber LCT/MCT (% total
Ratio Isolate Hydrolyzed Hydrolysate Acids Lactose Carbohydrate) free Polymers Blend (x) (%) fat) Osmolality Nucleotides Prebiotics Probiotics

Soy Milk-based
Follow-up
Formulas
(Intact Protein)
Enfagrow™ Soy ⻫ ⻫ ⻫ 100/0 0.32/0.64 230
Next Step®
Similac Go and ⻫ ⻫ ⻫ 100/0 0.15/0.40 200
Grow™ Soy
Cow Milk-based
Follow-up
Formulas
(Modified)
Enfagrow™ 60:40 ⻫ *50% ⻫ 100/0 0.32/0.64 230
Gentlease®
Next Step®
Good Start® 2 100:0 ⻫ 70% ⻫ 100/0 0.32/0.64 265
Gentle Plus™
Good Start® 2 100:0 ⻫ 70% ⻫ 100/0 0.32/0.64 265 ⻫
Protect Plus®
Good Start® 2 ⻫ ⻫ ⻫ ⻫ 100/0 0.32/0.64 180
Soy Plus™
1
Nutrient composition based on powdered product prepared at 20 kcal/oz (when applicable) unless otherwise noted.
2
Differences in nutrient composition and product characteristics may vary among available forms (powder, liquid ready-to-use, liquid concentrate) of a specific product. Manufacturers may alter specific ingredients at any time; refer to
product label for the most up-to-date information.
*Formula is marketed for management of “lactose sensitivity.”
Enfamil®, Prosobee®, Nutramigen®, Pregestimil®, Enfacare®, Enfagrow®, Enflora®, and Enfaport® are registered trademarks of Mead Johnson Nutrition, Evansville, IN. Patented Natural Defense™ prebiotic blend used in Enfamil
Premium® includes galacto-oligosaccharides and polydextrose.
LGG® is a trademark of Valio, Ltd.
Good Start®, Gentle Plus®, Protect Plus®, Soy Plus® are registered trademarks of Société des Produits Nestlé S.A., Vevey, Switzerland. Probiotic used in Good Start® Protect Plus® formulas: Bifidobacterium lactis.
Similac®, Isomil®, Expert Care®, Alimentum®, Special Care®, Neosure®, Elecare®, and Go and Grow® are registered trademarks of Abbott Nutrition, Columbus, OH. Similac Advance® contains galacto-oligosaccharides, a prebiotic.
Similac Sensitive Isomil Soy™ includes fructo-oligosaccharides, a prebiotic.
Parent’s Choice® is a registered trademark of PBM Nutritionals, Georgia, VT. Parent’s Choice® Advantage contains galacto-oligosaccharides, a prebiotic.
ARA⫽arachidonic acid, DHA⫽docosahexaenoic acid, LBW⫽low birthweight, LCHAD⫽long-chain 3-hydroxyacyl-CoAdehodrogenase, LCT⫽long-chain triglyceride, MCT⫽medium-chain triglyceride, RTU⫽ready to use.
nutrition

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infant formulas

Pediatrics in Review Vol.32 No.5 May 2011 183

nutrition infant formulas
all formula-fed infants receive iron-fortified formulas to
prevent anemia. Infant formula content of other micro-
nutrients is based on a combination of data sets, includ-
ing age-specific dietary reference intakes, human milk
composition, inherent differences in the bioavailability of
specific nutrients in human milk and formula, and regu-
latory guidelines.
Nucleotides
These nitrogenous substances have been added to several
cow milk-based formulas since the late 1990s due to
expanding knowledge of their physiologic role and rec-
ognition of their presence in relatively high concentra-
tions in human milk. Nucleotides, which consist of one
RNA nucleoside (adenine, guanine, cytosine, or uri-
dine), one 5-carbon sugar moiety, and one or more
phosphate groups, have been proposed as conditionally
essential during periods of rapid growth because they
possess immunomodulating capabilities. In clinical stud-
ies, nucleotide supplementation has been shown to en-
hance growth in small-for-gestational age infants, en-
hance immunoglobulin A (IgA) and IgM concentrations
in preterm infants, decrease the incidence of diarrheal
disease, and enhance antibody response to certain vac-
cines. However, additional research is needed to define
the mechanism of action, confirm the clinical response,
and monitor long-term effects of nucleotide supplemen-
tation of infant formulas.
Prebiotics, Probiotics, and Synbiotics
The intestinal flora of breastfed infants differs from that
of formula-fed infants. Breastfed infant flora is predomi-
nantly composed of Bifidobacterium and Lactobacillus,
whereas the flora of formula-fed infants is more complex,
including also Bacteroides, Enterobacteriaceae, Clostrid-
ium, and Streptococcus. This difference is due, in part, to
the high concentrations of oligosaccharides present in
human milk that selectively stimulate bifidobacteria and
lactobacilli. These bacteria are believed to be important
for nutrient absorption, protection against pathogen
colonization, development of the intestinal and systemic
immune systems, and acquisition of mucosal tolerance.
In an attempt to reproduce the intestinal flora of hu-
man milk-fed infants, prebiotics, probiotics, and synbiot-
ics have been added to formulas with promising results.
Prebiotics are nondigestible short-chain carbohydrates,
commonly galacto-oligosaccharides, fructo-oligosaccharides,
or lactulose, that stimulate growth and function of specific
species of bacteria. When added to formulas, prebiotics
have been shown to increase the concentration of bifido-
bacteria and lactobacilli in the stools of preterm and term
184 Pediatrics in Review Vol.32 No.5 May 2011
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infants. The fermentation of prebiotics in the colon can lead
to acidic, more frequent, and looser stools, but they are safe
at the currently prescribed doses. Probiotics are live micro-
organisms that survive digestion and colonize the colon,
leading to a more beneficial colonic microbiota. Synbiotics
are a combination of prebiotics and probiotics. Both pre-
biotics and probiotics allow for normal growth in infancy.
Prebiotics and probiotics have been used for the pre-
vention and treatment of allergy. The intestinal flora of
atopic infants differs from that of nonatopic infants in the
first few weeks after birth. These differences were noted
before the development of atopy, suggesting a possible
causative relationship. A lower number of bifidobacteria
and higher numbers of clostridia may lead to an unbal-
anced, Th2-predominant immune response with in-
creased IgE secretion, which is theorized to be a factor
in the development of atopy. Both prebiotics and pro-
biotics have been used in an attempt to achieve a more
favorable intestinal flora, thereby preventing the devel-
opment of atopic diseases. Evidence for the use of pre-
biotics in the prevention of atopy is inconclusive. This
uncertainty could be due to a significant heterogeneity
among the studies, including types and doses of pre-
biotics, types of milk used, and patient selection.
A Cochrane review showed that probiotic supplementa-
tion to high-risk infants decreased the incidence of clinical
eczema but not of other atopic diseases. However, caution
was raised about the heterogeneity of studies, the low
follow-up numbers, and the fact that this effect did not hold
for eczema with proven sensitization. (7) Probiotics have
been studied for the treatment of allergies. One study
showed that infants suspected of having cow milk protein
allergy (CMPA) had faster recoveries when Lactobacillus
GG was added to an extensively hydrolyzed formula, with
faster resolution of blood per rectum and increased reduc-
tion of fecal calprotectin concentrations. (8)
Perhaps the most promising effect of probiotics is in
the prevention of necrotizing enterocolitis (NEC). NEC
is believed to have a multifactorial cause, with contribu-
tory factors including prematurity, aggressive initiation
of feedings, pathogenic bacteria, and ischemia, all of
which ultimately lead to immunologic injury to the gut.
The intestinal flora of preterm infants contains less ben-
eficial bacteria, which may be due to delayed feedings,
broad-spectrum antibiotic courses, and acquisition of
pathogenic environmental bacteria. Probiotics are be-
lieved to reduce the intestinal inflammatory response and
may prevent NEC. In a recently updated meta-analysis,
probiotics led to a reduction in cases of NEC (at least a
30% reduced incidence) and all-cause mortality in very
low-birthweight (VLBW) infants (1,000 to 1,500 g).

Probiotics did not reduce the risk of sepsis or mortality
due to NEC. (9) There are rare reports of probiotic-
associated sepsis in neonates, but this complication was
not seen in the studies reviewed for the meta-analysis.
Other potential concerns about the safety of probiotics
have been raised, including risks for transmission of anti-
biotic resistance and negative effect on neurodevelopment.
In conclusion, probiotics appear to be effective in reduc-
ing the risk of NEC, but more studies are needed to
determine the most beneficial type, dose, and duration
of probiotic therapy. The safety and efficacy need to be
established for each product. Currently, data in extremely
low-birthweight (⬍1,000 g) infants are insufficient to
reach any conclusions. The evidence for use of prebiotics
in the prevention of NEC is very limited.
Studies have shown that formulas supplemented with
prebiotics led to prevention of respiratory and intestinal
infections. In one study, this beneficial effect persisted at
2 years of age. (10)
Preterm Infant Formulas
Preterm formulas were developed to meet the unique nu-
tritional needs of rapidly growing preterm or low-
birthweight infants. These products have a higher caloric
density than standard formulas (24 kcal/oz or 80 kcal/
100 mL). They contain supplemental taurine and 3 to
3.3 g/100 kcal of whey-predominant protein, which has
been demonstrated to support growth and body composi-
tion changes comparable to intrauterine standards. The fat
and carbohydrate compositions of these formulas are de-
signed to overcome nutrient losses from low concentrations
of lipase, bile salts, and intestinal lactase. In currently avail-
able products, medium-chain triglyceride (MCT) oil pro-
vides between 40% and 50% of total fat, with the remainder
derived from a vegetable oil blend and supplemental DHA
and ARA. MCT is absorbed directly into the portal vascular
system and does not depend on the availability of bile acids
for micellar solubilization.
Although lactase concentrations do not reach maxi-
mal values until term, carbohydrate is provided as a
60:40 or 50:50 mixture of glucose polymers and lactose
due to the beneficial effects of lactose for calcium absorp-
tion and as a prebiotic. Preterm formulas contain higher
amounts of numerous minerals and vitamins (particularly
calcium, phosphorus, and vitamins A and D). It is impor-
tant to note that intakes of some nutrients may be
excessive if preterm formulas are consumed in quantities
that exceed 12 oz/day (360 mL), and this risk increases
as the infant’s weight approaches 2,000 g. Preterm for-
mulas should always be discontinued before hospital
discharge.
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nutrition infant formulas
Preterm Transitional Formulas
“Transitional” or “enriched” formulas that have inter-
mediate nutrient concentrations have been available for
several years and are marketed to bridge the gap between
preterm and term formulas. Preterm infants are usually
transitioned from preterm formulas to enriched formulas
(22 kcal/oz or 73 kcal/100 mL) at 1,800 to 2,000 g or
34 weeks gestational age and continued on these for-
mulas until 6 to 9 months of age. These formulas can
achieve vitamin and mineral goal requirements without
additional supplementation. However, the data on growth
and neurodevelopment have been disappointing. In fact,
a 2007 Cochrane meta-analysis found no evidence that
feeding enriched formulas (versus standard infant for-
mulas) to preterm infants after hospital discharge leads
to improvements in growth or neurodevelopment by
18 months of age. (11)
Human Milk Fortifiers
Human milk alone is inadequate to meet the nutritional
needs of preterm infants, particularly VLBW infants
(⬍1,500 g). Thus, fortification of human milk (ie, the
addition of multinutrient supplements) is recommended.
Currently available commercial human milk fortifiers con-
tain protein, carbohydrate, fat, and up to 23 vitamins and
minerals. When mixed according to manufacturer’s direc-
tions, fortified human milk matches growth and metabolic
effects of preterm infant formulas. As with preterm formu-
las, ongoing use of commercial human milk fortifiers even-
tually may lead to excessive intake of certain nutrients that
have known potential for toxicity. Therefore, it has become
common clinical practice to use specific quantities of stan-
dard infant formula powder or liquid concentrate to fortify
human milk in preterm infants who have progressed be-
yond specific age, weight, and intake volumes.
Soy Formulas
Currently available soy formulas contain a higher con-
centration of protein (2.45 to 2.8 g/100 kcal) and
supplemental amino acids (L-methionine, taurine, and
L-carnitine) to improve their biologic value. Glucose
polymers from corn syrup solids or maltodextrin are the
primary source of carbohydrate in soy formulas. Some
products also contain sucrose, and all soy formulas are
lactose-free. Fiber oligosaccharides, naturally occurring
soy carbohydrates, are also present in soy formulas. These
compounds and soy phytates have a high affinity for
calcium, phosphorus, zinc, and iron and have been
shown to interfere with their absorption. Therefore, soy
formulas contain 20% higher concentrations of calcium
and phosphorus and additional zinc and iron to compen-
Pediatrics in Review Vol.32 No.5 May 2011 185
nutrition infant formulas
sate for their diminished bioavailability. The fat content
of soy formulas is similar to cow milk-based formulas,
containing a blend of vegetable oils and supplemental
ARA and DHA in all currently marketed products.
According to the 2000 United States Census, 18% of
infants were fed soy formula in their first postnatal year.
However, evidence-based indications for their use are
limited. Soy protein-based formulas have been shown to
be safe in term infants, with evidence for adequate
growth rates and bone mineralization compared with
infants fed cow milk-based formulas. However, for pre-
term infants, soy formulas cannot meet the increased
requirements for calcium and phosphorus to match intra-
uterine accretion values, and this inadequacy can lead to
osteopenia. Soy formulas contain increased concen-
trations of aluminum, which may compete with calcium
for absorption, further affecting bone mineralization.
For these reasons, soy formulas are not recommended
for preterm infants. Concerns have been raised about the
high concentrations of phytoestrogens/isoflavones in
soy. These compounds bind to estrogen receptors and
have been reported to have various negative effects on
estrogen-related functions in animal studies, although
results are conflicting and may be species-specific. In fact,
a recent retrospective follow-up study showed no repro-
ductive or estrogen-related adverse effects in adults who
had been fed soy formula exclusively as infants. (12)
Soy formulas have not been shown to be of benefit
in the management of infantile colic or cow milk intol-
erance, and there is no indication for their use in the
prevention of atopic diseases. Infants who have nonIgE
allergic enteropathy or enterocolitis due to CMPA have
a 30% to 64% rate of cross-reaction to soy protein.
Therefore, soy formulas are not indicated in the manage-
ment of nonIgE allergies to cow milk protein. However,
only 8% to 14% of infants who have IgE-mediated aller-
gic reactions to cow milk proteins are sensitized to soy.
A statement by the European Society for Pediatric
Gastroenterology, Hepatology, and Nutrition recom-
mends that use of soy formulas be limited to infants older
than 6 months of age who have signs consistent with
IgE-mediated allergy after successful clinical challenge.
(13) Soy formulas are free of all lactose and are indicated
when strict lactose avoidance is required, as in the rare
case of congenital lactase deficiency or in the manage-
ment of galactosemia. It is important to note that cow
milk protein formulas said to be free of lactose, in which
other sugars are the predominant source of carbohy-
drates, still can contain small amounts of lactose and are
not appropriate for infants who have galactosemia. Any
formula said to be lactose-free may be used for transient
186 Pediatrics in Review Vol.32 No.5 May 2011
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lactase deficiency, such as a postviral enteropathy, al-
though such affected infants generally tolerate continu-
ation of a standard lactose-containing formula. Because
soy formulas in this setting were only shown to decrease
the duration of the diarrhea from 6 to 4 days without a
significant change in weight at 14 days, their use for this
purpose is discouraged. (14) Finally, strict vegetarian
families may prefer soy formula for their infants.
Hydrolyzed and Amino Acid-based Formulas
More than 50 years ago, infant formulas containing
extensively hydrolyzed protein were developed for feed-
ing infants who were unable to digest or tolerate formu-
las containing intact cow milk protein. Casein, which is
heat-treated and enzymatically hydrolyzed, is the protein
source for all currently marketed formulas of this type
in the United States. Hydrolysis results in a combina-
tion of short-chain peptides and free amino acids. Spe-
cific free amino acids are supplemented to improve the
biologic value of the resulting nitrogenous content. It
has been shown that peptides containing as few as three
amino acids can induce T-cell activity in vitro. Thus, to
be labeled as hypoallergenic, the American Academy of
Pediatrics (AAP) guidelines state that “formulas must
demonstrate that they do not provoke reactions in 90% of
infants or children with confirmed cow milk allergy with
95% confidence when given in prospective randomized,
double-blind, placebo-controlled trials.” Currently, only
extensively hydrolyzed and free amino acid-based formu-
las are considered to be hypoallergenic by these criteria.
Glucose polymers from various combinations of in-
gredients are the primary carbohydrate source in exten-
sively hydrolyzed formulas (EHFs). One currently avail-
able formula (Similac Expert Care Alimentum®, Abbott
Nutrition, Columbus, OH) contains a combination of
glucose polymers and sucrose. All formulas are lactose-free.
The fat content of EHFs varies considerably. All
contain a blend of vegetable oils similar to that in stan-
dard formulas and a total fat content of 48%. In two of
three currently marketed products (Pregestimil®, Mead
Johnson Nutritionals, Evansville, IN, and Similac Expert
Care Alimentum®, Abbott Nutrition, Columbus, OH),
a portion of this oil blend is replaced with MCT oil,
which is helpful in certain malabsorptive conditions.
Because essential fatty acids are long-chain triglycerides,
no formula contains 100% MCT as a fat source.
Carbohydrate and fat composition are important cri-
teria for specific EHF selection because clinical applica-
tion of these formulas has expanded over time to in-
clude various conditions characterized by malabsorption
of nutrients. Examples include short bowel syndrome,

hepatobiliary disease, pancreatic insufficiency, autoim-
mune diseases, and immunodeficiency syndromes. These
formulas may be poorly accepted unless introduced early
in infancy, and their high cost necessitates judicious use.
In recent years, formulas containing partially hydro-
lyzed whey protein have been marketed in the United
States. They contain fat blends similar to those in stan-
dard formulas as well as reduced lactose content (lactose
partially or fully replaced by glucose polymers).
Three amino acid-based formulas have been approved
by the United States Food and Drug Administration:
Neocate® (Nutricia North America, Gaithersburg, MD),
Elecare® (Abbott Nutrition, Columbus, OH), and
Nutramigen AA® (Mead Johnson Nutritionals, Evansville,
IN). Unlike EHFs, the protein content of amino-acid based
products is composed of individual free amino acids.
Glucose polymers from various dietary sources are the
primary source of carbohydrate. With regard to fat content,
one product (Nutramigen AA®) contains an oil blend
similar to that in standard formulas. The other two products
(Neocate® and Elecare®) contain a combination of oils
resulting in a long-chain triglyceride-to-MCT ratio (67:33)
that can be beneficial for certain malabsorptive disorders.
The increasing incidence of atopic diseases in recent
decades has prompted interest in the use of hydrolyzed
formulas for the prevention of atopy, particularly ec-
zema, asthma, and food allergies. Hydrolyzed protein
formulas appear to be superior to standard cow milk
formulas, but not to human milk, in the prevention of
allergy. The German Infant Nutritional Intervention
Program, a longitudinal prospective study, showed that
infants who had a high risk for developing atopic diseases
(first-degree relative who had allergy) had a 33% lower
incidence of atopic dermatitis when human milk was
supplemented with hydrolyzed protein formula com-
pared with supplementation with regular cow milk for-
mula in the first 4 postnatal months. (15) This beneficial
effect persisted at 6 years of age. Extensively hydrolyzed
casein was more effective than partially hydrolyzed whey;
extensively hydrolyzed whey showed no benefit.
In 2008, updated AAP recommendations stated that
for infants at high risk of developing atopic disease who
are not breastfed exclusively for 4 to 6 months or are
formula-fed, there is evidence that atopic dermatitis may
be delayed or prevented by the use of EHF or partially
hydrolyzed formula (PHF) compared with cow milk-
based formula. (16)
A more recent meta-analysis of 18 studies of high-risk
infants who were fed a partially hydrolyzed whey formula
found a 45% reduced risk for atopic dermatitis at 1 year of
age and 36% reduction at 3 years of age. (17) Consider-
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nutrition infant formulas
ing the high prevalence of allergic diseases in the popu-
lation, one third of all infants would be candidates for a
hydrolyzed formula, but their higher cost must be taken
into consideration. Amino acid-based formulas have not
been studied in the prevention of allergy.
Today, CMPA or hypersensitivity is reported in 2%
to 3% of all infants. PHFs are not indicated for the
management of CMPA due to the high percentage of
reactions to these formulas. Therefore, infants who have
proven CMPA and are not breastfeeding should be fed
EHFs. A subgroup of patients who have CMPA, those
who have nonIgE-mediated enterocolitis and failure to
thrive, severe eczema, or symptoms during exclusive
breastfeeding, may respond better to amino acid-based
formulas than hydrolyzed formulas. (18) However,
amino acid-based formulas should be reserved for those
who do not respond to EHFs.
A percentage of infants who experience colic do re-
spond to hydrolyzed formulas. Thus, a 1- to 2-week trial
of a hydrolyzed formula can be recommended.
Modified Cow Milk- and
Soy-based Formulas for Term Infants
In the past several years, the infant formula market has
expanded to include several formulas marketed as solu-
tions to specific conditions such as acid reflux, diarrhea,
and excessive gas or fussiness often associated with colic.
These formulas vary considerably in their macronutrient
profile and typically contain one or more of the follow-
ing modifications: partially hydrolyzed whey and soy
proteins; reduced lactose or lactose-free carbohydrate
blends; and other added ingredients such as thickeners,
soy fiber, and prebiotics. With the exception of thickened
formula, evidence for and against these modifications has
been addressed in previous sections of this review.
Thickened infant formulas are commonly used to help
manage gastroesophageal reflux disease (GERD). A recent
meta-analysis reviewed 14 randomized, controlled trials
that used different thickeners, including carob-bean gum,
cornstarch, rice starch, cereal, and soy fiber. (19) Thickened
milk was associated with an increased percentage of infants
who had no regurgitation and reduced number of episodes
of vomiting, regurgitation, and signs of GERD such as
irritability and crying. However, the clinical significance of
this reduction is unclear because vomiting was reduced by
only 0.9 episodes/day. pH probe indices were not signifi-
cantly improved, with the exception of a shorter duration of
the longest episode of pH lower than 4. Thickened feedings
may reduce nonacidic episodes of reflux, which may explain
the disparity between clinical observations and standard pH
probe measurements. Prethickened formulas are not supe-
Pediatrics in Review Vol.32 No.5 May 2011 187
nutrition infant formulas
Summary
• Based on strong research evidence, formulas
supplemented with DHA (between 0.3% and 0.5%
of total fatty acids) and at least equal amounts of
ARA are beneficial for visual and neurological
development.
• Based on strong research evidence, formulas
supplemented with probiotics reduce the incidence
of clinical eczema in high-risk infants (parent or
sibling who has atopy).
• Based on strong research evidence, formulas
supplemented with probiotics reduce the incidence
of NEC and all-cause mortality in VLBW infants.
• Based on some research evidence, formulas
supplemented with prebiotics or probiotics decrease
the risk of infections during infancy.
• Based on strong research evidence, partially or
extensively hydrolyzed formulas are effective in
preventing or delaying development of atopic
dermatitis in high-risk infants.
• Based on strong research evidence, thickened
formulas reduce the number of episodes of vomiting,
regurgitation, and signs of GERD such as irritability
and crying.
rior to formulas thickened later with corn starch or rice
cereal. Concerns have been raised about the safety of thick-
ened milks, including malabsorption of macro- and micro-
nutrients. The only adverse effects reported in the meta-
analysis were increased coughing and diarrhea. Larger
studies are needed to address these safety concerns better.
Follow-up Formulas
Follow-up formulas were developed to meet the nutri-
tional needs of infants and young toddlers whose solid
food intake is not fully adequate to meet age-specific
nutritional requirements. As compared with standard
formulas, follow-up formulas are slightly higher in the
content of protein and selected minerals. They are avail-
able as modifications of both cow and soy milk-based
products. According to the AAP, follow-up formulas are
considered nutritionally adequate when used in combi-
nation with solid foods but offer no clear advantage over
infant formulas designed to meet 100% of nutritional
needs throughout the first postnatal year. These products
may offer a small cost advantage over standard infant
formulas.
References
1. Committee on the Evaluation of the Addition of Ingredients
New to Infant Formula. Comparing infant formulas with human
milk. In: Infant Formula: Evaluating the Safety of New Ingredients.
Washington, DC: The National Academies Press; 2004:41–54
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2. Electronic Code of Federal Regulations; Title 21:107, Infant For-
mulas. Washington, DC: Government Printing Office; 2010
3. Robbins ST, Beker LT, Pediatric Nutrition Practice Group.
Infant Feedings: Guidelines for Preparation of Formula and Breast-
milk in Health Care Facilities. Chicago, IL: American Dietetic
Association; 2004
4. Simmer K, Patole S, Rao SC. Long-chain polyunsaturated fatty
acid supplementation in infants born at term. Cochrane Database
Syst. Rev. 2008;1:CD000376
5. Schulzke SM, Patole SK, Simmer K. Long-chain polyun-
saturated fatty acid supplementation in preterm infants. Cochrane
Database of Syst. Rev. 2008;2:CD000375
6. Hoffman DR, Boettcher JA, Diersen-Schade DA. Toward opti-
mizing vision and cognition in term infants by dietary docosahexa-
enoic and arachidonic acid supplementation: a review of random-
ized controlled trials. Prostaglandins Leuko Essent Fatty Acids.
2009;81:151–158
7. Osborn DA, Sinn JK. Probiotics in infants for prevention of
allergic disease and food hypersensitivity. Cochrane Database Syst
Rev. 2007;4:CD006475
8. Baldassarre ME, Laforgia N, Fanelli M, Laneve A, Grosso R,
Lifschitz C. Lactobacillus GG improves recovery in infants with
blood in the stools and presumptive allergic colitis compared
with extensively hydrolyzed formula alone. J Pediatr. 2010;156:
397– 401
9. Deshpande G, Rao S, Patole S, Bulsara M. Updated meta-
analysis of probiotics for preventing necrotizing enterocolitis in
preterm neonates. Pediatrics. 2010;125:921–930
10. Arslanoglu S, Moro GE, Schmitt J, Tandoi L, Rizzardi S,
Boehm G. Early dietary intervention with a mixture of prebiotic
oligosaccharides reduces the incidence of allergic manifestations
and infections during the first two years of life. J Nutr. 2008;138:
1091–1095
11. Henderson G, Fahey T, McGuire W. Nutrient-enriched for-
mula versus standard term formula for preterm infants following
hospital discharge. Cochrane Database Syst Rev. 2007;4:CD004696
12. Strom BL, Schinnar R, Ziegler EE, et al. Exposure to soy-based
formula in infancy and endocrinological and reproductive out-
comes in young adulthood. JAMA. 2001;286:807– 814
13. ESPGHAN Committee on Nutrition, Agostoni C, Axelsson I,
Goulet O, et al. Soy protein infant formulae and follow-on formu-
lae: a commentary by the ESPGHAN Committee on Nutrition.
J Pediatr Gastroenterol Nutr. 2006;42:352–361
14. Allen UD, McLeod K, Wang EE. Cow’s milk versus soy-based
formula in mild and moderate diarrhea: a randomized, controlled
trial. Acta Paediatr. 1994;83:183–187
15. von Berg A, Filipiak-Pittroff B, Krämer U, et al. Preventive
effect of hydrolyzed infant formulas persists until age 6 years:
long-term results from the German Infant Nutritional Intervention
Study (GINI). J Allergy Clin Immunol. 2008;121:1442–1447
16. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional
interventions on the development of atopic disease in infants and
children: the role of maternal dietary restriction, breastfeeding,
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17. Alexander DD, Cabana MD. Partially hydrolyzed 100% whey
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cow’s milk allergy: a systematic review. Clin Exp Allergy. 2007;37: thickened-feed interventions on gastroesophageal reflux in infants:
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PIR Quiz
Quiz also available online at: http://pedsinreview.aappublications.org.

1. Which of the following statements about infant nutrition is true?

A. Human milk contains more casein than infant formulas.
B. Infants who receive increased whey protein have been shown to grow better than those who receive
primarily casein.
C. Iron is absorbed better from cow milk formulas than from human milk.
D. Lactose-free formulas result in decreased absorption of calcium.
E. There are no apparent negative effects from the addition of DHA and ARA to formulas.

2. Which of the following statements regarding prebiotics and probiotics is true?

A. Both have been proven to decrease the incidence of atopy.
B. Prebiotics are live microorganisms.
C. Probiotics are carbohydrates that stimulate bacterial growth.
D. The use of probiotics has been shown to reduce the incidence of necrotizing enterocolitis.
E. They should be routinely prescribed to exclusively breastfed infants.

3. The characteristic that is more typical of casein than of whey is that it:
A. Forms large curds on exposure to gastric acid.
B. Is only found in trace amounts in cow milk.
C. Is resistant to precipitation.
D. Is the predominant protein in human milk.
E. Undergoes more rapid gastric emptying.

4. Which infant feeding is best for the prevention of atopic disease?

A. Cow milk-based formula.
B. Extremely hydrolyzed formula.
C. Human milk.
D. Partially hydrolyzed formula.
E. Soy formula.

5. Which of the following supplements has been added to formulas for the longest period of time?
A. Arachidonic acid.
B. Docosahexaenoic acid.
C. Iron.
D. Nucleotides.
E. Prebiotics.

6. A young mother has brought her newborn to your clinic for his first visit. She has heard that soy formulas
are better than milk-based formulas. For which of the following conditions is soy formula indicated?
A. Allergic enteropathy.
B. Colic.
C. Galactosemia.
D. Gastroesophageal reflux.
E. Prematurity.

Pediatrics in Review Vol.32 No.5 May 2011 189

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 Infant Formulas
J. Andres Martinez and Martha P. Ballew
Pediatr. Rev. 2011;32;179-189
DOI: 10.1542/pir.32-5-179

Updated Information including high-resolution figures, can be found at:

& Services http://pedsinreview.aappublications.org/cgi/content/full/32/5/179

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 Addressing Environmental Contaminants in Pediatric Practice
Catherine Karr
Pediatr. Rev. 2011;32;190-200
DOI: 10.1542/pir.32-5-190

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Article poisoning

Addressing Environmental Contaminants in

Pediatric Practice
Catherine Karr, MD, MS,
Objectives After completing this article, readers should be able to:
PhD*
1. Recognize the basis for children’s susceptibility to environmental contaminants.
2. Identify common pediatric environmental health problems.
Author Disclosure 3. Take an environmental history to discern risks.
Dr Karr has disclosed 4. Access reliable and useful resources on pediatric environmental health topics.
no financial 5. Discuss environmental exposure reduction and prevention with patients and families.
relationships relevant
to this article. This
commentary does not
Introduction
The past decade has been marked by a rapid expansion of scientific inquiry, media reports,
contain a discussion
and public interest in the topic of environmental contaminants and child health. There are
of an unapproved/ few pediatric environmental health specialists, and most health conditions associated with
investigative use of a contaminants in food, water, the home environment, and the community present initially
commercial to the primary care clinician. Consequently, pediatricians are increasingly called on to
product/device. answer questions about environmental health.
Although standard medical education on these topics is limited and self-reported
confidence among pediatric clinicians is low, extensive knowledge of toxicology is not
required to suspect environmental health problems. This article reviews core concepts of
pediatric environmental health, commonly encountered pediatric environmental hazards,
and the environmental history. Understanding these areas of knowledge should allow the
clinician to develop a degree of suspicion that is the foundation for discerning and
preventing the potential adverse effects of environmental contaminants in child health.

Core Concepts in Pediatric Environmental Health

Children’s susceptibility to environmental contaminants differs from that of adults.
Pediatricians are familiar with the differences inherent in children across the life stages.
Therapeutic interventions such as dosing based on weight or surface area is part of everyday
practice. Injury prevention advice for a newborn is unique from that given during an
adolescent visit. Similar concepts apply to the potential vulnerability of children to adverse
consequences of exposure to environmental contaminants, reinforcing the perspective that
“children are not small adults.”

Disruption of Normal Developmental Processes

Maternal exposure in pregnancy to teratogenic drugs, chem-
icals, and infections may result in structural or functional
Abbreviations anomalies. Major organ development occurs in the embry-
onic period, just 18 to 60 days postconception, and this
ADHD: attention-deficit/hyperactivity disorder
period is a high-risk window for structural anomaly develop-
BLL: blood lead level
ment, such as the common birth defects. Organ system
BPA: bisphenol A
development, such as nervous, pulmonary, and immune
CDC: Centers for Disease Control and Prevention
system function and maturation, is a continuum that persists
EPA: Environmental Protection Agency
through later gestation, postnatally, and even into adoles-
FDA: Food and Drug Administration
cence. Endocrine system changes in later childhood and
HUS: hemolytic-uremic syndrome
pubertal periods influence ongoing reproductive system de-
NEEF: National Environmental Education Foundation
velopment. Chemicals that alter these processes may com-
PCB: polychlorinated biphenyl
promise the function of these organ systems. Chemicals that

*Assistant Professor of Pediatrics; Director, Pediatric Environmental Health Specialty Unit, University of Washington, Seattle,
WA.

190 Pediatrics in Review Vol.32 No.5 May 2011

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are associated with carcinogenesis are also of high con-
cern in children because cells that undergo carcinogenic
transformation in childhood have more time to develop
into tumors.
One well-described example of functional develop-
mental toxicity is lead exposure. The current public
health threshold for action is a blood lead level (BLL)
of 5 ␮g/dL for a pregnant woman and 10 ␮g/dL
(0.48 ␮mol/L) for a child, but 25 ␮g/dL (1.21
␮mol/L) is the threshold for a nonoccupationally ex-
posed adult. This discrepancy reflects the knowledge that
children are far more vulnerable than adults to lead
neurotoxicity. Accumulating evidence of neurodevelop-
mental effects in children who have BLLs below 10
␮g/dL (0.48 ␮mol/L) has led to an active debate that
the action level for children should be even lower. (1)(2)
Opportunities for Receiving Higher Doses
Because metabolic rate is largely influenced by an organ-
ism’s size, children eat more food, drink more water, and
breath more air than adults on a per-kilogram body
weight basis. Consequently, if food supplies, water, or air
contain a contaminant, exposed children receive a higher
dose.
Children have unique, life-stage-specific behaviors
that also may influence their exposure to environmental
contaminants. For example, the diet of young infants is
limited to single foods (eg, human milk or infant for-
mula). This unique feeding pattern partly explains the
vulnerability of Chinese infants who suffered acute renal
failure due to melamine-contaminated infant formula in
China in 2008. Despite the detection of melamine in
other foods and dairy products, infants whose sole source
of nutrition was highly contaminated formula received
doses hundreds of times higher than that received by
older children or adults, who consumed a variety of
foods. In older children eating idiosyncratic diets of
limited variety, if one of their primary foods is contami-
nated, they are at risk for accumulating relatively high
exposures. The recognition that children eat much larger
quantities of certain fruits and vegetables has been well
documented and is now among considerations for devel-
opment of federally regulated pesticide residue toler-
ances.
It is common for toddlers to explore nonfood items
orally. The crawling child is in close contact with surfaces
indoors and out, increasing his or her exposure to con-
taminated dust, soil, or household products as well as
items such as lead paint. This situation likely explains the
observation that peak BLLs in children typically occur at
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poisoning environmental contaminants
age 18 to 24 months, when mobility expands and oral
exploratory behaviors are still present.
Commonly Identified Pediatric Environmental
Hazards
Children may encounter environmental contaminants in
drinking water, food, inside their homes, or in the com-
munity. There are more than 80,000 chemicals in com-
merce and hundreds of human pathogens. The pediatric
clinician should be familiar with the relatively few agents
described in this article, which represent the more com-
monly encountered environmental contaminants that
have well-described health consequences, as well as
emerging contaminants undergoing enhanced scrutiny.
Sources of these contaminants and information on test-
ing and health-based regulatory levels are highlighted in
Table 1. In some cases, where suspicion of an environ-
mental factor is raised but remains unclear or is not
straightforward, consultation or referral to specialists
who have experience in pediatric environmental health is
necessary to determine appropriate next steps (Table 2).
Drinking Water Contaminants
Community or public drinking water supplies in the
United States are regularly monitored under the Safe
Drinking Water Act. Several regulatory standards are
established for multiple contaminants determined by the
United States Environmental Protection Agency (EPA).
The Act also requires suppliers to provide an annual
report explaining the source of the water, how it is
treated, a list of the chemicals for which it is tested, and
the highest concentration of each chemical found in the
past year. If a serious problem is identified, public water
suppliers are required to inform consumers quickly. All of
the contaminants discussed in this article are monitored
in public drinking water supplies.
This oversight does not apply to the approximately
15% to 20% of households in the United States that
obtain their water from private wells. With few excep-
tions, private well owners bear the responsibility for their
own wells, although states provide guidance on con-
struction, maintenance, and testing. A recent American
Academy of Pediatrics Policy Statement describes the
common concerns for groundwater and wells and in-
cludes recommendations for inspection, testing, and re-
mediation (Table 2).
Asking patients about their sources of drinking water,
such as whether it is from a public source or private well,
is a key component of the environmental history, dis-
cussed in more detail in the “Environmental History”
section of this article. The range of potential contami-
Pediatrics in Review Vol.32 No.5 May 2011 191
poisoning environmental contaminants
Common Environmental Contaminants of Concern for Children in
Table 1.
the United States: Sources and Testing Information
Contamination Source
Biological Agents
Cryptosporidium Pathogen shed in human and animal
feces can enter water used for
drinking water supplies.
Escherichia coli Human and animal fecal coliform found
0157 in contaminated water, raw milk, raw
or rare ground beef, unpasteurized
apple juice or cider, uncooked fruits
and vegetables.
Chemical Agents
Lead Lead service lines or corrosion of
plumbing systems leach lead into
water or natural deposits erode (rare).
Lead-containing paint may
contaminate house dust or soil. Take-
home lead dust from the workplace.
Lead in consumer products and other
emerging sources. (3)
Arsenic Natural sources in rock/sediment leach
into water supplies, foods.
Wood preservatives or arsenical
pesticides.
Nitrate/nitrite Nitrate-containing fertilizers, sewage
and septic tanks, and decaying animal
waste.
Trichloroethylene, Improper disposal to surface waters and
tetrachloroethylene groundwater by industry commerce
and individual consumers. Leaching
from hazardous waste landfills into
groundwater.
Pesticide residues Conventional agriculture results in
residues in foods and potential water
contamination in agricultural areas.
Residential use of pesticides may
contaminate indoor and outdoor
surfaces or air where children spend
time.
Fish contaminants: Industrial air pollution accumulates in
mercury streams and oceans and is converted
to methylmercury. Fish absorb the
methylmercury. Larger, long-lived fish
accumulate the highest
concentrations.
BLL⫽blood lead level, CDC⫽Centers for Disease Control and Prevention, EPA⫽Environmental Protection Agency, FDA⫽Food and Drug Administration
192 Pediatrics in Review Vol.32 No.5 May 2011
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Testing and Regulatory Information
• Routine testing is conducted in all municipal water
supplies.
• Recommend water testing if private well and
suspected illness.
• Routine testing is conducted in all municipal water
supplies.
• Conduct water testing if private well (see Table 2).
• Routinely tested in municipal water supplies and in a
sample of residential taps (point of use).
• EPA residential water regulatory level >15 ␮g/L
(0.72 ␮mol/L)
• Lead may be tested in paint, dust, soil (see Table 2).
• Biomarker for suspected child exposure: BLL.
• CDC Public Health Action Level: BLL >10 ␮g/dL
(0.48 ␮mol/L)
• Routine testing is conducted in all municipal water
supplies.
• Consider if private well. EPA regulatory level: >10 ␮g/L.
• Biomarker for suspected child exposure: consult pediatric
environmental health specialist or clinical toxicologist.
• Routine testing is conducted in all municipal water
supplies. Conduct testing if private well.
• If >10 mg/L, do not use for formula mixing or food
preparation for children <1 year of age.
• If >3 mg/L, indicates contamination.
• Biomarker of effect: methemoglobin value
• Routine testing is conducted in all municipal water
supplies.
• Consider if private well. EPA regulatory level for both
chemicals: >5 ␮g/L
• Food residues tolerances are enforced by the
Department of Health and Human Services/FDA for
most foods (United States Department of Agriculture
for meat, poultry, egg products). Surveys of pesticide
residues in food typically reveal that most samples are
below tolerance. Regulatory oversight for pesticide
application is shared by EPA and United States
Department of Agriculture.
• For biomarker for suspected child exposure: consult
pediatric environmental health specialist.
• Testing of fish and seafood jointly regulated by EPA
and FDA.
• See Joint Federal Fish consumption guidelines and
local fish advisories (Table 2).
• Biomarker for suspected methylmercury exposure:
whole blood mercury value. Reference dose for
possible health effects: >5.8 ␮g/L.
 poisoning environmental contaminants

Core Topics for the Environmental History and Related

Table 2.

Anticipatory Guidance and Resources

Environmental History
Topics Anticipatory Guidance Resources
General Help parents prioritize environmental risks • CDC/EPA-sponsored Pediatric Environmental Health
and discuss reduction strategies and Specialty Unit (PEHSU) Network. Regionally based
resources. expertise for consultation and information at:
www.pehsu.net.
• National Environmental Education Foundation.
Pediatric Environmental History Initiative at:
http://www.neefusa.org/health/PEHI/index.htm
• EPA. Children’s Environmental Health: Online
Resources for Health Care Providers at: http://
yosemite.epa.gov/ochp/ochpWeb.nsf/content/
hcp_resources.htm
Healthy Habits, Healthy
Products
Fish consumption Discuss federal and local fish advisories to FDA & EPA Joint Federal Advisory for Fish.
avoid fish with high concentrations of Consumption Advice: Joint Federal Advisory for
mercury or other contaminants. Mercury in Fish and links to local fish advisories at:
Nationally, avoid consumption of http://www.epa.gov/fishadvisories/advice/
swordfish, shark, king mackerel, and factsheet.html
tilefish.
Tobacco Promote no tobacco use/exposure. CDC. Smoking and Tobacco Use Resources at: http://
www.cdc.gov/tobacco/quit_smoking/how_to_quit/
index.htm
Occupational exposure to Address take-home pathway and Under the Hazard Communications Standard of the
toxic substances recommended strategies. Occupational Health and Safety Administration
Hobbies involving toxic Focus on specific risks identified and (OSHA), employers must maintain a Material Safety
substances (solvents, strategies to reduce contamination of Data Sheet for each hazardous chemical used and
lead in pottery glazes, child’s environments. make it available to workers. Information available
lead solder, lead dust at at: http://www.osha.gov/dsg/hazcom/index.html
firing range)
Organic versus Recommend washing of fresh produce with Information on produce that contains more versus
conventional foods water, peeling, scrubbing with a brush, less pesticide residues at Environmental Working
and throwing away the outer leaves of Group Shoppers Guide To Pesticides™ at: http://
leafy vegetables. This action may www.foodnews.org/fulllist.php
significantly reduce the amount of
pesticides.
Plastics: Bisphenol A (BPA) Avoid plastics with recycling codes 3, 6, or PEHSU Fact sheets for health care providers and
and phthalates 7 (may contain BPA or phthalates). patients at: www.pehsu.net
(emerging concern) Decrease leaching/degradation of these
chemicals by not microwaving plastics or
washing in dishwasher. Choose BPA- and
phthalate-free baby bottles, toys, and
other products for children.
Healthy Home
Water damage, leaks, Leaks and water damage should be cleaned EPA. Mold Resources at: http://www.epa.gov/mold/
floods, or mold odor/ up within 24 to 48 hours to reduce mold moldresources.html
growth growth, and relative humidity should be
kept at less than 60% (ideally 30% to
50%).
Active or recent Assume lead paint, unless tests show EPA. Lead in Paint, Dust, and Soil Resources at:
renovation or otherwise. Special containment http://www.epa.gov/lead/pubs/leadinfo.htm
remodeling in home methods applied by trained individuals
built before 1978 are needed for safe repair. Repair work
not applying these methods can escalate
exposure.
Home built before 1978, See above. EPA. Lead in Paint, Dust, and Soil Resources at:
paint chipping/peeling/ http://www.epa.gov/lead/pubs/leadinfo.htm
cracked
(Continued)

Pediatrics in Review Vol.32 No.5 May 2011 193

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poisoning environmental contaminants
Core Topics for the Environmental History and Related
Table 2.
Anticipatory Guidance and Resources—continued
Environmental History
Topics
Friable ceiling material or
degraded insulation
around pipes, boilers,
and furnaces.
Carbon monoxide detector
Radon testing
Drinking water source
(private or shared well
versus public)
Wood stove or fireplace
use
Pesticides in home or on
lawn/garden, storage
Healthy Community
Near highways or highly
trafficked roadways
Near industrial site,
hazardous waste site,
landfill
Near pesticide-treated
agricultural fields
Knowledge of air quality
index
Copper chromated arsenic
(CCA)-treated wood on
playgrounds/decks
School and child care
CDC⫽Centers for Disease Control and Prevention, EPA⫽Environmental Protection Agency
194 Pediatrics in Review Vol.32 No.5 May 2011
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Anticipatory Guidance
Asbestos materials that are crumbling,
damaged, or friable should be removed and
cleaned up by trained and licensed workers.
Asbestos-containing materials that are in
good condition do not present a risk and
should be left alone.
Use a carbon monoxide detector with
Underwriters Laboratory certification.
Do not use oven or charcoal to heat home
indoors. Do not idle car in attached garage.
Test home if living spaces are below third floor.
Fix home if radon level is 4 pCi/L or higher.
If private well, recommend testing.
If suspect lead-containing pipes or fixtures,
test home water.
Avoid use if child has asthma or respiratory
health conditions. If used as source of
heat, have a qualified technician inspect
fuel-burning appliances and chimneys
annually to ensure appropriate venting.
Store in locked box/cabinet outside of the
home.
Use least toxic products/integrated pest
management to manage pests. Do not use
broadcast sprays.
Avoid housing, play areas in close proximity.
Avoid play near these areas.
Identify specific exposures and information
from public health and regional EPA.
Advise against play on treated soil/fields. Wash National Pesticide Information Center. Pesticides in
hands and outdoor toys frequently. Avoid pet
contact with treated fields. Remove shoes
when entering home. Close windows, stay
inside during spray application.
Discuss patient susceptibility to poor air quality EPA. Local air quality conditions and forecasts at:
days, particularly for children who have
asthma. Discuss air quality alerts.
Avoid use of arsenic-treated wood on decks/ Consumer Product Safety Commission. Fact Sheet on
playgrounds. If present, wash hands after
contact and apply sealant annually. Do not
burn CCA-treated wood.
See topics above as applicable
Resources
EPA. Asbestos in Your Home at: http://www.epa.gov/
asbestos/pubs/ashome.html
EPA. Protect Your Family and Yourself From Carbon
Monoxide Poisoning at: http://www.epa.gov/iaq/
pubs/coftsht.html
EPA. A Citizen’s Guide to Radon at: http://
www.epa.gov/radon/pubs/citguide.html
Local health department for local contaminants of
concern
American Academy of Pediatrics Committee on
Environmental Health. Drinking water from private
wells and risk to children. Policy statement.
Pediatrics. 2009;123:1599–1605 at: http://
aappolicy.aappublications.org/cgi/reprint/pediatrics;
123/6/1599.pdf
Annual report of drinking water quality in public
systems at: http://water.epa.gov/drink/local/
index.cfm
EPA. Is There Lead in My Drinking Water? at: http://
www.epa.gov/ogwdw000/lead/leadfactsheet.html
EPA Fact Sheet. Reducing Air Pollution From
Residential Wood Burning at: http://www.epa.gov/
oaqps001/community/guide/wood_stoves_comm_
info.pdf
EPA Best Burn Practices at: http://www.epa.gov/
burnwise/bestburn.html
National Pesticide Information Center. Pesticides in
Indoor Air of Home at: http://npic.orst.edu/factsheets/
air_gen.pdf
Karr C, Solomon GM, Brock-Utne A. Health effects of
common home, lawn and garden pesticides. Pediatr Clin
North Am. 2007;54:63–80
EPA and CDC. Asthma and Outdoor Air Pollution at:
http://www.epa.gov/airnow/asthma-flyer.pdf
Local or state health or environmental department for
site-specific information
Indoor Air of Home at: http://npic.orst.edu/
factsheets/air_gen.pdf
http://www.airnow.gov/
EPA and CDC. Asthma and Outdoor Air Pollution at:
http://www.epa.gov/airnow/asthma-flyer.pdf
CCA-Treated Wood Used in Playground Equipment
at: http://www.cpsc.gov/phth/ccafact.html
EPA. Healthy School Environment Resources at:
http://cfpub.epa.gov/schools/Index.cfm

nants includes chemical, microbiologic, and physical (ra-
diation) hazards. Among those most commonly found
and to which children may be particularly vulnerable are
Cryptosporidium, Escherichia coli, lead, arsenic, nitrates/
nitrites, and trichloroethylene/perchloroethylene.
In some regions, source water comes in contact with
bedrock, soil, or sediment that contains naturally occur-
ring arsenic. Arsenic is a known human carcinogen, and
emerging evidence suggests that it may also be a neuro-
developmental toxicant. Local health departments can
provide information about regional experience with ar-
senic (or other important contaminants) detected in
regional well water.
Lead is one of the most important pediatric environ-
mental health concerns, and it has been estimated that,
on average, 20% of a child’s lead exposure is attributable
to water. Although rarely found in source water, lead
leaches into drinking water from lead-containing plumb-
ing materials, lead pipes, or lead-containing solder or
fixtures. This fact underlies practical recommendations
for running the faucet for 2 minutes or until the water
turns cold to ensure that the water in a system is
“flushed.” Removing water that has had long-standing
contact with plumbing components avoids consumption
of water that contains higher concentrations of leached
lead.
The two most common microbiologic water contam-
inants of concern for children are E coli and Cryptospo-
ridium. Cryptosporidium is a protozoan that causes se-
vere gastroenteritis and dehydration among infants or
immunocompromised individuals. Due to its small size,
standard water filtration may be inadequate, and boiling
for at least 1 minute (3 minutes above 6,500 feet [2,000
m] of altitude) is required for decontamination. The
presence of E coli in water is considered a marker of
recent sewage or animal waste that may contain disease-
causing organisms. Although most strains of E coli are
harmless and commensal in healthy mammals, E coli
0157:H7 produces a powerful toxin and can cause severe
hemorrhagic enterocolitis. Children younger than 5
years of age are at risk of hemolytic-uremic syndrome
(HUS) as a complication.
Nitrate is a common contaminant in well water from
sewage contamination or agricultural use of fertilizer.
The presence of nitrate is an indication for testing for
coliforms; lack of coliforms indicates the source is fertil-
izer. Young infants are at risk for developing methemo-
globinemia, which results from conversion of nitrate to
nitrite in their stomachs. With age, stomach acidity in-
creases, reducing the numbers of nitrite-producing bac-
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poisoning environmental contaminants
teria. After age 6 months, the conversion of nitrate to
nitrite in the gut is greatly reduced.
Trichloroethylene and perchloroethylene are com-
monly used industrial solvents. It has been estimated that
more than 400,000 sites in the United States contain soil
and ground water contaminated by chlorinated solvents.
The primary health concern for low-level chronic expo-
sure is increased cancer risk, and both compounds are
also liver and kidney toxicants. Reproductive and devel-
opmental effects have not been assessed adequately.
Whether used when the usual source of drinking
water is contaminated or as a convenience, bottled water
is an important source of drinking water for many people.
The United States Food and Drug Administration
(FDA) regulates bottled water products that are in inter-
state commerce under the Federal Food, Drug, and
Cosmetic Act. The FDA’s bottled water standard-of-
quality regulations generally mirror the EPA’s national
primary drinking water regulations under the Safe Drink-
ing Water Act.
Bisphenol A (BPA) is an emerging contaminant of
concern that may leach into water or food from plastic
container materials that contain the compound (eg,
polycarbonate bottles, linings of cans). The Centers for
Disease Control and Prevention (CDC) identified BPA
in 93% of Americans sampled (age 6 years and older).
This finding raises concern based on animal studies that
have linked prenatal exposure to this weakly estrogenic
compound with neurotoxicity, early puberty, mammary
tumors, prostate hypertrophy, and increased adiposity
and body weight. (4)
Food Contaminants
Food-borne infections pose an ongoing public health
challenge. Most are associated with acute enterocolitis
that may be mild to severe. Among the most concerning
food-borne chemical contaminants for children are pes-
ticide residues and other contaminants that concentrate
in some fish, including mercury and chlorinated hydro-
carbons such as polychlorinated biphenyls (PCBs). The
health concerns are related to potential chronic health
conditions, such as compromised cognitive or behavioral
development and cancer. In addition to BPA, phthalates
are contaminants of emerging concern that may leach
from plastic packaging materials into food. Concern for
the endocrine-disrupting properties of these newer
chemicals is largely derived from multiple animal studies
in which human health risks are inadequately character-
ized. An abbreviated review of the evidence base and
documents for guiding health care clinicians and families
Pediatrics in Review Vol.32 No.5 May 2011 195
poisoning environmental contaminants
is available from the Pediatric Environmental Health
Specialty Unit Network (Table 2). (4)
The predominant foodborne pathogens are Salmo-
nella, Campylobacter jejuni/coli, Toxoplasma gondii, and
Norwalk virus. Listeria monocytogenes and E coli
0157:H7 are of particular concern for newborns and
children. E coli 0157:H7 produces shiga toxin, and the
infection often is accompanied by severe abdominal
cramps, diarrhea (often bloody), and vomiting. If there is
fever, the temperature is usually not very high
(⬍38.5°C). Approximately 5% to 10% of those in whom
E coli 0157:H7 infection is diagnosed develop HUS,
with young children at higher risk for this severe compli-
cation. Listeria poses a risk to the fetus and newborn of
an infected mother because pregnant woman have an
approximately 20-fold increased risk of listeriosis. The
infection manifests with fever, muscle aches, and some-
times gastrointestinal symptoms such as nausea or diar-
rhea. With spread to the central nervous system, symp-
toms such as headache, stiff neck, confusion, loss of
balance, and seizures can occur.
The EPA, under the Food Quality Protection Act,
determines pesticide residue “tolerances” for food. Pes-
ticide chemicals comprise a broad group that has varying
types and levels of toxicity. Animal and epidemiologic
studies identify some agents that cause concern for im-
paired neurologic development, immune system effects,
endocrine disruption, and increased cancer risk. Current
policy is intended to consider children’s vulnerability,
which is increasingly understood from studies of expo-
sure and toxicologic science. For example, emerging
epidemiologic studies suggest that children who have
had higher in utero exposure to organophosphate pesti-
cides in both urban and agricultural settings are at in-
creased risk for abnormal neurodevelopment. (5)
In addition to exposure from indoor pest control or
proximity to agricultural production, children can be
exposed to these chemicals on some fruits that are com-
mon dietary staples. A study in which children were
placed on an organic diet for 5 consecutive days revealed
a rapid and dramatic decrease in their urinary excretion of
organophosphate metabolites. (6) Although this result
demonstrates the opportunity to reduce exposure, the
evidence base for the specific health implications from
low-level dietary exposures is not established.
Fish is an important source of nutrients for children
but may contain contaminants that outweigh this bene-
fit. In 2004, the EPA and the FDA issued targeted advice
concerning mercury in fish for women who might be-
come pregnant, women who are pregnant, nursing
mothers, and young children. The recommendations
196 Pediatrics in Review Vol.32 No.5 May 2011
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outline selecting and eating fish or shellfish that maintain
the benefits of fish eating while reducing exposure to the
harmful effects of mercury (Table 2). (7)
In addition, state, tribal, and local governments mon-
itor regional waterways and issue local fish advisories
when contaminant levels are unsafe, including posting
advisories at waterways. In addition to the well-
established neurodevelopmental toxicant mercury, most
advisories involve highly lipid-soluble organochlorines
such as PCBs, chlordane, dioxins, and DDT. In addition,
brominated flame retardant chemicals such as PBDE
(polybrominated diphenyl ethers) are of increasing con-
cern for having similar properties. These chemicals per-
sist in the environment and can bioaccumulate as they
move up the aquatic food chain. In some cases, prepara-
tion and cooking techniques to reduce consumption of
the lipid-rich fish components can reduce levels of con-
taminants significantly. The affected population is often
unaware of local advisories and identifies clinicians as the
most desirable source of information on such adviso-
ries. (8)
The Healthy Indoor Environment: Home,
School, Child Care
Children spend most of their time in indoor settings,
particularly their homes (85% of time), followed by
school or child care. Although the importance of ad-
dressing tobacco smoke or pet allergen is familiar to most
clinicians, the indoor environment is a primary source for
several other hazardous exposures. Many fact sheets and
resources for patients and health professionals on
“healthy home” topics have been developed (Table 2).
(9)(10). These resources include some focused particu-
larly on children who have asthma, given the importance
of indoor triggers for this disease. (11)(12)
More than 90% of the 2 million poisonings reported
to national poison centers each year occur in the home.
Household cleaning agents, pesticides that include insect
killers and lawn and garden products, and automotive
products may contain acutely toxic components that
pose a poisoning risk if not stored safely. Surveys suggest
that 75% of United States households used at least one
pesticide product indoors during the past year. These
and other chemical products may represent insidious
exposures that occur as daily low-level doses that accu-
mulate from exposure to contaminated indoor air, dust,
or surfaces and may increase chronic health risks such as
asthma or cognitive and behavioral problems.
An Institute of Medicine review found sufficient
evidence that leaks and water damage that give rise to
excess mold or other microbial growth may result in

upper respiratory tract (nasal, throat) symptoms,
cough, wheezing, and asthma in sensitized individuals.
Evidence was suggestive but more limited for lower
respiratory tract illness and new-onset asthma. (13)
Clues to excessive mold exposure include a known water
leak or damage, mildewy odor, and visible water damage
or mold growth on household surfaces such as walls or
ceilings.
Improper remediation and repair of surfaces that con-
tain lead-based paint or disruption of asbestos insulation
on pipes, boilers, or furnaces may result in concerning
indoor exposures. The use of asbestos-containing build-
ing materials has declined substantially since the 1970s.
Lead paint was also common before being banned in
1978. Deteriorating lead-containing paint is the most
common cause of lead poisoning in young children.
Low-level lead exposure is associated with a reduced
intelligence quotient and behavioral problems, including
attention-deficit/hyperactivity disorder (ADHD). Lead
dust can form when lead-based paint is dry scraped, dry
sanded, or heated. Dust also forms when painted surfaces
bump or rub together. Lead dust accumulates in win-
dowsills, on floors, and in soil.
Radon is estimated to cause approximately 21,000
lung cancer deaths each year. Radon comes from the
radioactive decay of naturally occurring uranium in soil,
rock, and water that can infiltrate into homes through
cracks and other holes in the foundation. An estimated 1
in 15 United States homes has elevated levels, and be-
cause it is difficult to predict specific risk for individual
homes, all homes below the third floor should be tested,
according to the EPA and Surgeon General of the
United States.
Improper or inadequate ventilation that allows
buildup of carbon monoxide from household combus-
tion sources (eg, furnace, fireplace, attached garage) may
cause health consequences ranging from mild nuisance
symptoms to fatalities. Clues to such exposures include
an environmental history that identifies potential sources
of carbon monoxide, clustering of symptoms among
individuals who spend the most time in the affected
areas, and symptom worsening and relief associated with
entering and leaving specific environments. Discussion of
a functional carbon monoxide detector should be a part
of routine anticipatory guidance.
Exposures encountered by household members at
work may be brought home as dust or residues on
clothing and shoes. It is important to become familiar
with the occupations of patients and household members
and ask about potential toxic exposures. If there are
questions about chemicals in the workplace, employers
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poisoning environmental contaminants
are required by law to provide material safety data sheets,
which offer information on the chemical constituents of
products that are used. Hygiene practices of removing
work clothes and shoes and showering before entering
the home can reduce the “take-home” pathway.
Recently, concern for exposure to phthalates in soft
plastic consumer products such as toys and personal care
products for children (lotions, shampoos, diaper creams)
has emerged. These antiandrogenic chemicals can
affect androgen-sensitive tissues adversely during
specific windows of development. Both animal and hu-
man studies suggest that exposure may compromise nor-
mal male reproductive system development and func-
tion. Preliminary data also link these chemicals to allergic
disease. (4)
The Healthy Community and Outdoor Settings
Community characteristics, such as proximity to
pesticide-treated agricultural fields, high-traffic road-
ways, industrial sites, or waste sites, should be assessed
for the areas where children spend time during outside
activities. In addition, children may encounter exposures
at a workplace (eg, teen workers or young children of
farm workers brought to fields). Community ozone con-
centrations typically are maximal in the late afternoon, a
time when children participate in outdoor play and sports
activities. The Air Quality Index can provide local infor-
mation on daily air quality and help guide decisions on
outdoor activities. Playground or decking equipment
made with copper chromated arsenic-treated wood may
increase a child’s exposure to arsenic. These factors may
compromise access or participation in outside play and its
healthful benefits. Such considerations are an important
topic of an emerging multidisciplinary subject termed
“the built environment.”
Some ambient pollutants permeate readily into the
indoor environment, such as traffic-derived fine partic-
ulate air pollution. Traffic-related pollutant concentra-
tions are much higher within 150 to 300 m of major
roadways and highways and drop off rapidly with
increasing distance. Such knowledge underlies policies
that consider proximity to large roadways in school
siting decisions or instigate “anti-idling” campaigns at
schools.
In studies of farm worker children, those living closer
to treated fields showed higher levels of exposure to
pesticides, based on urinary metabolites measurements,
than their peers who lived further away (⬎200 m). (14)
Also, concentrations of pesticides in household dust
exceeded concentrations in soil, demonstrating the
“take-home pathway.” Pets and people can track pesti-
Pediatrics in Review Vol.32 No.5 May 2011 197
poisoning environmental contaminants

more locally relevant factors (eg,

Brief Screening Environmental History
Table 3. toxic waste sites, wood smoke,
sportfishing, contaminants in well
Form Example* water) may direct guidance on pre-
Where does your child live and spend most of his/her time? vention measures or local or na-
What are the age, condition, and location of your home? tional resources that may help in
Does anyone in the family smoke? Yes No Not sure reducing the hazards identified.
Do you have a carbon monoxide detector? Yes No Not sure Table 2 summarizes the primary
Do you have any indoor furry pets? Yes No Not sure
topics and provides resources for
What type of heating/air system does your home have?
Radiator Forced air Gas stove Wood stove Other more detailed information on spe-
What is the source of your drinking water? cific topics and resources.
Well water City water Bottled water A basic environmental history has
Is your child protected from excessive sun exposure? Yes No Not sure been developed by the National En-
Is your child exposed to any toxic chemicals of which you are aware?
vironmental Education Foundation
Yes No Not sure
What are the occupations of all adults in the household? (NEEF) as part of their Pediatric
Have you tested your home for radon? Yes No Not sure Environmental Health History Ini-
Does your child watch TV or use a computer or video game system more than tiative (Table 3). This brief set of
2 hours a day? Yes No Not sure questions, designed to be adminis-
How many times a week does your child have unstructured, free play outside for
tered by the clinician in less than
at least 30 minutes?
Do you have any other questions or concerns about your child’s home 5 minutes, captures the most com-
environment or symptoms that may be a result of his or her mon environmental exposures in
environment? children. The NEEF Pediatric Envi-
*From the National Environmental Education Foundation Pediatric Environmental History Initiative. ronmental Health Initiative pro-
Form available as pdf with supplementary materials at www.neefusa.org/health/PEHI/. vides additional background infor-
mation on issues included in this
brief history as well as a more de-
tailed environmental history and
cide residues from treated fields or lawns indoors and recommendations that clinicians can make to families to
contaminate surfaces where children crawl and play. control or eliminate the hazards identified.
Knowledge of environmental hazards in the community In the context of illness or disease, an environmental
can help in the creation of prevention messages and history helps discern the link between environmental
community improvements that promote healthier resi- factors (activities/place/time/substances) and the na-
dences, schools, and play areas. ture, onset, worsening, and improvement of symptoms.
Such information can help elevate or reduce suspicion
The Environmental History regarding a role for particular environmental hazards and
One of the most important tools in discerning the im- help determine the need for further evaluation through
portance of environmental hazards for health conse- specific aspects of physical examination or laboratory
quences or to prioritize anticipatory guidance is the testing. Consultation with a pediatric environmental
environmental history. Questions about the environ- health specialist may be appropriate in some situations
ment are a natural component of the routine clinical (Table 2).
history. The environmental history focuses on under-
standing the quality and extent of hazards in environ- Emerging Knowledge and Risk
ments where a child spends time and on identifying Communication
suspicious patterns or aspects that prompt further evalu- Fortunately, frank acute poisonings from lead and pesti-
ation. cides are rare because public health and regulatory ac-
In routine child health supervision, taking an environ- tions have reduced exposures in United States children.
mental history can help identify potential risks in the Concern now reflects information gathered from emerg-
environments of children and the need for focused antic- ing basic, applied, and community-based research ef-
ipatory guidance on reducing exposures. Asking about forts. These studies link chronic, routine, low-level
generally recognized exposures of concern (eg, tobacco exposures to environmental factors with many of the
smoke, lead, pesticides, radon, occupation) as well as major current chronic pediatric morbidities, such as

198 Pediatrics in Review Vol.32 No.5 May 2011

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asthma, obesity, ADHD, learning disabilities, birth de-
fects, cancer, and low birthweight or preterm birth.
Public interest in children’s environmental health is
high, and media attention raises questions and concerns.
Interest and knowledge should expand with ongoing
research commitments to topics in children’s environ-
mental health, including the National Children’s
Study. This landmark project of the National Institutes
of Health, CDC, and EPA plans to follow 100,000
mothers and their children from birth to adulthood,
exploring the role of environmental exposures in the
context of other influences on child health, such as genes,
the psychosocial context, and gene-environment interac-
tions.
Pediatricians are a trusted source of reliable informa-
tion. They play an important role in providing reassur-
ance, allaying fears and anxiety, and avoiding misplaced
resources. They are practiced in making use of
imperfect, evolving information and promoting precau-
tion. Knowing the potential vulnerabilities of children,
major exposures of concern, environmental history tak-
ing, and evidence-based resources, pediatricians are
uniquely poised to identify established and emerging
Summary
• Pediatricians are a trusted, desired, and important
source of information on environmental health
topics. (8)(15)
• It is well established that children are more
vulnerable to environmental contaminants due to
their rapid and ongoing growth and development
and potential for higher exposures based on
behavioral and physiologic differences. (16)
• Evidence and consensus highlight the importance of
the environmental history in identifying and
reducing children’s exposure to hazardous
contaminants. (11)(16)
• There is sufficient evidence that lead exposure is
common among United States children and that
concentrations below the current action level (BLL
>10 ␮g/dL [ 0.48 ␮mol/L]) are associated with
adverse effects on neurodevelopment and behavior.
(1)(2)(3)
• A joint federal advisory from the FDA and the EPA
recommends reducing exposure to mercury by
highlighting the importance of selecting fish that
contain lower concentrations of methylmercury. (7)
• Multiple studies identify risks in the indoor
environment that reflect housing quality, choice of
building sites, and exposures that include lead from
paint or water, asbestos, radon, particulate matter,
mold, pesticide use patterns, and carbon monoxide.
(2)(3)(11)(13)(16)
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poisoning environmental contaminants
environmental health threats to children and provide
important anticipatory guidance for reducing risks in
their patients and their communities.
References
1. Gilbert SG, Weiss B. A rationale for lowering the blood lead
action level from 10 to 2 ␮g/dL. Neurotoxicol. 2006;27:693–701
2. Binns HJ, Campbell C, Brown MJ, for the Advisory Committee
on Childhood Lead Poisoning Prevention. Interpreting and man-
aging blood lead levels of less than 10 ␮g/dL in children and
reducing childhood exposure to lead: recommendations of the
Centers for Disease Control and Prevention Advisory Committee
on Childhood Lead Poisoning Prevention. Pediatrics. 2007;120:
e1285– e1298
3. Karr CJ. Reducing childhood lead exposure: translating new
understanding into clinic-based practice. Pediatr Ann. 2008;37:
748 –756
4. Pediatric Environmental Health Specialty Unit. Health Care
Provider Guide to Safer Plastics: Phthalates and Bisphenol A.
Accessed February 2011 at: www.pehsu.net
5. Rosas LG, Eskenazi B. Pesticides and child neurodevelopment.
Curr Opin Pediatr. 2008;20:191–197
6. Lu C, Toepel K, Irish R, Fenske RA, Barr DB, Bravo R. Organic
diets significantly lower children’s dietary exposure to organophos-
phorus pesticides. Environ Health Perspect. 2006;114:260 –263
7. United States Environmental Protection Agency/Food and
Drug Administration. Consumption Advice: Joint Federal Advisory
for Mercury in Fish. Backgrounder for the 2004 FDA/EPA Consumer
Advisory: What You Need To Now About Mercury in Fish and
Shellfish. (Advice for women who might become pregnant, women
who are pregnant, nursing mothers, young children.) Accessed
February 2011 at: http://www.epa.gov/fishadvisories/advice/
factsheet.html
8. Kuntz SW, Hill WG, Linkenbach JW, Lande G, Larsson L.
Methylmercury risk and awareness among American Indian women
of childbearing age living on an inland northwest Indian reserva-
tion. Environ Res. 2009;109:753–759
9. United States Environmental Protection Agency. Healthy
Home. (20-page consumer booklet.) Accessed January 2011 at:
http://www.epa.gov/ne/healthyhomes/pdfs/healthyhomes.pdf
10. Centers for Disease Control and Prevention. Healthy Homes
(Web-based consumer information on multiple topics.) Accessed
February 2011 at: http://www.cdc.gov/healthyhomes/
11. National Environmental Education Foundation. Pediatric
Asthma Initiative. (Evidence-based guidelines for environmental
management of asthma and environmental history form for
children who have asthma.) Accessed February 2011 at: http://
www.neefusa.org/health/asthma/index.htm
12. United States Environmental Protection Agency. EPA’s
Asthma Program. (Information for patients and health care profes-
sionals on asthma and environmental triggers.) Accessed February
2011 at: http://www.epa.gov/asthma/programs.html
13. Committee on Damp Indoor Spaces and Health. Board on
Health Promotion and Disease Prevention. Institute of Medicine.
Damp Indoor Spaces and Health. Washington, DC: National Acad-
emies Press; 2004
14. Loewenherz C, Fenske RA, Simcox NJ, Bellamy G, Kalman D.
Biological monitoring of organophosphorus pesticide exposure
among children of agricultural workers in central Washington State.
Environ Healt Perspect. 1997;105:1344 –1353
Pediatrics in Review Vol.32 No.5 May 2011 199
poisoning environmental contaminants

15. Galvez M, Peters R, Graber N, Forman J. Effective risk com- 16. American Academy of Pediatrics Committee on Environmen-
munication in children’s environmental health: lessons learned tal Health. Handbook on Pediatric Environmental Health. 2nd ed.
from 9/11. Pediatr Clin North Am. 2007;54:33– 46 Elk Grove Village, IL: American Academy of Pediatrics; 2003

PIR Quiz
Quiz also available online at: http://pedsinreview.aappublications.org.

7. Which of the following best describes the reason why young infants are at risk for developing
methemoglobinemia from agricultural nitrate contamination of water?
A. Increased nitrates in the gut cause severe constipation in young infants.
B. In infants, lower stomach acidity results in more nitrite-producing bacteria.
C. Iron in infant formula protects against nitrate toxicity.
D. Significantly more absorption of nitrates occurs through the skin of young infants.
E. Younger children have a higher exposure to contaminated water.

8. What major complication of E coli 0157:H7 infection occurs in approximately 5% to 10% of affected
children?
A. Bacterial meningitis.
B. Erythema multiforme major.
C. Hemolytic-uremic syndrome.
D. Osteomyelitis.
E. Seizures.

9. Which of the following statements about organophosphate pesticide exposure in children is true?
A. Animal and epidemiologic studies have identified only birth defects as an area of concern.
B. A normal diet poses no risk for exposure to these chemicals.
C. Children placed on organic diets show marked decreases in urinary excretion of organophosphate
metabolites.
D. Exposure results from proximity to agricultural production but not from indoor pest control.
E. In utero exposure produces no discernible effect on the developing fetus.

10. Which of the following is true about leaks and water damage in the home?
A. Strong evidence suggests that excessive mold growth can lead to pneumonia.
B. This issue has not been studied by the Institute of Medicine.
C. Water damage in the home has no effect on the health of children.
D. Water damage that gives rise to mold can result in upper respiratory tract symptoms.
E. Water stains on walls do not correlate with excessive mold growth.

11. What are the potential health risks to children from exposure to phthalates?
A. Their antiandrogenic effect may compromise development of the male reproductive system.
B. They are linked to poor enamel deposition in developing teeth.
C. They have a subtle adverse effect on linear growth.
D. They may lead to interstitial nephritis.
E. They pose no risk to children.

200 Pediatrics in Review Vol.32 No.5 May 2011

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 Addressing Environmental Contaminants in Pediatric Practice
Catherine Karr
Pediatr. Rev. 2011;32;190-200
DOI: 10.1542/pir.32-5-190

Updated Information including high-resolution figures, can be found at:

& Services http://pedsinreview.aappublications.org/cgi/content/full/32/5/190

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 Complementary, Holistic, and Integrative Medicine: Mind-Body Medicine
Hilary McClafferty
Pediatr. Rev. 2011;32;201-203
DOI: 10.1542/pir.32-5-201

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
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Complementary, Holistic, and Integrative
Medicine: Mind-Body Medicine
Hilary McClafferty, MD*
Author Disclosure
Dr McClafferty has
disclosed no financial
relationships relevant
to this article. This
commentary does not
contain a discussion
of an unapproved/
investigative use of a
commercial
product/device.
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Article complementary medicine
Objectives After completing this article, readers should be able to:
1. Define mind-body medicine.
2. Review evidence-based pediatric mind-body therapies and identify medical conditions
where these therapies have proven beneficial.
3. Encourage pediatricians to consider integrating mind-body medicine into practice.
What is Mind-Body Medicine?
Mind-body medicine might be defined as the deliberate harnessing of positive thought and
emotion and using them for the purpose of enhancing health.
It has been well established that poorly managed pain and stress can activate the
inflammatory cascade, depress immune function, and increase the risk of chronic depres-
sion, anxiety disorders, and posttraumatic stress disorder. (1)(2)(3)(4)(5) The field of
mind-body medicine capitalizes on the inverse association that positive emotions and use
of self-regulation skills can trigger beneficial physiologic reactions, including enhanced
immunity, decreased inflammation, and improved mental health. (6)
A wide variety of mind-body techniques can be used to achieve a state of calm, positive
focus. The modalities that have the best supporting evidence of efficacy in pediatrics
currently are biofeedback, hypnosis, guided imagery, mindfulness, music therapy, and
yoga. (7)
Challenges in Mind-Body Medicine
New fields of medicine present unique challenges, and mind-body medicine is no excep-
tion. This broad, wide-ranging topic rarely is addressed in medical education. Mastery of
new skills is required, treatment is highly individualized, insurance reimbursement may
vary, colleagues may be skeptical, and pressure to prescribe medication rather than suggest
an unfamiliar therapy may deter physicians from recommending it.
Why is Mind-Body Medicine Important?
Mind-body therapies encourage children to become active participants in their care and are
low risk and cost-effective. They can be used as evidence-based alternatives to conventional
therapies if conventional treatments have undesirable adverse effects, as adjunct supportive
therapies, or as primary treatments in cases where they offer superior efficacy. Mind-body
therapies can provide powerful, noninvasive techniques to reduce fear, stress, and pain,
while building confidence, self-control, and resiliency. Mind-body therapies have been
used successfully in the treatment of children experiencing acute or chronic pain, anxiety
and stress, dysfunctional voiding, constipation and encopresis, sleep disorders, habit
disorders, attention-deficit/hyperactivity disorder (ADHD), asthma, obesity, diabetes,
inflammatory bowel disease, irritable bowel syndrome, and cancer. (7)
The Importance of Language in Mind-Body Medicine
Word choice can inadvertently increase fear and anxiety or convey calm, confident
encouragement. (8) Thoughtful language use is important in mind-body treatments. In
fact, skillful use of language in educating parents about mind-body modalities can
influence treatment outcomes. Studies show that parents, children, and clinicians all may
have preexisting expectations about which mind-body modalities are most likely to be
*Assistant Director of the Fellowship, Arizona Center for Integrative Medicine, University of Arizona Health Sciences Center,
Phoenix, AZ.
Pediatrics in Review Vol.32 No.5 May 2011 201
complementary medicine mind-body medicine
effective. It is important to be able to offer more than one
choice of therapy if the first suggestion does not meet
expectations. (9)
Stress Diagnosis in Children
Ideally, stress diagnosis and management would be in-
cluded in routine anticipatory guidance, and children
would learn self-regulatory skills from a very early age.
Nonjudgmental questions about stressors can provide an
opening to discuss the impact of stress on children’s
health as well as an opportunity to educate families about
the power of the mind-body connection.
In reality, however, stress is not discussed routinely in
health supervision visits, and even experienced practitio-
ners can find it challenging to diagnose pediatric stress
accurately, which often manifests as vague or confusing
physical or behavioral symptoms. Familiarity with com-
mon stress symptoms by age group and an elevated
degree of suspicion can be useful in helping to avoid
excessive medical testing. (10) The possibility of stressors
is important to consider in any pediatric evaluation when
symptoms do not make sense after a thorough history
and physical examination are complete.
In some cultures, succumbing to stress implies weak-
ness, making it harder to initiate a discussion on the
topic. Reluctance to discuss stressors can also be found in
cases of bullying, a prevalent, serious, and often hidden
cause of childhood stress. Mind-body therapies have
been shown to be helpful in certain patterns of bullying
and should be considered in the approach to this com-
plex and challenging problem. (11)(12)(13)(14)(15)
Selected Mind-Body Modalities: Best
Evidence in Children
Biofeedback
Biofeedback can be defined as the systematic process of
increasing awareness and control over various physical
functions by using instruments that provide immediate
feedback to the individual. Biofeedback is painless, and
child-friendly tools are available that use games and
appealing graphics to help children learn self-regulation
skills in an enjoyable process.
A recent survey of 43 accredited academic pediatric
anesthesia centers in the United States indicated that
biofeedback was the most frequently chosen therapy for
pain management in the 38 centers offering complemen-
tary or integrative therapies. (16)
The types of biofeedback used most commonly in
children are electromyography for reduction of muscle
tension, thermal biofeedback to promote vasodilation,
heart rate monitoring in regulation of heart rate variabil-
202 Pediatrics in Review Vol.32 No.5 May 2011
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ity, and neurofeedback using electroencephalography for
regulation of slow cortical potentials.
Although biofeedback has the potential for use in a
range of conditions, some of the strongest evidence
supporting this therapy is in children who have migraine
headaches, (17)(18)(19)(20) tension headaches, (21)
chronic pain, (22) dysfunctional voiding, (23)(24) con-
stipation, and recurrent abdominal pain. (25) Newer
research provides evidence of benefit with impulsivity in
ADHD. (26)(27)
Hypnosis
Clinical hypnosis is an especially powerful mind-body
therapy for children and has been described by Olness
and Gardner as “an altered state of consciousness, usually
involving relaxation, in which a person develops height-
ened concentration on a particular idea or image for the
purpose of maximizing potential in one or more areas.”
(28) An excellent hypnosis resource for the interested
practitioner is Olness and Kohen’s definitive text Hypno-
sis and Hypnotherapy with Children. (29)
A hypnosis session has six classic stages: introduction,
induction, deepening, therapeutic suggestions, awaken-
ing, and debriefing. Each session is unique to the indi-
vidual patient. (30) Children as young as 2 to 3 years of
age have been successfully taught self-hypnosis, which
often involves guided imagery and is facilitated by their
openness to storytelling, imagination, and fantasy.
A wealth of research supports the use of hypnosis in
pediatrics for a wide variety of conditions, including
acute and chronic pain, migraine, habit disorders, anxi-
ety, asthma, nausea and vomiting associated with cancer
treatment, insomnia, hypertension, and anxiety as well as
in preparation for surgery and other invasive procedures,
such as voiding cystourethrography and bone marrow
aspiration. (31)(32)(33)(34)(35)(36)(37)(38)
A 2005 survey of 43 pediatric anesthesia fellowship
programs in the United States indicated that 44% of the
38 responding institutions offered hypnosis as a treat-
ment therapy for pain. (16) Hypnosis has also been used
to reinforce health suggestions and reduce anxiety in the
routine pediatric office visit. (39) It is important to work
with fully certified hypnosis practitioners and consider
consultation with a mental health specialist for any child
who has a history of abuse or preexisting mental illness.
Music Therapy
Research exploring the science of music therapy is reveal-
ing the amazingly complex nature of the positive effect of
music on the neurohormonal and immune systems and
its links to pain perception and emotional processing.

(40)(41) The American Music Therapy Association de-
fines music therapy as the clinical and evidence-based use
of music interventions to accomplish individualized goals
within a therapeutic relationship by a credentialed pro-
fessional who has completed a music therapy program
degree.
A growing body of research in infants and children
demonstrates the efficacy of music therapy for reduction
of pain and anxiety in a variety of pediatric settings,
including neonatal intensive care units, procedure
rooms, emergency department waiting rooms, and in the
perioperative setting. (42)(43)(44)(45)(46)(47)(48)
Music therapy can be used alone or combined with other
mind body therapies.
Mindfulness
Mindfulness is the cultivation of awareness in the present
moment, regardless of ongoing events, and can be
adapted for use in children of a variety of ages who have
a wide range of conditions. Mindfulness is often linked to
breath work or body scanning exercises. Mindfulness
training has been shown to improve coping capacity, aid
in chronic pain management, and reduce anxiety and
depression. (6)(49)(50)(51)(52)(53)(54) Training in
mindfulness was offered by 21% of academic pediatric
anesthesia pain management services in the United States
surveyed for provision of complementary and alternative
medicine programs at their institutions. (16) Innovative
research exploring the potential of mindfulness training
on brain plasticity and neuronal allocation is ongoing.
Yoga
The word “yoga” comes from the Sanskrit root yuj,
which means “to join” or “to yoke”, and the practice is
based on the concept of bringing together mind, body,
and spirit. It is an ancient combination of breathing
exercises and postures used to increase mindfulness, im-
prove fitness and flexibility, and reduce stress. Yoga is
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complementary medicine mind-body medicine
versatile and can be adapted to many skill levels and age
groups in both inpatient and outpatient settings. Studies
show yoga’s beneficial effects in children who have
chronic pain, (55) asthma, (56)(57) irritable bowel syn-
drome, (58) and ADHD symptoms. (59)
Progressive Muscle Relaxation
Progressive muscle relaxation, a systematic tensing and
relaxing of muscle groups, is easy for children to master
and is often used with other mind-body therapies. Al-
though few studies have evaluated it as an isolated treat-
ment, progressive muscle relaxation has been used suc-
cessfully with other therapies in the treatment of chronic
pain, (36) asthma, depression, (60) migraine headache,
anxiety, and juvenile arthritis. (61)
Summary
• Mind-body therapies can add an important
dimension to pediatric care and allow practitioners
to offer gentle, effective, drug-free, and cost-
effective treatment options.
• Children of all ages can derive benefit from mind-
body therapies, which are used in a both inpatient
and outpatient settings.
• Some of the best-studied populations for mind-body
interventions are children who have chronic
conditions, such as pain, anxiety, arthritis, migraine
or tension headache, recurrent abdominal pain,
dysfunctional voiding, and cancer.
• Use of mind-body skills to mitigate caregiver stress
is an interesting area of emerging research that may
have important pediatric implications in the future.
• Many educational and training programs are
available in the field of mind-body medicine, some
of which are included in the resources section.
Note: To view the references for this article as well as
online resources, visit http://pedsinreview.
aappublications.org and click on the article title.
Pediatrics in Review Vol.32 No.5 May 2011 203
 Complementary, Holistic, and Integrative Medicine: Mind-Body Medicine
Hilary McClafferty
Pediatr. Rev. 2011;32;201-203
DOI: 10.1542/pir.32-5-201

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Ethics for the Pediatrician: Just Distribution of Health-care Resources and the
Neonatal ICU
Charles C. Camosy
Pediatr. Rev. 2011;32;204-207
DOI: 10.1542/pir.32-5-204

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
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ethics for the pediatrician
Author Disclosure
Dr Camosy has disclosed no financial
relationships relevant to this article.
This commentary does not contain a
discussion of an unapproved/
investigative use of a commercial
product/device.
204 Pediatrics in Review Vol.32 No.5 May 2011
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Just Distribution of Health-care
Resources and the Neonatal ICU
Charles C. Camosy, PhD*
Objectives After completing this article, readers should be able to:
1. Explore some implications of the finite nature of human beings (as exem-
plified by sickness and mortality) and of resources, both for medicine in
general and the neonatal intensive care unit (NICU) in particular.
2. Explain the refusal to discriminate on the basis of disability for even the
sickest members of the NICU population.
3. Show how taking cost into consideration, at both macro and clinical levels,
does not violate human dignity.
4. Respond to arguments that NICU care is among the most cost-effective in
medicine.
5. Suggest future strategies for combating a culture of overtreatment in the
NICU.
Introduction must not impair the quality of care
The debate over health-care reform delivered. Physicians must play an
in the United States brought discus- important role in establishing princi-
sions of “comprehensive health ben- ples of evidence-based medicine, val-
efits” and “cost containment mea- idating the measurements used, and
sures” to the dinner tables of average ensuring quality in any cost-
Americans. However, the American containment process. Responsibility
Academy of Pediatrics (AAP) faced for controlling costs should be a
this issue in 1998: (1) combined responsibility of employ-
“The American Academy of Pedi- ers, families, clinicians, payers, and
atrics (AAP) advocates universal and administrators of health care plans.”
insured financial access to quality Two additional points could ben-
health care for all newborns, infants, efit the the approach outlined by the
children, adolescents, young adults AAP. First, especially when discuss-
through age 21 years, and pregnant ing health-care financing, the disci-
women . . . Such insurance should pline of pediatrics should not imag-
provide a comprehensive benefit ine itself in an isolated vacuum,
package that should include, but not somehow disconnected from other
be limited to, pregnancy related ser- areas of medicine and concerns about
vices, preventive care services recom-
human flourishing more generally.
mended by the AAP, acute and
Second, although some cost contain-
chronic care services, and emergency
ment measures do not hurt quality of
care services.”
care (and may even help it), we must
In this same statement, the AAP
nevertheless face the tragic fact of
acknowledged that:
virtually unlimited health needs (we
“Cost containment is essential but
are all going to die some day, after
all) competing with limited health-
*Department of Theology, Fordham University, care resources. We simply cannot
Bronx, NY. provide as much of the best health

care we wish to every patient who
needs it. Rationing is part of the hu-
man condition. Although every as-
pect of medicine should take this fact
more seriously, this article briefly ex-
plores the issues in the context of
neonatology (see Camosy (2) for a
more detailed argument).
The Moral Status of
Neonates
For many, rationing conjures up im-
ages of “death panels” that decide
which lives are fit to live and which
are not. This concern is not without
reason. Some NICUs that would like
to limit care explicitly claim that not
every member of the population has a
life worth living, and some, such as
Princeton’s Peter Singer, even argue
that they are nonpersons. (3) The
argument is set forth that the limited
health-care resources should be
spent only on persons who have lives
worth living. The AAP, however,
could not accept this argument. The
organization’s past refusal to support
taking organs from anencephalic in-
fants is evidence of a belief that even
the most brain-damaged infant is a
person who has rights. Further, AAP
policies specifically forbid discrimina-
tion on the basis of disability, (4)
which rules out claims that certain
disabilities constitute a life that is not
worth living.
Some claim that rationing is off
the table once we admit that all pa-
tients, even the very sickest NICU
infants, have full moral status. Ra-
tioning would violate the dignity and
right to equal care and respect that all
persons deserve. However, although
all patients should be treated equally,
I argue that it is precisely this right
that necessitates rationing of care.
For although a person’s dignity is not
violated by refusing him or her a
disproportionately large share of
community resources, giving some-
one just such a share does violate
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the right to equal treatment of those
left with a disproportionately small
share.
Taking Cost into
Consideration
Explicit cost consideration is obvious
in the context of federal or state gov-
ernments working with fixed bud-
gets to cover their Medicare/
Medicaid populations. Indeed, the
Department of Health and Human
Services decides not only what will be
covered, but in issuing the Center for
Medicare & Medicaid Services
(CMS) rate, it decides how much will
be covered. Private insurance compa-
nies also use the CMS number as a
baseline to determine their own re-
imbursement rates and until recently,
used preexisting conditions, ability
to pay, and lifetime limits to ration
care themselves.
However, a person could accept
this argument and still object to cli-
nicians being forced to consider
these facts. Should not the clinician’s
only concern be the patient in front
of him or her? Edmund Pellegrino (5)
says:
“The physician is then bound by a
covenant of trust which must not be
compromised by other roles of, for
example, the physician as gatekeeper,
entrepreneur, guardian of social re-
sources, or by the economic pres-
sures to undertreat . . . The welfare
of the patient, jointly determined be-
tween physician and patient or pa-
tient’s morally valid surrogate must
continue to be the end of medicine in
the clinical encounter and first in the
order of priorities for the physician’s
role.”
Although this is a good rule of
thumb, an absolute prohibition plays
into the anthropologic myth that hu-
mans can act in total isolation from
each other. Is a triage medic acting
against the “end of medicine” when
putting the care of one very seriously
ethics for the pediatrician
ill patient ahead of another who is
less seriously ill? What about a family
practice physician who refuses to pre-
scribe antibiotics that would benefit a
patient but might harm society at
large by helping to create drug-
resistant diseases? Insofar as clinicians
make medical decisions that have ef-
fects beyond the isolated physician-
patient relationship, they should not
be prohibited absolutely from taking
into account external considerations.
Why Pick on the NICU?
Even if accepting the argument to
this point, why take the approach of
the United Kingdom’s Nuffield
Council on Bioethics? (6)
“There is now much broader pub-
lic awareness of the need for difficult
choices to be made by the providers
of national healthcare. . . . Conten-
tiously, this has caused questioning
of whether funds spent on resuscitat-
ing or prolonging the life of babies
where the prognosis is very poor are
spent appropriately.”
Should we not instead follow the
lead of John Lantos and William
Meadow, (7) who claim that neona-
tal treatment and care is cost-
effective and that rationing should be
directed elsewhere? After all, if a baby
survives the NICU, then any added
years of life are, on the average, much
greater than those associated with
the care offered by other types of
medicine. Further, very few bed days
are given to nonsurvivors because
most NICU patients who die do so
quickly. Thus, NICU care looks like
a good investment of health-care
dollars.
Although the de facto rationing
situation in which clinicians find
themselves certainly applies to other
areas of medicine, this perspective
does not give a reason to spend re-
sources disproportionately in the
NICU. In response to Lantos and
Meadow, it must be pointed out that
Pediatrics in Review Vol.32 No.5 May 2011 205
ethics for the pediatrician
Medicaid and other community re-
sources are almost never limited to
what is spent in the NICU. As the
Nuffield Council says, “Economic
studies of premature birth and low
birthweight have tended to overlook
the costs, for example, of day-care
services and respite care, as well as
those borne by the local authorities,
voluntary organizations and by fam-
ilies as a result of modifications of
their everyday activities.” (6) It is
notoriously difficult to estimate the
costs of these treatments and services
over time, but the Nuffield Council
cited an EPICure study that looked
at spending (in pounds) over 12
months at age 6, comparing the cost
for extremely low-birthweight chil-
dren with that of a control group of
term infants (Table). These numbers
are even more striking when consid-
ered in total over the entire life of the
patient. Consider the case of “Baby
Sidney,” who was the subject of the
important HCA v. Miller case in
Houston, Texas, in 1998. Sidney’s
parents decided that they would not
resuscitate her after she was born, but
the hospital did so anyway. After
winning a lawsuit, the jury awarded
“reasonable expenses of necessary
medical which, in reasonable proba-
bility, SIDNEY MILLER will incur
in the future” at a whopping
Spending Over 12 Months for 6-year-old
Table.
Children
Cost Category
Hospital Inpatient
Hospital Outpatient
Community Health
Drug Cost
Education
Additional Family Expenses
Indirect Costs
Data from Nuffield Council on Bioethics. (6)
206 Pediatrics in Review Vol.32 No.5 May 2011
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$28,500,000. Claims about the cost-
effectiveness of NICU care must
consider long-term follow-up care.
Although extremely low-birthweight
infants are rare within the context of
total live births, it is unclear how this
should be considered when deciding
whether to incorporate cost into the
treatment of such patients. Whether
we should spend $30 million of com-
munity money on patients such as
Sidney, for example, has almost
nothing to do with how frequently
(or not) her medical condition oc-
curs.
Some Tentative Conclusions
Both the Nuffield Council and Lan-
tos and Meadow acknowledge that
we have a long way to go before we
could ever have a public policy that
would take into account these long-
term considerations. Acceptably ac-
curate prognoses may loom as the
next frontier in neonatal medicine,
but until then, caution must guide
us. There remain important points to
take into consideration within the
central argument of this article.
Some factors appear to lead to dis-
proportionate spending in the
NICU:
1. The perspective of parents who,
regardless of the situation, “want ev-
erything done,” often based on a
Cost for Extremely
Low-birthweight Cost for
Child Term Child
£605 £116
£255 £53
£422 £104
£10 £3
£7,620 £3,470
£573 £120
£56 £17
Summary
• Human beings have virtually
unlimited health-care needs
and limited health-care
resources. The question is not if
we will ration, but what kind of
rationing we will do.
• Even the most brain-damaged
or sick patient is a person who
deserves to be treated the same
as any other patient. It is never
acceptable to aim at the death
of a person because his or her
disability makes life “not worth
living.”
• Taking cost into a consideration
does not violate the rights of a
person. Indeed, the right to
equal treatment may require
explicit steps to avoid a
disproportionately small share
of community health-care
resources going to certain
individuals.
• The data show that NICU
treatment is among the most
expensive in the health-care
system, especially when
including the costs over a
patient’s lifetime.
• The data show that although
the technology is not available
to make acceptably accurate
long-term prognoses in
neonates, several important
approaches can be undertaken
to combat disproportionate
spending in the NICU.
misunderstanding of the Christian
tradition on withdrawal and refusal
of treatment. (2)
2. Institutionalization of NICU
treatments in which “doctors act like
doctors” and “nurses act like
nurses.” Health-care professionals
are often viewed simply as organic
plumbers who are neither trained nor
encouraged to take broader goods
into consideration. (8) Of note, re-
cent moves toward family-centered
and palliative care have moved the
focus of the attention in a better di-
 ethics for the pediatrician

rection, but not far enough to con-
sider broader community concerns.
3. Prestige and ego. Some neona-
tologists (including the acclaimed fa-
ther of neonatology) admit that this
factor is a motivation in some cases of
overtreatment. (9)
4. Indirect and direct application
of the law. Many wrongly believe that
Baby Doe regulations demand more
than what is actually required. (10)
5. Profitability. The market and
CMS rates help to contribute to a
culture of disproportionate spend-
ing. Many hospitals are building
NICUs because of this profitability.
Lantos and Meadow (11) make this
argument in some detail. For exam-
ple, they cite a study that showed that
from 1980 to 1995 the number of
hospitals grew by 99%, the number
of NICU beds by 138%, and the
number of neonatologists by 268%.
By contrast, the growth in needed
NICU bed days was only 84%.
If clinicians accept the central ar-
gument of this article and its applica-
bility to the NICU, attacking the
previously cited problems is a good
starting point.
References
1. American Academy of Pediatrics Com-
mittee on Child Health Care Financing.
Principles of child health care financing.
Pediatrics. 1988;102:994 –995
2. Camosy C. Too Expensive to Treat?—
Finitude, Tragedy, and the Neonatal ICU.
Grand Rapids, MI: Wm. B. Eerdmans Press;
2010
3. Camosy C. Common ground on surgical
abortion?—Engaging Peter Singer on the
moral status of potential persons. J Med
Philos. 2009;33:577–593
4. American Academy of Pediatrics Com-
mittee on Pediatric Workforce. Nondis-
crimination in pediatric health care. Pediat-
rics. 2007;120:922
5. Pellegrino E. The goals and ends of med-
icine: how are they to be defined? In: Han-
son MJ, Callahan D, eds. The Goals of Med-
icine: The Forgotten Issue in Health Care
Reform. Washington, DC: Georgetown
University Press; 1999:55– 68
6. Nuffield Council on Bioethics. Critical
Care Issues in Fetal and Neonatal Medicine:
Ethical Issues. London, United Kingdom:
Nuffield Council on Bioethics; 2006. Ac-
cessed February 2011 at: http://www.
nuffieldbioethics.org/sites/default/files/
CCD%20web%20version%2022%20June%
2007%20(updated).pdf
7. Lantos J, Meadow W. Changes in mor-
tality for extremely low birth weight infants
in the 1990s: implications for treatment de-
cisions and resource use. Pediatrics. 2004;
113:1226
8. Guillemin JH, Holmstrom LL. The
sanctity of newborn life: aggressive inter-
vention. In: Mixed Blessings: Intensive Care
for Newborns. New York, NY: Oxford Uni-
versity Press; 1986: 114 –115
9. Silverman WA. Overtreatment of neo-
nates? A personal retrospective. Pediatrics.
1992;90:971
10. Stanley JM. The Appleton Consensus:
Suggested International Guidelines for Deci-
sions to Forego Medical Treatment. Vol. 15.
London, United Kingdom: British Medical
Association; 1989:129
11. Lantos J, Meadow W. Neonatal Bioeth-
ics. Baltimore, MD: Johns Hopkins Univer-
sity Press; 2006: 31, 131

Correction
In the article entitled “Sacral Dimples” in the March issue (Pediatr Rev. 2011;32:109 –
114), Figure 1 inadvertently contains the wrong picture. The image in this correction
should be substituted, and the caption should read, “Solitary dimple whose location
greater than 2.5 cm above the anus indicated the need for further evaluation, which
revealed an occult spinal dysraphism requiring neurosurgical intervention.” Also, Figures
2A and 4 of the same article are published through the courtesy of Janelle Aby, MD. We
regret the error.

Pediatrics in Review Vol.32 No.5 May 2011 207

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Ethics for the Pediatrician: Just Distribution of Health-care Resources and the
Neonatal ICU
Charles C. Camosy
Pediatr. Rev. 2011;32;204-207
DOI: 10.1542/pir.32-5-204

Updated Information including high-resolution figures, can be found at:

& Services http://pedsinreview.aappublications.org/cgi/content/full/32/5/204

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Visual Diagnosis: Sore Throat and Difficulty Swallowing in a 9-year-old Boy
Nirav Shastri, Gretchen Black and Milton A. Fowler, Jr
Pediatr. Rev. 2011;32;215-217
DOI: 10.1542/pir.32-5-215

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

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 visual diagnosis

Sore Throat and Difficulty

Swallowing in a 9-year-old Boy
Nirav Shastri, MD, FAAP,* Gretchen Black, DO,*
Milton A. Fowler, Jr, MD, FACEP†

Presentation
A 9-year-old boy presents with sore throat and difficulty
swallowing of 3 days’ duration. He was seen at a clinic on
the first day of his illness, where the result of a rapid
streptococcal antigen test was negative. He was dis-
charged with a diagnosis of sore throat with cough and
prescribed a 5-day course of azithromycin and a 3-day
course of prednisolone suspension. However, his sore
throat has persisted and his dysphagia has worsened. His
mother is seeking further medical attention because she
has noted the roof of his mouth to be red and swollen
posteriorly. The boy describes a feeling that “something
is stuck in my throat” but still can swallow. Dysphagia
occurs with both solids and liquid foods.
On physical examination, his vital signs are within
normal limits; there is no fever or respiratory distress.
Examination of the pharynx reveals an erythematous,
swollen uvula (Fig. 1). He has no drooling, cervical
lymphadenopathy, or erythema or exudate on his pha-
ryngeal wall. No other abnormality is noted. He has
taken three doses of azithromycin and two doses of
prednisolone.
The boy had croup last winter, has occasional nasal
symptoms due to seasonal allergies, and underwent ton-
sillectomy with adenoidectomy 2 years ago for repeated
ear infections. His immunizations are up to date. He has
had no ill contacts.
Figure 1. Erythematous, swollen uvula. Diagnosis is made on clinical findings.

Author Disclosure
Drs Shastri, Black, and Fowler have disclosed no financial
relationships relevant to this article. This commentary does
not contain a discussion of an unapproved/investigative
use of a commercial product/device.

*Assistant Professor of Pediatrics, University of Missouri, Kansas City, MO; Children’s Mercy South Urgent Care Center, Overland Park, KS.
†
University of Missouri, Kansas City, MO; Section Chief, Children’s Mercy South Urgent Care Center, Overland Park, KS.

Pediatrics in Review Vol.32 No.5 May 2011 215

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visual diagnosis
Figure 2. Neck radiograph documenting a lack of epiglottitis.
Eⴝesophagus, Uⴝuvula.
Diagnosis: Uvulitis
The diagnosis of uvulitis is based on the complaints of a
sore throat with dysphagia; the presence of a red, swollen
uvula; and the absence of physical findings suggestive of
other causes of sore throat and dysphagia, such as retro-
pharyngeal abscess or peritonsillar abscess.
Discussion
Uvulitis is defined as inflammation of the uvula and
typically presents with marked uvular edema and ery-
thema. (1) The condition most commonly results from
cellulitis due to infection by group A Streptococcus in
children 5 to 15 years of age. Among unimmunized
children younger than 5 years of age, Haemophilus influ-
enzae type b (Hib) is the next most common bacterial
cause. (1)(2)(3) Other reported pathogens include Fuso-
bacterium nucleatum, Prevotella, and Streptococcus pneu-
moniae. (4) Uvulitis can also be caused by viral infections
due to coxsackievirus, herpes simplex virus, and varicella-
zoster virus and by fungal infection due to Candida
albicans. Noninfectious causes of uvulitis include trauma
during instrumentation (eg, intubation), inhalation of
chemical irritants (eg, cannabis), inhalation of steam, and
vasculitis. (5)(6)
Presentation
Uvulitis usually presents with fever, sore throat, dyspha-
gia, drooling, and respiratory distress. Significant respi-
ratory distress is uncommon unless there is an associated
216 Pediatrics in Review Vol.32 No.5 May 2011
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epiglottitis or if the uvulitis is due to a noninfectious
cause such as a chemical irritant. Diagnosis is based on
clinical characteristics alone in the absence of other find-
ings. However, if respiratory distress is present or if an
adequate examination of the oropharynx cannot be per-
formed, imaging is essential to rule out epiglottitis or
retropharyngeal abscess. (2) Blood and throat cultures
may help to identify an infectious cause.
Differential Diagnosis
The most common differential diagnosis for uvulitis is
streptococcal pharyngitis, which presents with pharyn-
geal edema and erythema with tonsillar exudates and
palatal petechiae. Other potential diagnoses include ret-
ropharyngeal and peritonsillar abscesses and epiglottitis.
Retropharyngeal abscesses present with swelling of the
pharyngeal wall; peritonsillar abscesses manifest with
tonsillar swelling and deviation of the uvula. Both may
present with signs of upper airway obstruction and lim-
ited ability to open the mouth adequately for examina-
tion. Epiglottitis presents with fever, drooling, stridor,
anxiety, and rapid progression of upper airway obstruc-
tion.
Management
Treatment should be decided on a case-by-case basis and
directed at the most likely pathogens that cause age-
associated symptoms (pharyngitis or epiglottitis) and
local antimicrobial susceptibility data. Many children can
be treated as outpatients. If group A Streptococcus is
isolated or suspected on the basis of associated pharyn-
gitis, oral therapy with penicillin or amoxicillin is appro-
priate. The initial treatment of isolated uvulitis without
evidence of pharyngitis or epiglottitis or uvulitis with
epiglottitis consists of empiric antimicrobial treatment,
such as a third-generation cephalosporin (eg, ceftriax-
one) to provide coverage for typical pathogens such as
Hib and S pneumoniae, which may produce beta-
lactamase or be resistant to penicillin, respectively. Once
blood cultures are negative, changing to an oral antibi-
otic such as amoxicillin-clavulanate or an oral cephalo-
sporin such as cefuroxime or cefdinir is appropriate to
continue treatment for a possible bacterial uvulitis. Non-
infectious causes of uvulitis can be treated with conser-
vative supportive care. Evidence to support the role of
corticosteroid therapy in the management of uvulitis is
not apparent in the medical literature.
Patient Course
The patient was admitted for 1 day for observation.
Testing showed a white blood cell count of 12.0⫻103/␮L

Summary
• Uvulitis is an infrequently recognized pediatric
condition.
• The diagnosis should be considered for the patient
who presents with a sore throat, dysphagia, and an
erythematous, edematous uvula in the absence of
other, more serious disorders such as retropharyngeal
or peritonsillar abscess.
(12.0⫻109/L) with 65% neutrophils, 26% lymphocytes,
and 7.8% monocytes. His hemoglobin measured
12.8 g/dL (128 g/L), hematocrit was 36.5% (0.365),
and platelet count was 295⫻103/␮L (295⫻109/L).
Neck radiographs did not show any evidence of epiglot-
titis (Fig. 2). He received intravenous ampicillin-
sulbactam at 200 mg/kg per day in four divided doses
and dexamethasone 0.5 mg/kg for three doses every
8 hours after an otolaryngology consultation. His blood
and throat cultures were negative. He was able to eat and
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visual diagnosis
drink without difficulty, and he did not have any oxygen
desaturations or fever throughout his inpatient stay. He
was discharged on the second inpatient day receiving oral
amoxicillin-clavulanic acid 500 mg twice a day for
10 days for presumed bacterial uvulitis.
References
1. Woods CR. Clinical features and treatment of uvulitis in chil-
dren and adolescents. UptoDate Online 18.3. 2010
2. McNamara RM. Clinical characteristics of acute uvulitis. Am J
Emerg Med. 1994;12:51–52
3. Wynder SG, Lampe RM, Shoemaker ME. Uvulitis and Haemo-
philus influenzae b bacteremia. Pediatr Emerg Care. 1986;2:23–25
4. Brook I. Uvulitis caused by anaerobic bacteria. Pediatr Emerg
Care. 1997;13:221
5. Holden JP, Vaughan WC, Brock-Utne JG. Airway complication
following functional endoscopic sinus surgery. J Clin Anesth. 2002;
14:154 –157
6. Boyce SH, Quigley MA. Uvulitis and partial upper airway ob-
struction following cannabis inhalation. Emerg Med. 2002;14:
106 –108
Pediatrics in Review Vol.32 No.5 May 2011 217
 Visual Diagnosis: Sore Throat and Difficulty Swallowing in a 9-year-old Boy
Nirav Shastri, Gretchen Black and Milton A. Fowler, Jr
Pediatr. Rev. 2011;32;215-217
DOI: 10.1542/pir.32-5-215

Updated Information including high-resolution figures, can be found at:

& Services http://pedsinreview.aappublications.org/cgi/content/full/32/5/215

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 Correction
Pediatr. Rev. 2011;32;207
DOI: 10.1542/pir.32-5-207

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/cgi/content/full/32/5/207

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

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 ethics for the pediatrician

rection, but not far enough to con-
sider broader community concerns.
3. Prestige and ego. Some neona-
tologists (including the acclaimed fa-
ther of neonatology) admit that this
factor is a motivation in some cases of
overtreatment. (9)
4. Indirect and direct application
of the law. Many wrongly believe that
Baby Doe regulations demand more
than what is actually required. (10)
5. Profitability. The market and
CMS rates help to contribute to a
culture of disproportionate spend-
ing. Many hospitals are building
NICUs because of this profitability.
Lantos and Meadow (11) make this
argument in some detail. For exam-
ple, they cite a study that showed that
from 1980 to 1995 the number of
hospitals grew by 99%, the number
of NICU beds by 138%, and the
number of neonatologists by 268%.
By contrast, the growth in needed
NICU bed days was only 84%.
If clinicians accept the central ar-
gument of this article and its applica-
bility to the NICU, attacking the
previously cited problems is a good
starting point.
References
1. American Academy of Pediatrics Com-
mittee on Child Health Care Financing.
Principles of child health care financing.
Pediatrics. 1988;102:994 –995
2. Camosy C. Too Expensive to Treat?—
Finitude, Tragedy, and the Neonatal ICU.
Grand Rapids, MI: Wm. B. Eerdmans Press;
2010
3. Camosy C. Common ground on surgical
abortion?—Engaging Peter Singer on the
moral status of potential persons. J Med
Philos. 2009;33:577–593
4. American Academy of Pediatrics Com-
mittee on Pediatric Workforce. Nondis-
crimination in pediatric health care. Pediat-
rics. 2007;120:922
5. Pellegrino E. The goals and ends of med-
icine: how are they to be defined? In: Han-
son MJ, Callahan D, eds. The Goals of Med-
icine: The Forgotten Issue in Health Care
Reform. Washington, DC: Georgetown
University Press; 1999:55– 68
6. Nuffield Council on Bioethics. Critical
Care Issues in Fetal and Neonatal Medicine:
Ethical Issues. London, United Kingdom:
Nuffield Council on Bioethics; 2006. Ac-
cessed February 2011 at: http://www.
nuffieldbioethics.org/sites/default/files/
CCD%20web%20version%2022%20June%
2007%20(updated).pdf
7. Lantos J, Meadow W. Changes in mor-
tality for extremely low birth weight infants
in the 1990s: implications for treatment de-
cisions and resource use. Pediatrics. 2004;
113:1226
8. Guillemin JH, Holmstrom LL. The
sanctity of newborn life: aggressive inter-
vention. In: Mixed Blessings: Intensive Care
for Newborns. New York, NY: Oxford Uni-
versity Press; 1986: 114 –115
9. Silverman WA. Overtreatment of neo-
nates? A personal retrospective. Pediatrics.
1992;90:971
10. Stanley JM. The Appleton Consensus:
Suggested International Guidelines for Deci-
sions to Forego Medical Treatment. Vol. 15.
London, United Kingdom: British Medical
Association; 1989:129
11. Lantos J, Meadow W. Neonatal Bioeth-
ics. Baltimore, MD: Johns Hopkins Univer-
sity Press; 2006: 31, 131

Correction
In the article entitled “Sacral Dimples” in the March issue (Pediatr Rev. 2011;32:109 –
114), Figure 1 inadvertently contains the wrong picture. The image in this correction
should be substituted, and the caption should read, “Solitary dimple whose location
greater than 2.5 cm above the anus indicated the need for further evaluation, which
revealed an occult spinal dysraphism requiring neurosurgical intervention.” Also, Figures
2A and 4 of the same article are published through the courtesy of Janelle Aby, MD. We
regret the error.

Pediatrics in Review Vol.32 No.5 May 2011 207

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 Correction
Pediatr. Rev. 2011;32;207
DOI: 10.1542/pir.32-5-207

Updated Information including high-resolution figures, can be found at:

& Services http://pedsinreview.aappublications.org/cgi/content/full/32/5/207

Permissions & Licensing Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
http://pedsinreview.aappublications.org/misc/Permissions.shtml
Reprints Information about ordering reprints can be found online:
http://pedsinreview.aappublications.org/misc/reprints.shtml

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 Index of Suspicion • Case 1: Abdominal Pain and Coffee Ground Emesis in a
9-year-old Boy • Case 2: Vomiting, Headache, and Seizures in a 7-year-old Boy •
Case 3: Primary Amenorrhea in a 15-year-old Girl
Thomas C. Martin, Joshua M. Careskey, Heather Harle, Sean Rose, Howard P.
Goodkin, Rachel Dawson and Shana Hansen
Pediatr. Rev. 2011;32;209-214
DOI: 10.1542/pir.32-5-209

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/cgi/content/full/32/5/209

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

Downloaded from http://pedsinreview.aappublications.org. Provided by Health Internetwork on May 2, 2011


The reader is encouraged to write
possible diagnoses for each case before
turning to the discussion.
The editors and staff of Pediatrics in
Review find themselves in the
fortunate position of having too
many submissions for the Index of
Suspicion column. Our publication
slots for Index of Suspicion are filled
through 2013. Because we do not
think it is fair to delay publication
longer than that, we have decided
not to accept new cases for the
present. We will make an
announcement in Pediatrics in
Review when we resume accepting
new cases. We apologize for having
to take this step, but we wish to be
fair to all authors. We are grateful
for your interest in the journal.
Author Disclosure
Drs Martin, Careskey, Harle, Rose,
Goodkin, Dawson, and Hansen have
disclosed no financial relationships
relevant to these cases. This
commentary does not contain a
discussion of an unapproved/
investigative use of a commercial
product/device.
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Case 1: Abdominal Pain and Coffee Ground Emesis
in a 9-year-old Boy
Case 2: Vomiting, Headache, and Seizures
in a 7-year-old Boy
Case 3: Primary Amenorrhea in a 15-year-old Girl
Case 1 Presentation
A 9-year-old boy presents to the ED
with severe abdominal pain and vom-
iting. He has no history of diarrhea,
fever, chills, rash, trauma, arthralgia,
or headache. He has no prior history
of gastrointestinal complaints or
other chronic illnesses. He cannot
tolerate clear liquids and is admitted
for observation. He vomits coffee
ground material and then blood.
On physical examination, his tem-
perature is 38.5°C, heart rate is
140 beats/min, blood pressure is
123/83 mm Hg, and respiratory rate
is 24 breaths/min. He is uncomfort-
able and diaphoretic. He has tachy-
cardia, but his cardiopulmonary ex-
amination results are normal
otherwise. He has generalized ab-
dominal tenderness, with guarding
and rebound tenderness most pro-
nounced in the periumbilical region
and extending to the right lower
quadrant. Hip abduction elicits pain.
CBC documents a normal Hgb
value and platelet and leukocyte
counts, with a left shift and 78% neu-
trophils. Urinalysis shows moderate
blood and trace proteinuria, with 2
RBCs per high-power field. The
chest radiograph appears normal.
The abdominal radiograph shows a
few mildly distended small bowel
loops but no radiographic evidence
of obstruction. CT scan of the abdo-
men leads to exploratory laparoscopy
and the correct diagnosis.
Case 2 Presentation
A 7-year-old developmentally appro-
priate boy presents to the ED with a
index of suspicion
3-day history of forceful vomiting,
headache, and reduced oral intake.
Several times after vomiting, he had
complained of numbness in his hands
and feet that lasted several seconds.
Two hours after receiving a dose of
promethazine prescribed by his pedi-
atrician, he could not be aroused by
his parents.
On arrival at the ED by ambu-
lance, he is initially sleepy and con-
fused. He is afebrile. His blood pres-
sure is 99/74 mm Hg, heart rate is
89 beats/min, and oxygen saturation
is 98% in room air. He has no dys-
morphic features and no skin find-
ings. His funduscopic findings and
extraocular movements are normal.
There is a left homonymous hemi-
anopsia. He has difficulty moving his
left upper extremity that is more pro-
nounced distally. He has decreased
sensation to light touch and pin prick
in the left upper extremity. His re-
flexes are symmetric, but the left toe
is upgoing.
Laboratory evaluation, including
CBC, serum electrolytes, ESR,
C-reactive protein, antinuclear anti-
bodies, liver function tests, and CSF
analysis, yields normal results. Re-
sults of a noncontrast cranial CT scan
are within normal limits.
The following day, the boy has
multiple brief seizures characterized
by left gaze version, behavioral ar-
rest, and clonic movements of the left
hand. Benzodiazepines, fospheny-
toin loading, and rapid titration of
oxcarbazepine are necessary to ob-
tain control of these events. EEG
shows generalized slowing of the
background and focal slowing over
Pediatrics in Review Vol.32 No.5 May 2011 209
index of suspicion

the right hemisphere. Additional im-

aging studies reveal the diagnosis.

Case 3 Presentation
When a 15-year-old girl presents for
evaluation of pectus excavatum, she
reports that she has never had a men-
strual period. Pubarche and the-
larche occurred at ages 13 and 14
years, respectively. She denies any
sexual activity, medication use, or
substance abuse and has had no re-
cent weight changes, heat or cold
intolerance, constipation, skin or hair
problems, vision difficulties, or head-
aches. She does report infrequent
lower abdominal cramping. Past
medical history includes a urinary
tract infection as an infant and subse-
quent diagnosis of a single kidney
and pectus excavatum. Her father has
pectus excavatum, and her mother
was found to have a brain aneurysm
at 42 years of age.
On physical examination, the
girl’s height is at the 40th percentile,
weight is at the 33rd percentile, body
Frequently Used Abbreviations
ALT: alanine aminotransferase
AST: aspartate aminotransferase
BUN: blood urea nitrogen
CBC: complete blood count
CNS: central nervous system
CSF: cerebrospinal fluid
CT: computed tomography
ECG: electrocardiography
ED: emergency department
EEG: electroencephalography
ESR: erythrocyte sedimentation
rate
GI: gastrointestinal
GU: genitourinary
Hct: hematocrit
Hgb: hemoglobin
MRI: magnetic resonance imaging
WBC: white blood cell
Figure 1. Axial image from CT scan showing a dilated loop of small bowel with
increased wall thickness and surrounding soft-tissue edema.
mass index is at the 30th percentile,
blood pressure is 107/65 mm Hg,
and heart rate is 81 beats/min. Her
skin is normal and without any ab-
normal hair pattern or hirsutism. Her
palate is high-arched, with mandibu-
lar dental crowding. She has pectus
excavatum. Her breasts are at Sexual
Maturity Rating 3 and appear nor-
mal. External genitalia appear nor-
mal, with moist, pink mucosa. A little
finger can be passed 3 cm into the
vagina. She reports discomfort with
manual examination, and further ex-
amination is deferred.
On laboratory evaluation, serum
electrolytes, BUN, creatinine, glu-
cose, follicle-stimulating hormone,
luteinizing hormone, prolactin, free
thyroxine, thyroid-stimulating hor-
mone, and estradiol results are within
normal limits for age. Imaging stud-
ies identify the cause of her amenor-
rhea.
Case 1 Discussion
CT scan without contrast revealed a
dilated loop of small bowel with wall
thickening and surrounding edema
located anteriorly in the midline (Fig.
1). There was excess free fluid in the
abdomen. The differential diagnosis
of acute abdominal pain with these
abnormal CT findings includes ap-
pendicitis, volvulus, enteric duplica-
tion cyst, intussusception, inflamma-
tory bowel disease, and abscess.
Following blood and urine cul-
tures, the boy was placed on nothing
by mouth and started on intravenous
(IV) fluids at 11⁄2 times maintenance.
IV lansoprazole, metronidazole, and
cefotaxime also were initiated, and
his pain was controlled by morphine
as needed. Following evaluation by a
pediatric surgeon, exploratory lapa-
roscopy was recommended. The lap-
aroscopy showed dilated loops of
ischemic small bowel (Fig. 2). The
procedure was converted to a lapa-
rotomy, which revealed a Meckel di-
verticulum connected by a fibrous
adhesive band to the mesentery. An
internal hernia was present, and ap-
proximately 2 ft of bowel had
herniated through this space, result-
ing in ischemia. The adhesive band
was divided. Approximately 23 in
(58 cm) of small bowel between the

210 Pediatrics in Review Vol.32 No.5 May 2011

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Figure 2. A photograph from the initial
exploratory laparoscopic procedure
showing dusky, dilated loops of bowel.
Meckel diverticulum and the termi-
nal ileum was resected, and an
end-to-end ileoileostomy was per-
formed. The boy had an uneventful
recovery.
Differential Diagnosis
Vomiting and abdominal pain are
common symptoms in childhood.
The causes may range from func-
tional abdominal pain or viral gastro-
enteritis to abdominal abscess or
ischemic bowel. The initial approach
is to consider common, self-limited
causes and provide symptomatic re-
lief and oral rehydration therapy. The
use of IV fluids may be considered if
oral rehydration therapy is not toler-
ated. Antiemetic, opioid analgesic,
and sedative medications are not
needed for the self-limited causes of
abdominal pain and vomiting.
If abdominal pain and vomiting
fail to improve with symptomatic
treatment, additional assessment is
indicated. A chemistry panel may be
useful in documenting hydration sta-
tus and electrolyte abnormalities.
A CBC may provide useful informa-
tion regarding infection or other sys-
temic diseases. A urinalysis can help
assess hydration status and rule out a
urinary tract infection. Finally, bil-
ious emesis in a neonate, infant, or
child is never normal and should be
evaluated promptly for potential me-
chanical bowel obstruction, such as
intestinal malrotation with midgut
volvulus.
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Imaging studies have assumed an
increasing role in the assessment of
abdominal complaints in children.
An abdominal radiograph may be
helpful in assessing for the presence
of bowel obstruction or perforation.
Abdominal ultrasonography is useful
for diagnosing some age-specific
causes of vomiting, such as pyloric
stenosis or appendicitis, but accuracy
is largely operator-dependent. In the
absence of a clear clinical diagnosis,
CT scans are used widely as an ad-
junctive diagnostic tool for evaluat-
ing severe or persistent abdominal
pain with vomiting. The use of con-
trast makes the CT scan sensitive and
specific for diseases such as appendi-
citis and abdominal abscess. MRI has
some advantages in terms of soft-
tissue imaging compared with CT
scan, but the lack of availability, need
for sedation, and added time for im-
aging make MRI less attractive than
CT scan.
The Condition
Meckel diverticulum is a vestigial
remnant of the omphalomesenteric
duct located on the antimesenteric
border in the terminal ileum that oc-
curs in about 2% of the general pop-
ulation. The diverticulum is about
2 in long, is present in twice as many
boys as girls, and is located within 2 ft
of the ileocecal valve. Most Meckel
diverticula are asymptomatic.
The most common clinical mani-
festation is painless acute lower gas-
trointestinal bleeding (eg, hemato-
chezia) caused by ectopic gastric
mucosa in the diverticulum. Sixty
percent of patients present before the
age of 2 years. A Meckel scan (99m
technetium pertechnetate, which has
affinity for gastric mucosa) may help
make the diagnosis in the 50% of
diverticula that contain gastric tissue.
A Meckel diverticulum in older chil-
dren may present with diverticulitis,
perforation, bowel obstruction, vol-
index of suspicion
vulus, or intussusception. Symptom-
atic Meckel diverticula should be re-
sected. Whether an asymptomatic
Meckel diverticulum discovered in
older children or adults should be
resected remains controversial.
In this case, the bowel was dam-
aged by the ischemia that resulted
from trapping of small intestine in a
space created by a band of tissue that
was attached to the diverticulum.
Lessons for the Clinician
● Meckel diverticulum is an uncom-
mon pediatric condition most of-
ten presenting with painless hema-
tochezia.
● Meckel diverticulum may be asso-
ciated with a variety of acute pedi-
atric surgical problems, including
intussusception and small bowel
obstruction due to volvulus.
(Thomas C. Martin, MD, Joshua
M. Careskey, MD, Eastern Maine
Medical Center Bangor, ME)
Case 2 Discussion
This boy’s original presentation of
acute-onset left homonymous hemi-
anopsia, left upper extremity weak-
ness, and sensory change as well as a
left upgoing toe was concerning for a
right posterior quadrant cerebral
process. The history of forceful vom-
iting was concerning for an arterial
dissection. Therefore, the initial dif-
ferential diagnosis considered at the
time of his presentation included
stroke, postictal state, complicated
migraine, and, less likely, an expand-
ing mass, encephalitis, or a demyeli-
nating lesion.
Brain MRI/angiography was per-
formed. Both MRI and EEG con-
firmed an abnormality of the right
cerebral hemisphere. Imaging of the
intracranial vessels and vessels in the
neck was negative for evidence of a
dissection. The postcontrast MRI
Pediatrics in Review Vol.32 No.5 May 2011 211
index of suspicion
Figure 3. MRI with contrast (A, B) demonstrates prominent pial vascular enhance-
ment over the right posterior, frontal, temporal, and parietal cortex. FLAIR
sequence (C) demonstrates hyperintensity and swelling, with partial effacement of
the sulci over the same area.
(Fig. 3) showed enhancement of the
pial blood vessels and swelling of the
underlying gyri. This finding can be
seen in Sturge-Weber syndrome
(SWS) as well as hemiplegic migraine
and meningoencephalitis. Results of
studies of the CSF were within nor-
mal limits, reducing the possibility
that this presentation was the result
of an infectious process. The com-
mencement of seizures during his
hospital stay made SWS without fa-
cial nevus the likely diagnosis.
The Condition
SWS is a neurocutaneous disorder
characterized by angiomas of the lep-
tomeninges and skin of the face, of-
ten with eye abnormalities. The facial
angiomas or port wine stains are, at a
minimum, in the distribution of the
ophthalmic (V1) division of the tri-
geminal nerve and may extend into
the maxillary (V2) division. Initially
pink, this congenital lesion can
darken with age to a dark red or
purple. However, in darkly pig-
mented individuals, the facial angi-
oma may be difficult to see. The lep-
tomeningeal angioma (LA) is
believed to be an embryonic remnant
of the venous plexus that fails to re-
gress. The LA is most frequently uni-
lateral, overlying the parietal and oc-
cipital lobes, and ipsilateral to the
facial nevus.
212 Pediatrics in Review Vol.32 No.5 May 2011
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Not all patients born with port
wine stain have LA. Port wine stains
are present in 3 to 5 in 1,000 live
births. They can occur anywhere on
the body but are located most fre-
quently on the face. The frequency of
SWS is more difficult to quantify, but
experts estimate that the condition
occurs in approximately 1 in 20 to
50,000 live births. Furthermore, not
all patients born with SWS have a
facial nevus; to date, approximately
25 such cases have been reported.
Some have suggested that between
10% and 13% of people who have
SWS do not have a facial nevus. To
account for these individuals, Roach
(1) proposed the following classifica-
tion system:
● Type I: The presence of both a
facial nevus and LA with possible
glaucoma (classic SWS)
● Type II: Facial nevus, may have
glaucoma, in the absence of LA
● Type III: Isolated LA with low
likelihood of glaucoma
Classically, SWS was diagnosed
when linear calcifications resulting in
the “tram-track sign” were seen on
skull radiographs. More recently,
cranial CT scan has confirmed the
presence of calcifications in the men-
ingeal arteries as well as cortical and
subcortical veins in the region of the
LA.
Several mechanisms can contrib-
ute to the development of the calci-
fications. Altered venous drainage
and impaired perfusion results in per-
sistent hypoxia in the brain underly-
ing the LA. The hypoxia, exacer-
bated by ischemia as the result of
thrombosis within the LA or pro-
longed or frequent seizures, poten-
tially may lead to neuronal death
with resultant laminar necrosis, glio-
sis, and calcifications. In addition, it
has been proposed that the increased
permeability of the abnormally thin-
walled vessels of the LA may lead to
deposition of calcium and phospho-
rus outside the blood vessels.
Today, the diagnosis of SWS is
confirmed by the presence of LA on
cerebral MRI with contrast. Other
MRI findings can include cortical at-
rophy, accelerated myelination, en-
largement of the choroid plexus, and
enlargement of the deep draining
veins.
SWS often is complicated by
headache, strokelike episodes, sei-
zures, hemianopsia, glaucoma, and
intellectual disability. Seizures usu-
ally begin before 5 years of age, with
onset before 2 years potentially her-
alding a greater probability of medi-
cally refractory epilepsy and intellec-
tual disability. Type III SWS tends to
present later and have a less severe
course. Glaucoma or other eye ab-
normalities typically are absent in this
group.
Treatment
Aspirin at a dose of 2 mg/kg has
been recommended at the onset of
seizures or neurologic deficit or even
as soon as the diagnosis is confirmed
on imaging. The antiplatelet effects
of aspirin are believed to prevent the
progressive neurologic deterioration
that accompanies SWS by reducing
the risk of thrombosis due to venous
stasis within the LA.
Therapy for focal seizures with an
 index of suspicion

appropriate antiepileptic agent is ad-

vised after the first seizure. Emergent
evaluation and potentially hospital-
ization are necessary to control pro-
longed or frequent seizures as
quickly as possible to prevent neuro-
nal death from impaired blood flow.
Seizures may be medically refractory,
and hemispherectomy may be re-
quired.
Ophthalmologic surveillance for
buphthalmos and glaucoma is re-
quired. If they are present, treatment
should be undertaken to decrease in-
traocular pressure and prevent visual
loss.
Figure 4. MRI of pelvis shows widely divergent uterine corneae with cervices in close
Finally, laser therapy can be con-
approximation.
sidered for those who have port wine
stains. cornuate uterus with cervical sep- ● Primary amenorrhea without sec-
Six months after discharge, this tum, bicornuate bicollis uterus ondary sexual characteristics but
patient has had no additional sei- (uterus with two horns and two cer- with normal genitalia (uterus and
zures, and his neurologic deficits vical openings), and uterine didel- vagina)
have resolved. phys (double uterus with two cervi- ● Primary amenorrhea with normal
ces). Asymmetric enlargement of the breast development but absent or
Lessons for the Clinician right ovary, which otherwise ap- abnormal uterus
● SWS may be diagnosed with appro- peared normal, also was noted. MRI ● Primary amenorrhea with no breast
priate MRI imaging of an LA, even of the pelvis favored uterus didelphys development and no uterus
when a facial nevus is not present. and indicated a lower likelihood of ● Primary amenorrhea and second-
● Those patients who do not have bicornuate bicollis uterus, displaying ary amenorrhea with normal sec-
port wine stains may present later complete duplication of widely diver- ondary sexual characteristics and
and have less severe courses. gent uterine corneae and cervices in normal genitalia
● Treatment of SWS attempts to pre- close approximation (Figs. 4 and 5).
In this case, the adolescent pre-
vent progressive problems caused The possibility of myometrial tissue
sented with normal growth and puber-
by neuronal death and gliosis that between the two cervical canals was
occurs as a consequence of the LA. believed to be unlikely.
The development of the female
(Heather Harle, MD, Sean Rose,
genital tract begins at 3 weeks of
MD, Howard P. Goodkin, MD, PhD,
gestation and continues into the sec-
The University of Virginia School of
ond trimester of pregnancy. It is a
Medicine, University of Virginia
complex process involving cellular
Health Systems, Charlottesville, VA)
differentiation, migration, fusion,
and canalization. Disrupted develop-
Reference ment of müllerian ducts, such as
1. Roach ES. Neurocutaneous syndromes. agenesis, failure of lateral fusion, or
Pediatr Clin North Am. 1992;39:591– 620 failure of canalization, results in var-
ious congenital anomalies.

Case 3 Discussion Evaluation and Differential

Pelvic ultrasonography showed a Diagnosis
uterine anomaly. The differential di- Primary amenorrhea can be orga- Figure 5. MRI showing two cervical ca-
agnosis for this anomaly included bi- nized into four categories: nals.

Pediatrics in Review Vol.32 No.5 May 2011 213

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index of suspicion
tal development, including breast de-
velopment, but abnormal menstrual
onset due to a structural abnormality
of the female reproductive organ.
Congenital structural abnormali-
ties of the female reproductive or-
gans account for approximately 20%
of cases of primary amenorrhea.
Congenital abnormalities of the fe-
male reproductive tract are common,
occurring in 1% to 3% of women.
These abnormalities are caused by
genetic errors or teratologic events
during embryonic development.
Anomalies of the müllerian system
clinically present at varying times, in-
cluding during pubertal develop-
ment, and major abnormalities may
lead to serious impairment of men-
strual and reproductive functions.
Menses cannot occur without an
intact uterus, endometrium, cervix,
cervical os, and vaginal conduit. In
women who have an imperforate hy-
men, the menstrual cycle is normal,
but the menstrual products cannot
be expelled. This condition occurs in
approximately 1 in 1,000 live-born
females, and the diagnosis often is
made after puberty. Primary amenor-
rhea and cyclic abdominal cramping
are the most common symptoms.
However, many patients are
symptom-free. A bluish, bulging
membrane at the introitus (hemato-
colpos) is a characteristic finding.
Transverse vaginal septum occurs
in 1 in 75,000 females. The patient
may complain of cyclic cramping and
primary amenorrhea. On physical ex-
amination, the vagina appears short,
and a mass is palpable above the ex-
amining finger. At puberty, if the
transverse septum is complete, pa-
tients present with hematocolpos
and hematometrium. If the septum is
incomplete, some bleeding does oc-
cur, but over time, it leads to the
development of hematocolpos and
hematometrium.
Uterine fusion anomalies usually
214 Pediatrics in Review Vol.32 No.5 May 2011
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do not result in complete disruption
of menstrual flow. Instead, they typ-
ically manifest as heavy menstrual
flow, increased pain at menses, pelvic
masses, ectopic pregnancy, or mis-
carriage.
Other congenital causes of absent
uterus or outflow problems include
complete androgen insensitivity and
vaginal agenesis. Vaginal agenesis is
the congenital absence of the vagina
with variable müllerian duct abnor-
malities. This condition usually is as-
sociated with cervical and uterine
agenesis, but 7% to 10% of affected
females may have a normal but ob-
structed uterus. Androgen insensitivity
syndrome is categorized by normal
breast development but sparse or ab-
sent pubic and axillary hair. The vagina
is short, and the uterus and cervix are
absent. The karyotype is 46 XY, with
gonads that are usually intra-
abdominal and a serum testosterone
value in the pubertal male range.
The Condition
Uterus didelphys represents a uterine
malformation in which the uterus is
present as a paired organ due to failed
fusion of the müllerian ducts. Among
müllerian duct anomalies, didelphic
uteri account for approximately 11%
of anomalies. In the United States,
uterus didelphys is reported to occur
in 0.1% to 0.5% of the population.
The abnormality is characterized by a
double uterus with two separate cer-
vices and, in approximately 75% of
cases, a longitudinal vaginal septum
that presents as a double vagina This
was not the case in this patient. Each
uterus has a single horn linked to the
ipsilateral fallopian tube that faces its
ovary. Unilateral hematometrocol-
pos can occur even without a hori-
zontal vaginal septum.
The constellation of a single kid-
ney, uterine anomaly, joint hypermo-
bility, high-arched palate with dental
crowding, hypertelorism, and pectus
is very common with the 22q11 de-
letion syndrome. However, this di-
agnosis could not be established in
this patient because the family re-
fused fluorescence in situ hybridiza-
tion testing.
Management
Treatment of primary amenorrhea in
a patient born with uterine didelphys
is directed toward correcting the un-
derlying pathologic anatomy, maxi-
mizing fertility potential, and pre-
venting complications of the disease
process. Treatments include weight
management, hormone therapy, sur-
gery, and psychological support.
Imaging studies did not show he-
matocolpos in this patient. There-
fore, the decision was made to defer
any further examinations until she
turned 16 years of age, with the plan
to follow up sooner if she experi-
enced marked cyclic pain without
menses efflux.
Lessons for the Clinician
● When evaluating a patient who has
primary amenorrhea, it is important
to consider structural anomalies.
● MRI may be necessary to delineate
abnormalities found on ultra-
sonography.
● All females who have primary
amenorrhea should be counseled
regarding the cause, treatment,
and their reproductive potential.
Psychological counseling is impor-
tant in many patients, particularly
those with who have absent mülle-
rian structures or a Y chromosome.
(Rachel Dawson, DO, Fort Sam
Houston Primary Care Clinic, Fort
Sam Houston, TX; Shana Hansen,
MD, Naval Medical Center Ports-
mouth, Portsmouth, VA)
To view Suggested Reading lists for
the cases, visit pedsinreview.
aappublications.org and click on
Index of Suspicion.
 Index of Suspicion • Case 1: Abdominal Pain and Coffee Ground Emesis in a
9-year-old Boy • Case 2: Vomiting, Headache, and Seizures in a 7-year-old Boy •
Case 3: Primary Amenorrhea in a 15-year-old Girl
Thomas C. Martin, Joshua M. Careskey, Heather Harle, Sean Rose, Howard P.
Goodkin, Rachel Dawson and Shana Hansen
Pediatr. Rev. 2011;32;209-214
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 Histiocytosis
Jan E. Drutz
Pediatr. Rev. 2011;32;218-219
DOI: 10.1542/pir.32-5-218

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/cgi/content/full/32/5/218

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

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in brief
In Brief
Histiocytosis
Jan E. Drutz, MD
Texas Children’s Hospital and
Baylor College of Medicine
Houston, TX
Author Disclosure
Dr Drutz has disclosed no financial
relationships relevant to this article.
This commentary does not contain a
discussion of an unapproved/
investigative use of a commercial
product/device.
Langerhans Cell Histiocytosis: A Review
of the Current Recommendations of
the Histiocyte Society. Satter EK,
High WA. Pediatr Dermatol. 2008;25:
291–295
LCH in Children. Histiocytosis Associa-
tion of America. Accessed March
2011 at: http://www.histio.org/site/
c.kiKTL4PQLvF/b.1764433/k.8BCD/
LCH_in_Children.htm
Langerhans Cell Histiocytosis, Juvenile
Xanthogranuloma, and Erdheim-
Chester Disease. McClain KL.
UpToDate Online 18.3. 2010. Ac-
cessed for subscription March 2011
at: http://www.uptodate.com/contents/
langerhans-cell-histiocytosis-juvenile-
xanthogranuloma-and-erdheim-chester-
disease?source⫽search_result&selected
Title⫽1%7E86
Case 16-2010: A 48-year-old Man
With a Cough and Pain in the Left
Shoulder. Medoff BD, Abbott GF,
Louisaint A, Jr. N Engl J Med. 2010;
362:2013–2022
The term “histiocyte” refers to a num-
ber of different cell types (monocytes/
macrophages, dermal/interstitial den-
dritic cells, and Langerhans cells [LCs]),
all believed to arise from a common bone
218 Pediatrics in Review Vol.32 No.5 May 2011
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marrow progenitor cell (CD⫺34⫹). For
purposes of this review, discussion of
histiocytosis is confined to Langerhans
cell histiocytosis (LCH). First described
at the beginning of the 20th century,
LCH is considered a rare proliferative
disorder that primarily affects children.
LCs have the potential to accumulate in
a number of different sites and organs,
including the bone, lungs, liver, spleen,
and lymph nodes, ultimately leading to
a disease process.
To simplify confusing terminology
previously used to describe LCH (eosino-
philic granuloma, Letterer-Siwe disease,
Hand-Schuller-Christian disease, histio-
cytosis X), it is preferable to define
histiocytosis with regard to involve-
ment of a single system (ie, skin, bone,
lymph node), multiple systems, a single
organ, or multiple organs. This perspec-
tive is extremely important in helping
to determine treatment and prognosis
when organs such as the liver, spleen,
bone marrow, and lungs are involved.
LCs generally are localized to epi-
thelial surfaces, particularly skin. Their
primary function is to transport foreign
antigens to T cells within the lymphatic
system, contributing to an overall im-
mune response.
Although the cause of LCH remains
unknown, this disorder possibly is an
autoimmune phenomenon. LCH is nei-
ther a cancer nor believed to be attrib-
utable to an infectious process. Of note,
several studies have been unsuccessful
in establishing a linkage between hu-
man herpesvirus 6 and LCH.
Every year, LCH affects nearly
200,000 individuals, particularly chil-
dren 1 to 15 years of age. Among those
younger than 4 years of age, 50% to
70% present with multiorgan involve-
ment. Symptoms in children vary and
may include abdominal pain, bone pain,
or other complaints; those younger than
5 years generally present with bone
pain only. Of the bone sites in chil-
dren, the most frequent finding is a
lytic scalp lesion. Such a lesion may be
accompanied by a mass impinging on
the dura. The most common endocrine
abnormality associated with LCH is
diabetes insipidus.
Diagnosis of LCH requires the iden-
tification of specific clinical features as
well as characteristic histopathologic
and immunohistochemical findings. In
more than 50% of affected patients,
skin findings are evident. A diffuse,
vesicular (herpes simplex virus-like) or
excoriated exanthem may be present at
birth. In older infants, LCH may present
with scaling of the scalp, suggestive
of seborrhea. In addition to the skin
findings and bone pain, other clinical
features can include abdominal pain,
pulmonary infiltrates, gingival hyper-
trophy and ulcerations, exophthalmos,
destructive damage to the mandible,
and marked developmental delay.
Definitive diagnosis is dependent
upon specific characteristics of cell
staining and the identification by elec-
tron microscopy of Birbeck granules.
The number of LCs containing these
granules varies, depending on the organ
from which the tissue specimen is ob-
tained. Whether the patient has single-
site or multiorgan involvement, evalu-
ation should include a skeletal survey,
skull radiographic series, bone scan,
chest radiograph, computed tomogra-
phy (CT) head scan (if there is orbital or
mastoid involvement), and CT scan of
the spine or pelvis if there is neurologic
dysfunction. In neonates, a CT scan of
the lungs should be performed.

Treatment consists primarily of corti-
costeroids or immunosuppressive agents,
such as 6-mercaptopurine, vinblastine,
or methotrexate. Individual treatment
protocols should be tailored to specific
risk factors. Those patients who have
only single-system involvement should
be subcategorized according to the
number of sites involved within that
system. For those who have multiorgan
disease, treatment should be deter-
mined in relation to whether organ
dysfunction is present.
In general, no therapy is required
for individuals whose involvement is
limited to the skin. Treatment is some-
what controversial for those who have
multiorgan disease. Some experts advo-
cate high-dose prednisone as first-line
therapy; others advocate single-agent
chemotherapy. A review of a large num-
ber of cooperative studies revealed that
multiagent chemotherapy, administered
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over a long period of time, resulted in a
greater response with fewer recurrences.
The prognosis for patients who have
LCH depends on the number of organ
systems involved and the degree of
organ dysfunction. To a less significant
degree, the patient’s age may be a
factor. Mortality is greater for the young
child who has multiorgan involvement
and organ failure. Involvement of the
spleen, lung, liver, or hematopoietic sys-
tem portends a poor prognosis. Newborns
who have isolated cutaneous lesions do
exceptionally well. The best indicator for
a favorable prognosis is the patient’s
response to chemotherapy during the
first 6 weeks of the induction phase.
Those who respond to initial chemother-
apy have an 88% to 91% survival rate;
those who do not exhibit an early re-
sponse have only a 17% to 34% survival.
Comment: LCH is a fascinating dis-
ease. I have been involved with two
in brief
cases: a neonate who had an enlarged
inguinal lymph node without a perineal
rash, thus having no readily apparent
reason for the adenopathy, and a
2-year-old child initially believed to
have periorbital cellulitis who subse-
quently developed proptosis and was
found to have an orbital bone lesion.
These diagnoses were challenging to
make because the patients presented
with more common initial symptoms
that became atypical over time. Be-
cause of the multiple sites and organs
in the body that can be involved, pedi-
atricians need to have knowledge of
this disease and consider it when what
initially appear to be common symp-
toms recur or do not resolve in the
expected time frame.
Janet R. Serwint, MD
Consulting Editor, In Brief
Pediatrics in Review Vol.32 No.5 May 2011 219
 Histiocytosis
Jan E. Drutz
Pediatr. Rev. 2011;32;218-219
DOI: 10.1542/pir.32-5-218

Updated Information including high-resolution figures, can be found at:

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 The Preparticipation Sports Evaluation
Andrew R. Peterson and David T. Bernhardt
Pediatr. Rev. 2011;32;e53-e65
DOI: 10.1542/pir.32-5-e53

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

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 Article sports medicine

The Preparticipation Sports Evaluation

Andrew R. Peterson, MD,
Objectives After completing this article, readers should be able to:
MSPH,* David T.
Bernhardt, MD† 1. Perform a preparticipation history and physical examination and identify children and
adolescents who may be at increased risk of morbidity or mortality from sports
participation.
Author Disclosure 2. Recognize that many adolescents make infrequent contact with the medical system
Drs Peterson and and that the mandatory preparticipation evaluation serves as an opportunity to address
Bernhardt have medical issues not necessarily associated with sports participation.
disclosed no financial 3. Know the conditions that should be evaluated by a cardiologist before sports
relationships relevant participation.
to this article. This 4. Discuss the importance of assessing and documenting neurocognitive function in a
commentary does not preparticipation sports examination.
contain a discussion 5. Understand that disqualification from one sport does not imply disqualification from
of an unapproved/ all sports.
investigative use of a
commercial
product/device.
Introduction
Sports participation among people of all ages has increased steadily over the past 4 decades.
This trend generally has been considered to be a positive development, with conventional
wisdom asserting that sports participation teaches leadership and cooperative skills that
have a lifelong impact. In addition, as the obesity pandemic worsens, organized sports
participation and unstructured play or physical exercise can be a source of needed physical
activity for children and adolescents. The pediatrician often is asked to evaluate a child’s or
adolescent’s suitability for sports participation. The purpose of this evaluation has re-
mained constant since it was first described in 1978. (1)(2) The goals are to fulfill the
institution’s legal and liability requirements, provide some assurance to coaches that
athletes will start the season at an acceptable level of health and fitness, provide an
opportunity to discover treatable conditions, and aid in predicting and preventing future
injuries. The evaluation should be practical and applicable to all sports. The specific
objectives of the evaluation can vary, depending on viewpoint, which can create a situation
in which parents, athletes, clinicians, and sponsoring institutions or organizations have
discordant expectations. Parents may want to ensure the health and safety of their child.
Clinicians may seek to provide preventive care and anticipatory guidance. Institutions and
organizations may want to limit or transfer their liability for injuries
or illnesses caused or worsened by sports participation. Finally, the
athletes may just want to have their paperwork signed so they can
Abbreviations go play with their friends. The clinician should coordinate and
ADHD: attention-deficit/hyperactivity disorder address the goals of parents, athletes, and organizations while
AHA: American Heart Association promoting safe participation in physical activity.
DM1: type 1 diabetes mellitus The utility of the sports preparticipation evaluation (PPE) has
EIB: exercise-induced bronchospasm been questioned in recent years. Very few athletes are disqualified
NCT: neurocognitive testing from sports on the basis of findings from the PPE. In the largest
PPE: preparticipation evaluation evaluation of the PPE, only 1.9% of 2,729 high school athletes
TUE: therapeutic use exemption were disqualified from sports participation and only 11.9% required
VCD: vocal cord dysfunction any type of follow-up evaluation. (3) A recent systematic review of
the literature identified 310 studies of the PPE and concluded that

*Department of Pediatrics, University of Iowa, Iowa City, IA.

†
Departments of Pediatrics and Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI.

Pediatrics in Review Vol.32 No.5 May 2011 e53

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sports medicine preparticipation sports evaluation
the evaluation likely does little to prevent morbidity and
mortality in screened athletes and is ineffective for iden-
tifying athletes at risk for sudden cardiac death or ortho-
pedic injuries and at detecting exercise-induced bron-
chospasm (EIB). (4) However, use of the PPE is
endorsed by the American Academy of Pediatrics, Amer-
ican Academy of Family Physicians, and American Col-
lege of Sports Medicine because it allows for establish-
ment of a medical home, updating of immunizations,
identification and management of chronic health condi-
tions, and provision of anticipatory guidance related to
sports and other lifestyle risk factors.
Structure of the Evaluation
The PPE is required before practice and play by most
sporting organizations. The requirement is typically in
place to shield the organization from liability and to
ensure that the athlete can participate safely in sports.
The evaluation is required by law in many states and
some countries. Nearly all high-school and middle-
school athletes are required to obtain signed documen-
tation of a completed examination every 1 to 2 academic
years. Athletes engaged in club- or federation-level sports
are also often required to have documentation of an
evaluation, but this practice varies regionally and by
sport. Rarely, sports competitions not affiliated with
institutions or federations (eg, open races or tourna-
ments) require documentation of the athlete’s suitability
for competition. Generally, open or free play (such as on
an open playground) does not require such documenta-
tion. However, the 2010 PPE Monograph emphasizes
that clinicians should perform a PPE-type evaluation on
all patients when promoting physical activity. (5)
Most institutions and organizations that require an
evaluation strictly prevent participation until proper doc-
umentation has been obtained. This practice seems to be
due to a sense that protection from liability is not present
until there is “proof” that the athlete is safe to participate.
(6)(7) Although this concept has not been legally tested,
a 1990 New York State Appellate Court decision (Mur-
phy v. Blum) suggests that the issue of transfer of liability
depends on the specifics of the relationship between the
organization and the physician as well as between the
physician and the athlete. (8)
The athlete should be encouraged to schedule the
PPE well in advance of the season, ideally at least 6 weeks
before the start of practice. This timing allows sufficient
time for full evaluation of issues that may arise during the
initial visit. It also allows implementation of injury pre-
vention programs or rehabilitation of injuries before the
start of the season. The clinician should not be pressured
e54 Pediatrics in Review Vol.32 No.5 May 2011
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into premature clearance of an athlete before appropriate
evaluation is completed.
The PPE can be completed in any of several formats,
each of which has advantages and shortcomings. The
most common and ideal format is the office-based PPE in
which an athlete visits his or her primary care clinician in
the office. The advantages of this strategy include im-
proved continuity of care, access to medical records, time
for anticipatory guidance, and ease of arranging
follow-up diagnostic tests and treatment. The primary
disadvantages are the time burden and cost of an office
visit in addition to the possible limited availability of
appointments before the start of sports seasons.
To alleviate the time and cost burden of the PPE, the
other strategy commonly employed is the station-based
PPE. With this approach, the athlete cycles through a
series of stations at which a single aspect of the evaluation
is performed. Separate stations may address vital signs,
visual acuity screening, medical history and physical ex-
amination, orthopedic history and physical examination,
updating immunizations, and finally meeting with a cli-
nician to review all of the accumulated data and make a
decision regarding clearance. This approach is very effi-
cient, can be inexpensive, and allows specialty care at
each of the stations, limiting the need for a specialist.
Entire teams or schools can be evaluated in a single
session, reducing the administrative burden of schedul-
ing each athlete privately.
However, there are significant disadvantages to the
station-based approach. Continuity of care is severely
limited, including access to previous medical records.
Coordination of care may be difficult for issues requiring
follow-up. There is less privacy and time for anticipatory
guidance, and the athlete may be less likely to discuss
sensitive issues. Finally, athletes who previously have
been disqualified from sports participation may attempt
to take advantage of unfamiliar clinicians and use the
station-based format as a second chance to get cleared.
Obtaining the Medical History
The history portion of the PPE is similar to the history in
a typical health supervision visit for a child or adolescent
of the same age. Although several efficient screening
tools that have been designed specifically for the PPE are
endorsed by multiple professional societies, they should
not replace more extensive history collection when it is
warranted. The history form from the 2010 PPE Mono-
graph is shown in Figure 1.
It is important to explore the past medical, surgical,
family, social, and developmental histories, much as it
would be done for a nonsports-related evaluation. It is
 sports medicine preparticipation sports evaluation

Figure 1. History form for preparticipation evaluation.

Pediatrics in Review Vol.32 No.5 May 2011 e55

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sports medicine preparticipation sports evaluation
also important to interview a parent or guardian, if
available, because athlete and parent histories are often
inconsistent. (9)(10)
Some aspects of the history require additional atten-
tion. Although the following list is not comprehensive, it
represents some of the most common challenges to the
clinician during the PPE.
Cardiovascular
The component of the PPE that receives the most atten-
tion from parents, coaches, administrators, the medical
literature, and the popular press is the cardiovascular
evaluation. Although a comprehensive discussion of the
controversy surrounding preparticipation cardiovascular
screening is beyond the scope of this article, Pediatrics in
Review has published a summary of the topic, (11)(12)
and clear guidelines from the American Heart Associa-
tion (AHA) discuss the controversy surrounding the
evaluation and the role of preparticipation electrocardi-
ography and echocardiography. (13) The AHA-
recommended components of the preparticipation car-
diovascular evaluation are listed in the Table.
Several red flags that may appear in the past medical
and family history should prompt further investigation.
Known congenital heart disease, cardiac channelopathies
(such as long QT or Brugada syndrome), any history of
myocarditis, and coronary anomalies such as those
caused by Kawasaki disease should be evaluated by a
cardiologist before sports participation. A personal his-
tory of syncope, near-syncope, chest pain, palpitations,
or excessive shortness of breath or fatigue with exertion
should prompt a more thorough evaluation, either by the
primary clinician or a cardiologist. Postexertional syn-
cope is a common occurrence that is frequently elicited in
the PPE history. This benign condition should be differ-
entiated from exercise-associated collapse, which occurs
during exertion and is an ominous sign of hemodynam-
ically significant cardiovascular disease or ventricular
tachyarrhythmias. All patients who experience syncope
should undergo electrocardiography, with further test-
ing on a case-by-case basis.
A family history of early sudden cardiac death, Marfan
syndrome, cardiomyopathy, and arrhythmias (especially
long QT syndrome) should prompt further cardiovascu-
lar evaluation. Particular attention should be paid to any
family history of unexplained or poorly characterized
deaths, such as from drowning, unexplained motor vehi-
cle crashes, or seizures. These events may represent un-
recognized sudden cardiac death.
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Musculoskeletal
The musculoskeletal history is a remarkably sensitive
method for identifying abnormalities and injuries. Go-
mez and associates (14) found the sensitivity of a basic
musculoskeletal history to be 92%, which compares fa-
vorably with the estimated 75% sensitivity of a general
medical history. Inquiring about current injuries and a
history of injuries requiring evaluation, casting, bracing,
surgery, or missed practice or play captures nearly all
musculoskeletal abnormalities that require evaluation or
treatment before sports participation. A sports medicine
specialist may ask about specific orthopedic injuries that
are unique or common to the athlete’s sport, but this
inquiry generally is not necessary for a primary care
screening evaluation.
Medications
A review of the athlete’s list of current and past medica-
tions may provide clues to chronic or recurring medical
conditions that may affect sports participation. In addi-
tion, the athlete’s institution or governing sports feder-
ation may ban some medications and substances. A com-
prehensive review of banned substances is beyond the
scope of this article. In general, the athlete is responsible
for knowing what medications may be banned in his or
her sport. The clinician may assist athletes by directing
them to their governing body’s website and banned
substance list. Physicians who frequently care for
college-, national-, and international-level athletes
should be aware of the substances that are banned by the
National Collegiate Athletic Association (15) and the
World Anti-Doping Agency. (16) Comprehensive lists of
banned substances can be found at: http://www.
ncaa.org/wps /wcm/connect/public/ncaa/student-
athlete⫹experience/ncaa⫹banned⫹drugs⫹list and
http://www.wada-ama.org/en/World-Anti-Doping-
Program/.
Some medications can be taken if the athlete has a
therapeutic use exemption (TUE) on file. In some cases,
special testing may need to be obtained to meet the
requirements of the TUE. TUEs should be filed well
before the start of the season to avoid the possibility of
miscommunication or a gap in treatment of chronic
medical conditions. Often, a permitted medication can
be substituted for a banned substance.
Use of alcohol, tobacco, and other recreational drugs
is common among teenagers, including athletes. It is
useful to discuss these substances when discussing med-
ications, vitamins, and supplements that the athlete may
be taking.
 sports medicine preparticipation sports evaluation

Dermatologic
Athletes in certain sports are at addi- The 12-element American Heart
Table.
tional risk for dermatologic conditions
associated with their environment or
Association Recommendations for
contact with other athletes. Open Preparticipation Cardiovascular Screening
wounds should be cleaned and cov- of Competitive Athletes
ered for practice and play to reduce the
risk of blood-borne pathogen trans- Medical History
mission. Methicillin-resistant Staphylo- • Personal history
coccus aureus infections have received –Exertional chest pain/discomfort
considerable attention because they –Unexplained syncope/near-syncope
can result in necrotizing fasciitis, sep- –Excessive exertional and unexplained dyspnea/fatigue associated with
exercise
sis, and even amputation. Skin infec-
–Prior recognition of a heart murmur
tions such as impetigo, molluscum –Elevated systemic blood pressure
contagiosum, tinea, and herpes sim- • Family history
plex infection are common in sports –Premature death (sudden and unexpected, or otherwise) before age 50
that involve close skin-to-skin contact, years due to heart disease in first-degree relative
–Disability from heart disease in a close relative younger than 50 years of
such as wrestling and rugby. Each of
age
these conditions requires treatment to –Specific knowledge of certain cardiac conditions in family members:
minimize the risk of transmission. hypertrophic or dilated cardiomyopathy, long QT syndrome and other ion
Many sport federations have spe- channelopathies, Marfan syndrome, and clinically important arrhythmias
cific regulations for how skin infec- Physical Examination
tions should be treated and how long
• Heart murmur
athletes should be asymptomatic or • Femoral pulses to exclude aortic coarctation
under treatment before returning to • Physical stigmata of Marfan syndrome
practice and competition. Some ath- • Brachial artery blood pressure (sitting position)
letes and teams use prophylactic doses Data from American Heart Association, Inc.
of antiviral medications, such as acy-
clovir, for prevention of herpes out-
breaks during the season. This practice has not been ically, the clinician should ask about any type of head
systematically evaluated but anecdotally does seem effec- injury, feeling “dazed” or “foggy,” memory loss, head-
tive for decreasing herpes gladiatorum transmission aches following a hit to the head, difficulty playing or
among wrestlers. practicing following a hit to the head, and any type of
Athletes who practice and compete in the sun should injury that resulted in a loss of consciousness. The clini-
use a sun block lotion to minimize their risk of sun cian should be attuned to the fact that the presenting
damage and skin cancer. Controversy surrounds the ap- signs and symptoms of concussion can be subtle.
propriate sun protection factor for outdoor athletes. In If the athlete does provide a history of concussion,
general, any over-the-counter sun block applied liberally more detailed questioning is required to determine the
and frequently provides sufficient protection. Athletes presence or absence of frequent concussions, prolonged
who have already had significant sun exposure require a postconcussion symptoms, and concussions that oc-
careful examination of the sun-exposed skin to monitor curred with seemingly trivial trauma. Athletes who have
for skin cancer and precancerous lesions. had rare, mild concussions that resolved spontaneously
do not need additional evaluation. For athletes who have
Neurologic had frequent concussions, are more easily concussed, or
Although sports-related concussions are most common have had prolonged postconcussive symptoms, careful
in contact and collision sports, all athletes should be discussion with the athlete and family is necessary to
asked about a personal history of concussion or other understand the risks of repeated concussions. A symp-
head injury. Often, directed questions about head inju- tomatic athlete should never be allowed to return to play,
ries are required to elicit a history of concussion because and a graduated, stepwise approach should be used for
many athletes do not consider an injury in which there returning to physical activity. (17)
was no loss of consciousness to be a concussion. Specif- Obtaining baseline computer-based neurocognitive

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sports medicine preparticipation sports evaluation
testing (NCT) before the start of the season is contro-
versial. Although clinical assessment should be the main-
stay of concussion evaluation, NCT increases the sensi-
tivity for detecting residual concussion symptoms. (18)
Specifically, if baseline NCT is available when a con-
cussed athlete clinically appears ready to return to play,
repeat NCT can provide an objective measurement of his
or her recovery. However, NCT has poor specificity for
concussion, and the utility of postinjury NCT in an
athlete who does not have a baseline study is controver-
sial.
“Stingers,” also called “burners,” are injuries to the
brachial plexus caused either by direct trauma or a trac-
tion injury. Symptoms are typically brief. Athletes who
have had stingers with persistent symptoms of arm pain,
paresthesia, or weakness may have more significant inju-
ries to the brachial plexus or cervical nerve root injury.
No athlete should be permitted to return to practice or
play who has persistent symptoms.
Cervical cord neurapraxia, also called transient quad-
riplegia, is a frightening condition characterized by tem-
porary loss of motor control, with or without loss of
sensation or paresthesia, caused by transient compression
of the cervical spinal cord due to forced hyperextension,
hyperflexion, or axial loading. The condition is more
common in athletes who have cervical spinal stenosis.
(19) Episodes are transient and typically last less than
15 minutes. It is very rare for symptoms to last longer
than 48 hours. There is no increased risk of permanent
spinal cord injury following a single episode, (19)(20)
but athletes who have multiple episodes or persistent
symptoms require additional evaluation. Those who are
found to have instability, fractures, or degenerative
changes in the cervical spine should not be allowed to
return to contact or collision sports. Although athletes
who have cervical spinal stenosis are at increased risk of
cervical cord neurapraxia, it is unknown if they are at
increased risk for permanent spinal cord injury. Whether
athletes who have spinal stenosis should be allowed to
play contact sports is controversial and should be evalu-
ated on a case-by-case basis by a qualified physician.
Heat Illness
Heat illness kills more than 1,000 people in the United
States every year. (21) Athletes who have had a history of
heat illness are at risk for future heat illness, including
heat stroke. Once identified, the athlete can take mea-
sures to assure proper hydration and acclimatization to
minimize their risk. In addition, stimulants and antihis-
tamines increase the risk of heat illness and should be
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avoided, if possible, during training and competition in
warmer weather.
Ophthalmologic
Athletes who require corrective lenses for sports partici-
pation may need to work with an optometrist or ophthal-
mologist to ensure that they have appropriate lenses for
sport. Some sports, such as wrestling, boxing, and rugby,
do not allow eyewear, so athletes in need of corrective
lenses must use contact lenses. Athletes whose best-
corrected vision is worse than 20/40 in one eye (also
referred to as “functionally one-eyed”) must wear Amer-
ican Society for Testing and Materials-approved protec-
tive eyewear. (22)
Athletes who practice and compete in the sun or on
the snow should wear ultraviolet-blocking eyewear to
prevent acute photoretinitis and possibly decrease the
chance of developing cataracts. In addition, any baseline
ocular abnormality or normal variant should be docu-
mented. Being aware of baseline anisocoria or abnor-
mally shaped pupils can help to prevent an unnecessary
evaluation if the athlete presents later with a head or eye
injury.
Pulmonary
Athletes who have baseline lung disease may require
additional evaluation or a change in their treatment
regimen before the season. Athletes who have known
EIB should have an active prescription for a bronchodi-
lator such as albuterol. Such athletes may benefit from
having multiple inhalers to keep in multiple settings,
such as at home, at school, and with their coach or
athletic trainer. In general, athletes who have isolated
EIB do not benefit from inhaled corticosteroids. How-
ever, there is significant overlap between asthma and
EIB. In general, if an athlete has symptoms in other
settings and the EIB is poorly controlled with broncho-
dilator monotherapy, adding a controller medication,
such as an inhaled corticosteroid, may be beneficial. (23)
Some athletes compete in sports or under federation
rules that require them to obtain a TUE before using
bronchodilators. As mentioned, it is important to obtain
appropriate pulmonary function tests and to complete
the TUE paperwork well in advance of the season.
Vocal cord dysfunction (VCD) is another common
respiratory complaint among athletes. Triggers or asso-
ciated risk factors for VCD include allergic rhinitis, gas-
troesophageal reflux disease, anxiety, and poorly con-
trolled asthma. The diagnosis can be made with a history
of isolated inspiratory stridor (typically worse in compe-
tition situations) or with laryngoscopy. Most athletes can

control their symptoms with special breathing tech-
niques that require intensive teaching and are best taught
by speech therapists or other professionals who are famil-
iar with VCD. Like other chronic medical conditions,
gaining control of VCD symptoms before the start of the
sports season is important for increasing the likelihood of
success.
A history of other chronic pulmonary diseases, such as
cystic fibrosis or chronic lung disease due to bronchopul-
monary dysplasia, should not automatically disqualify a
child or adolescent from sports participation. Careful
partnership and close follow-up with a pulmonologist or
other clinician who is familiar with the specific disorder is
essential. It may be reasonable to dissuade children and
adolescents who have severe lung disease from participat-
ing in sports that impose a high cardiovascular demand
and steer them toward sports in which they are more
likely to find success.
Gastrointestinal
Although gastrointestinal complaints are common
among children and adolescents, very few require dis-
qualification or modified sports participation. Diarrhea
may put the athlete at increased risk of dehydration, but
dehydration usually can be prevented with increased fluid
intake. Gastroesophageal reflux disease can worsen with
increased physical activity but usually can be controlled
with diet modification. Gastric acid-suppressing medica-
tions (histamine-2 receptor blockers and proton pump
inhibitors) may be necessary in some patients. Because
inflammatory bowel disease can cause a profound anemia
that can make physical activity more difficult and impair
performance, close follow-up with a gastroenterologist
to help ensure good control of symptoms is essential.
Infectious Disease
Mononucleosis and mononucleosis-like infection caused
by viral infections (typically Ebstein-Barr virus, but occa-
sionally cytomegalovirus) can cause splenomegaly and
put the athlete at increased risk for splenic rupture. Any
athlete who has mononucleosis should be disqualified
from practice and competition in any sport in which
there is a risk of abdominal trauma. Most athletes are safe
to return to sport by 3 to 4 weeks after the start of
symptoms. (24)
Blood-borne pathogens, including human immuno-
deficiency virus and infectious hepatitis, should not
prompt disqualification from sports. (25) The athlete
may participate in any sport that his or her health allows.
Universal precautions should be used for all athletes, and
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sports medicine preparticipation sports evaluation
skin lesions should always be covered properly, regardless
of any known or suspected infectious disease.
Genitourinary
Few components of the genitourinary history should
disqualify an athlete or require modified participation.
Athletes who have a solitary or horseshoe kidney require
individual assessment for contact and collision sports.
(26) Protective equipment may be necessary to protect
the remaining kidney, and the risks of injury should be
weighed carefully against the benefits of contact or col-
lision sport participation. Inguinal hernias may worsen
with increased physical exertion, especially in sports such
as weightlifting that impose a high static demand (in-
creased muscle tension with relatively no change in mus-
cle length or joint mobility). Females who experience
amenorrhea or oligomenorrhea should be assessed for
eating disorders and impaired bone health. Female ado-
lescents who exercise intensively or play sports (especially
those sports that emphasize leanness) are at risk for
developing the “female athlete triad” of disordered eat-
ing, amenorrhea, and osteoporosis that is associated with
significant health problems later in life.
Psychological
Eating disorders are common among athletes in weight-
restricted and esthetic sports. Many athletes do not meet
diagnostic criteria for anorexia nervosa or bulimia ner-
vosa but clearly have disordered eating patterns. They
can be diagnosed as having eating disorder not otherwise
specified, which has been included in the most recent
version of the Diagnostic and Statistical Manual of Men-
tal Disorders. (27) Screening for disordered eating
should be performed as part of every PPE. Several vali-
dated screening instruments are available, but the most
commonly used is the 26-item Eating Attitudes Test.
(28) Screening tools for disordered eating generally as-
sess the patient’s body image and screen for abnormal
eating behaviors, such as irrational avoidance of certain
foods, ritualistic approaches to meals (eg, very slow eat-
ing, cutting food into very small pieces, extraordinary
calorie counting), vomiting, or engaging in excessive
exercise after meals.
Disordered eating is one of the three elements of the
female athlete triad, along with amenorrhea and de-
creased bone mineral density. The presence of any one of
these conditions should prompt the clinician to evaluate
for the other two. The female athlete triad puts the
athlete at risk for stress fractures. Although not an abso-
lute contraindication to sports participation, complica-
tions of an eating disorder (including electrolyte abnor-
Pediatrics in Review Vol.32 No.5 May 2011 e59
sports medicine preparticipation sports evaluation
malities and cardiac rhythm disturbances) need to be
monitored. A multidisciplinary team, including physi-
cians, dietitians, and mental health professionals, is essen-
tial for the necessary care of an athlete who has an eating
disorder.
Depression and anxiety are common mental health
problems that can appear in athletes. Unless severe, these
conditions should not disqualify the athlete from sports
participation. Mental health professionals may help the
athlete to cope better with his or her psychological
symptoms. Often, athletes can be persuaded to use men-
tal health services by discussing the possible performance
improvements that might come from controlling their
depression or anxiety.
The prevalence of attention-deficit/hyperactivity dis-
order (ADHD) among athletes is similar to the preva-
lence among other children and adolescents of the same
age. Stimulant medications are a common treatment but
may require a TUE or documentation of ADHD testing
before the start of the sports season.
Immunization
The PPE provides an opportunity to review the immu-
nization history and provide catch-up immunizations.
Although missing immunizations should not be criteria
for sports disqualification, athletes and clinicians should
be aware that some immunizations are required by
schools and colleges for enrollment. In addition, athletes
who are competing internationally may need documen-
tation of specific immunizations to gain entry into certain
countries.
The Physical Examination
The PPE physical examination varies little from the stan-
dard health supervision evaluation, although a few com-
ponents require additional attention in the athlete.
Vital Signs
The vital signs of an athlete may be different from what a
clinician is used to seeing in nonathletes. A child or
adolescent who has a high degree of cardiovascular fit-
ness may have bradycardia and a wide pulse pressure.
Respiratory rate may be lower than expected when rest-
ing but may be elevated for several hours after exercise.
Body mass index may be an inaccurate method of screen-
ing for overweight and obesity in some athletes who are
very muscular. The blood pressure should be normal.
Elevated blood pressure in children and adolescents,
regardless of sports participation, requires evaluation and
treatment. For idiopathic or “essential” hypertension,
one of the first-line treatments is exercise. Athletes who
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have mild-to-moderate hypertension (⬎95th percentile
for age, sex, and height) require evaluation but should be
encouraged, rather than prohibited, from participating in
sports. Athletes who have severe hypertension (charac-
terized as ⬎5 mm Hg over the 99th percentile for age,
sex, and height) should be disqualified from sports char-
acterized by a high static demand and avoid heavy weight
training and powerlifting. (29)(30)
Head and Neck
Corrected visual acuity should be better than 20/40 in
both eyes. If not, protective lenses are required for con-
tact sports participation. (22) Auricular cartilage damage
should prompt the clinician to remind the athlete to use
ear protection for sports such as wrestling and rugby.
Nasal septum damage should prompt referral to an oto-
laryngologist. Dental carries may indicate overuse of
sports drinks or eating disorders such as bulimia.
Cardiovascular
The AHA-recommended elements of the cardiovascular
evaluation are listed in the Table. In general, any cardiac
abnormality that is not clearly benign should be fully
evaluated before sports participation. A pediatric cardiol-
ogist who is familiar with the demands of sport partici-
pation should perform the follow-up evaluation. It is best
to avoid ordering echocardiography and other advanced
cardiac testing from facilities that are unfamiliar with
congenital heart disease and sport participation in chil-
dren.
Genitourinary
The female genitourinary examination is not a standard
part of the PPE. However, any concerns raised by find-
ings on the patient’s history should be evaluated appro-
priately. Males should have two descended testicles. Any
male who has an undescended or absent testicle should
be evaluated by a urologist. Athletes who have only one
functional testicle may participate in all sports but should
be encouraged to use a protective cup to decrease the risk
of injury in contact or collision sports. The PPE allows
the clinician an opportunity to discuss testicular self-
examination with the older adolescent. Males who have a
history of groin pain should be evaluated for an inguinal
hernia with a digital examination of the inguinal ring.
Asymptomatic athletes do not need to be screened for
hernias. (5)
Dermatologic
Any infectious skin condition should be treated before
the athlete’s return to sport. Any skin lesions that are

suspicious for malignancy should be removed and evalu-
ated by a pathologist.
Neurologic
Any history of neurologic injury, including concussions
and stingers, should prompt a detailed neurologic eval-
uation. The assessment should include cognitive func-
tion, cranial nerves, sensation, strength, tone, reflexes,
and cerebellar function. Any abnormality should be eval-
uated thoroughly before sports participation.
Musculoskeletal
Clinicians often feel compelled to perform a detailed
musculoskeletal examination on athletes who present for
a PPE. However, as discussed, the physical examination
adds little diagnostic value to the orthopedic history.
(14) A cursory evaluation of strength and range of mo-
tion is sufficient for athletes who have no musculoskeletal
complaints. Focused, detailed examinations of specific
joints can be reserved for evaluating previous injuries or
current complaints.
The Laboratory Evaluation
No screening laboratory or imaging tests are required as
part of a routine PPE. Significant controversy surrounds
the use of screening echocardiography and electrocardi-
ography to detect occult congenital heart disease. (13) In
addition, the utility of testing for hemoglobinopathies,
anemia, bleeding disorders, infectious diseases, cardio-
vascular risk factors (such as hypercholesterolemia), and
other chronic diseases that may affect athletic perfor-
mance or general health is unclear.
Special Situations
Fewer than 2% of PPEs result in disqualification of the
athlete from sport. However, many medical conditions
require adaptation or close monitoring for complications
related to sports participation. In addition, sporting ac-
tivities are heterogeneous in their physical and cardiovas-
cular demands as well as in their level of contact. Certain
medical conditions may be incompatible with particular
static or dynamic (changes in muscle length or joint
mobility with relatively small change in muscle tension)
demands or with the risks associated with contact or
collision sports. A comprehensive review of the medical
conditions affecting sports participation is beyond the
scope of this article, but several conditions that fre-
quently come to clinical attention during the PPE are
discussed. This list is far from exhaustive, and the reader
who is interested in learning more about the specific
demands of sports participation and how many common
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sports medicine preparticipation sports evaluation
and uncommon medical conditions affect sports partici-
pation should see the American Academy of Pediatrics
Council on Sports Medicine and Fitness’s report on
“Medical Conditions Affecting Sports Participation.”
(26)
Seizures
The child or adolescent who has a well-controlled seizure
disorder should not be disqualified from sports participa-
tion. (26) In these athletes, the risk of having a seizure
during practice or competition is very low, partially due
to their already low seizure frequency but also due to the
antiepileptic effects of exercise. It is sometimes surprising
to officials and policy makers that athletes who have
known seizure histories can be allowed to participate in
contact and collision sports and in sports where they
would seem to be at increased risk of injury should they
have a seizure. The clinician may need to advocate for the
athlete in such situations. A useful point of reference is
the individual state’s legal seizure-free interval before
individuals who have epilepsy are allowed to return to
driving. In most states, it is 3 to 6 months.
Children and adolescents who have poorly controlled
epilepsy also benefit from physical exercise, but more care
must be taken to ensure the safety of these athletes and
those around them. An individual assessment should be
made to determine the athlete’s suitability for contact
and collision sports. The following sports should be
avoided:
● Archery
● Power lifting
● Riflery
● Swimming
● Weight lifting
● Weight training
● Sports involving heights (eg, parachuting, hang-
gliding)
Down Syndrome
Down syndrome, also known as trisomy 21, is a genetic
syndrome involving multiple congenital anomalies. Chil-
dren born with Down syndrome often require interdis-
ciplinary care to maximize their health outcomes and
quality of life, regardless of sports participation. Of note,
instability of the cervical spine (primarily atlantoaxial
instability, but also occipitoatlantal instability) has been
reported in up to 30% of patients who have Down
syndrome. (31) The Special Olympics® organization
requires radiographic evaluation of the cervical spine
before sports participation. It is common for patients
Pediatrics in Review Vol.32 No.5 May 2011 e61
sports medicine preparticipation sports evaluation
who have had normal cervical spine radiographs to ac-
quire cervical instability. For this reason, patients who
have Down syndrome should be prohibited from partic-
ipating in collision sports regardless of the radiographic
appearance of their spines. However, no other limita-
tions need be imposed for patients who have normal
cervical spine radiographs. Patients who have radio-
graphic evidence of cervical instability but no neurologic
signs or symptoms should be disqualified from “neck-
stressing” sports. Special Olympics considers diving,
gymnastics, butterfly stroke, high jumping, soccer, and
pentathlon to be “neck-stressing.” Athletes who have
Down syndrome and cervical instability may use a cervi-
cal collar, but this practice does not change their sport
restriction.
Down syndrome is associated with other abnormali-
ties that may influence sports participation, such as car-
diac abnormalities (septum defects in particular), cata-
racts, diabetes, thyroid disease, hip and patellar
instability, and foot abnormalities. Each of these condi-
tions, if present, requires evaluation before sports partic-
ipation. However, no other special precautions need to
be taken for these children.
Acute Febrile Illness
Athletes who have a fever should be prohibited from
practice and competition. (26) Fever puts the athlete at
risk for acute heat illness (due to increased heat storage),
reduced maximal exercise capacity, and hypotension
(due to decreased peripheral vascular tone and possibly
dehydration).
Type 1 Diabetes Mellitus
Athletes who have type 1 diabetes mellitus (DM1) are
permitted to participate in any sport without restriction.
(26) However, DM1 monitoring and treatment often
becomes more complex with the varying demands of
organized sports. Careful evaluation and monitoring of
blood glucose, diet, insulin types and doses, and hydra-
tion status are essential. Blood glucose should be
checked more frequently than usual. At a minimum,
athletes who have DM1 should measure their blood
glucose every 30 minutes during continuous exercise,
15 minutes after completion of exercise, and at bedtime.
For optimum control and performance, many athletes
who have DM1 find that they need to measure their
blood glucose and modulate their insulin and carbohy-
drate intake frequently. Insulin pumps and rapid-acting
insulins have allowed athletes to fine-tune their glycemic
control much more effectively than in the past. It is not
uncommon for athletes who have DM1 to develop com-
e62 Pediatrics in Review Vol.32 No.5 May 2011
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plex treatment plans involving both pump and injectable
insulin therapy.
The Disabled Athlete
Disabled athletes may face special challenges, but the
clinician should encourage exercise and sports participa-
tion for the same reasons they are encouraged in able-
bodied athletes. (5) Good communication among ath-
letes, coaches, parents, and clinicians is essential for
ensuring safe and successful sports participation. The
supplemental history form from the 2010 PPE mono-
graph (Fig. 2) can help to facilitate this communication.
When to Disqualify an Athlete From Sports
Participation
Although most complaints and abnormalities identified
during the PPE are not absolute contraindications to
sports participation, several conditions should prompt
disqualification from sport. Most of these are cardiovas-
cular conditions and have been outlined in the 36th
Bethesda Conference guidelines: (32)
● Pulmonary vascular disease with cyanosis or a hemody-
namically significant right-to-left shunt
● Severe pulmonary stenosis (untreated)
● Severe aortic stenosis or regurgitation (untreated)
● Severe mitral stenosis or regurgitation (untreated)
● Any cardiomyopathy
● Vascular Ehlers-Danlos syndrome
● Coronary anomalies (especially anomalous coronary
origins)
● Catecholaminergic polymorphic ventricular tachycar-
dia
● Acute pericarditis
● Acute myocarditis
● Acute Kawasaki disease
Although the guidelines from the 36th Bethesda con-
ference only comment on disqualification for these
specific conditions, any cardiovascular disease should
be thoroughly evaluated and treated by a pediatric
cardiologist to ensure the athlete’s safe participation in
sports.
In addition to cardiac abnormalities, any condition
that cannot be well controlled and puts the athlete at risk
of significant injury or death or endangers the health of
teammates or competitors requires further evaluation or
disqualification from sport. For example, a musculoskel-
etal injury that impairs the athlete’s ability to protect
him- or herself during practice and competition should
prompt disqualification until the athlete is safely able to
return to play. For a discussion of the evaluation and
 sports medicine preparticipation sports evaluation

Figure 2. Supplemental history form for athletes who have special needs.

Pediatrics in Review Vol.32 No.5 May 2011 e63

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sports medicine preparticipation sports evaluation
Summary
• In general, the evidence base for the PPE is limited.
(5)
• The clinician should coordinate and address the
goals of parents, athletes, and organizations while
promoting safe participation in physical activity.
• Based on at least fair evidence, the PPE does little to
prevent morbidity and mortality in athletes. (4)
• Based on expert opinion, the PPE is best performed
well in advance of the competitive season. (5)
• Based on expert opinion, the office-based PPE is
preferable to the station-based approach. (5)
• Based on at least fair evidence, clinicians should
focus on the medical and musculoskeletal history
because most conditions that affect participation are
elicited from that history. (5)(13)(14)
• Based on expert opinion, athletes who have suffered
a concussion should not be allowed to return to play
while symptomatic and should follow a stepwise
progression of graduated return to full activity. (17)
• Based on expert opinion, screening echocardiography
and electrocardiography should not be routine parts
of the PPE. (13)
• Based on expert opinion, athletes who have lost a
paired organ may compete in any sport with proper
protective equipment. (22)(26)
• Based on expert opinion, most athletes who have
chronic medical conditions can compete safely in
most sports. (26)
management of specific sports-related injuries, please see
the recent Pediatrics in Review article, “Managing Sports
Injuries in the Pediatric Office.” (33)
In performing the PPE, the clinician’s first responsi-
bility is to ensure the health and safety of the patient.
However, the physical and psychological benefits of ex-
ercise and sport participation should weigh heavily on
decisions to disqualify an athlete from sport.
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HealthyChildren.org Parent Resources from AAP

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 The Preparticipation Sports Evaluation
Andrew R. Peterson and David T. Bernhardt
Pediatr. Rev. 2011;32;e53-e65
DOI: 10.1542/pir.32-5-e53

Updated Information including high-resolution figures, can be found at:

& Services http://pedsinreview.aappublications.org/cgi/content/full/32/5/e53

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