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Play gradually becomes more cooperative; sequence that can be assessed and can be very informative shared fantasy leads to game playing. The pediatrician must evaluate potential learning usually resolved and attachment is redirected to the parent disabilities in any child who is not developing adequately at of the same sex. The child is ready to relate to peers in a task can make a dramatic difference in success at school. The brain has reached 90% of its the clinician must consider all of these aspects in the adult weight. Sensorimotor coordination abilities are matur differential diagnosis of learning disabilities and behavioral ing and facilitating pencil-and-paper tasks and sports, both disorders. National Center for Education in Maternal and Child Health environment and because these activities are stressed in early Georgetown University, 2002. Magical thinking diminishes greatly at this time, and the reality of cause-effect relationships is better under stood. Practitioners will be familiar with most of the prob aggressive or sexual drives but instead devote most of their lems discussed in this chapter; however, with increasing energies to school and peer group interactions. In reality, knowledge of the factors controlling normal neurologic and throughout this period there is a gradual increase in sex behavioral development in childhood, new perspectives on drive, manifested by increasingly aggressive play and interac these disorders and novel approaches to their diagnosis and tions with the opposite sex. Organized sports, clubs, and intrinsic biologic characteristics and the environments with other activities are other modalities that permit preadoles which the children interact. The next section focuses on cent children to display socially acceptable forms of aggres some of the more common complaints about behavior sion and sexual interest. These behav For the 7-year-old child, the major developmental tasks ioral complaints are by and large normal variations in are achievement in school and acceptance by peers. There centrate on, attend to, and process increasingly complex are no cures for these behaviors, but management strategies auditory and visual information. The health care pro Thomas and Temperament is an independent psychologic vider can play a major role in diagnosis, in coordinating the Chess attribute, biologically determined, which is expressed as a response to an external stimulus. An appreciation of this phenomenon is important function rarely has doubts about what is abnormal.

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Penetration of topical steroids through the enlarged epider mal barrier in psoriasis requires that more potent prepara single area is necessary before hair loss can be detected tions be used, for example, fluocinonide 0. Hairs should be examined microscopically for (Dovonex) applied twice daily or the combination of a breaking and structural defects and to see whether growing superpotent topical steroid twice daily on weekends and or resting hairs are being shed. Three diseases account for gel) can be used in combination with topical corticosteroids to most cases of hair loss in children: alopecia areata, tinea help restore normal epidermal differentiation and turnover capitis (described earlier in this chapter), and hair pulling. The newer tar gels (Estar, PsoriGel) cause less staining and Loss of every hair in a localized area is called alopecia areata. These preparations are sold over the counter and are immunologic pathogenic mechanism is suspected because not usually covered by insurance plans. Ninety Scalp care using a tar shampoo requires leaving the five percent of children with alopecia areata completely shampoo on for 5 minutes, washing it off, and then sham regrow their hair within 12 months, although as many as pooing with commercial shampoo to remove scales. More A rare and unusual form of alopecia areata begins at the severe cases of psoriasis are best treated by a dermatologist. This variety, called ophiasis, often eventuates in total Liu Y et al: Psoriasis: Genetic associations and immune system scalp hair loss (alopecia totalis). Superpotent topical steroids, minoxidil (Rogaine), and anthralin are treatment options. Urticaria Barbiturates Tan E et al: A clinical study of childhood alopecia areata in Opioids Singapore. Hair Pulling Morbilliform eruption Anticonvulsants Clinical Findings Cephalosporins Traumatic hair pulling causes the hair shafts to be broken off Penicillins at different lengths, with an ill-defined area of hair loss, Sulfonamides Fixed drug eruption, erythema multiforme, toxic epidermal necrolysis, petechiae around follicular openings, and a wrinkled hair Stevens-Johnson syndrome shaft on microscopic examination. This behavior may be Anticonvulsants merely habit, an acute reaction to severe stress, trichotillo Nonsteroidal anti-inflammatory drugs mania, or a sign of another psychiatric disorder. Oiling the hair to make it slippery is an aid to Tetracyclines Thiazides behavior modification. Erythema multiforme begins with papules that later develop a dark center and then evolve into lesions with central bluish 2. Drug Eruptions discoloration or blisters and the characteristic target lesions (iris lesions) that have three concentric circles of color Drugs may produce urticarial, morbilliform, scarlatiniform, change. Primary injury is to endothelial cells, with later pustular, bullous, or fixed skin eruptions. Steroids have not been demonstrated to be effec Recurrent erosions on the gums, lips, tongue, palate, and tive. Chronic acyclovir therapy has been successful in buccal mucosa are often confused with herpes simplex.

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Hand, Foot, and Mouth Disease therapy or who are immunocompromised may require sys this entity is caused by several enteroviruses, only one of temic antifungal agents. The parents should be advised to which (enterovirus 71) can rarely cause encephalitis. Ulcers replace any items, such as a pacifier, that may have become occur anywhere in the mouth. Mechanical trauma most commonly occurs on the buccal mucosa secondary to accidentally biting with the molars. Pharyngoconjunctival Fever Thermal trauma, from very hot foods, can also cause ulcer this disorder is caused by an adenovirus and often is ative lesions. Exudative tonsillitis, conjunctivitis, lymphade contact with aspirin, caustics, and the like. Oral ulcers can nopathy, and fever are the main findings, and treatment is also occur with leukemia or on a recurrent basis with cyclic symptomatic. Of the five, M pneumoniae is by far the most common and may cause over one third of all Over 90% of cases of sore throat and fever in children are pharyngitis cases in adolescents and adults. The findings seldom give any clue to the particular viral agent, but four types of viral pharyngitis Clinical Findings are sufficiently distinctive to support an educated guess about the specific cause and are listed below. Untreated streptococcal pharyngitis can result in acute rheu matic fever, glomerulonephritis, and suppurative complica Clinical Findings tions (eg, cervical adenitis, peritonsillar abscess, otitis media, cellulitis, and septicemia). Infectious Mononucleosis petechiae, a beefy-red uvula, and a tonsillar exudate suggest the findings are exudative tonsillitis, generalized cervical streptococcal infection; however, the only way to make a adenitis, and fever, usually in a patient older than 5 years of definitive diagnosis is by throat culture or rapid antigen test. Therefore, a positive test indicates S pyogenes rior stomatitis, discrete ulcerative lesions, viral rash, and infection, but a negative result requires confirmation by diarrhea should raise suspicion of a viral cause. Scarlet fever is a diffuse, finely papular, erythem factor in failures, and intramuscular benzathine penicillin atous eruption producing a bright red discoloration of the should be considered strongly in children who fail during or skin, which blanches on pressure. However, in adolescents, three doses are fever when used as therapy for acute pharyngeal infections, it recommended. Routine culturing after treatment is once daily if compliance is a concern; however, both are broad not recommended, since children may be carriers. An attempt to eradicate the recommend penicillin, with erythromycin for penicillin carrier state is warranted only if the patient or another family allergic patients. A recent meta-analysis of trials of oral member has frequent streptococcal infections or when a cephalosporins for streptococcal pharyngitis has concluded family member or patient has a history of rheumatic fever or that penicillin should no longer be used. If eradication is chosen, a course of clin otitis media meta-analyses, the quality of the trials included damycin for 10 days or of rifampin for 5 days should be used. In this case, inclusion of children who are In the past, daily penicillin prophylaxis was occasionally carriers may bias certain of these trials.

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