PE5.1-4 | Behavioural Problems — Graded Quiz

Wessel's rule-of-three (crying >3 hours/day, >3 days/week, >3 weeks) in an otherwise well, thriving infant defines infantile colic. It is benign and resolves spontaneously by 3-4 months. Management is parental reassurance and behavioural techniques.

Infantile colic (Wessel's rule-of-three) affects 10-25% of infants, peaks at 6 weeks, and resolves by 3-4 months. Key: normal weight gain and examination. Treatment is parental support; simethicone and probiotics (Lactobacillus reuteri) have limited evidence.

Cow's milk protein allergy is suspected when there are associated symptoms (blood in stool, eczema, eosinophilia). Intussusception has intermittent colicky pain with currant-jelly stool and lethargy — not seen here. Non-accidental injury should be considered when there are unexplained injuries, not for colic meeting Wessel's criteria.

This is a classic cyanotic breath-holding spell. With a normal EEG and characteristic history, no further neurological workup is needed. The standard of care is: check for iron deficiency anaemia (iron supplementation reduces spell frequency), and reassure and educate parents. Investigations beyond iron studies are not routinely warranted.

Cyanotic BHS is a diagnosis of history; investigations are reserved for atypical features. Iron deficiency anaemia (Hb and iron studies) is the only routinely checked investigation, and correction reduces episode frequency. Parents must be counselled to stay calm — anxiety-driven parental over-reaction can inadvertently reinforce the behaviour.

Anti-epileptics are not indicated for BHS. Cardiac monitoring and MRI are not warranted in typical cyanotic BHS with a normal EEG and characteristic trigger-cry-cyanosis-recovery sequence.

This is a cyanotic BHS complicated by brief tonic posturing (anoxic tonic episode) in the context of iron deficiency anaemia. Iron supplementation corrects the anaemia and significantly reduces BHS frequency. Parental reassurance and education are essential. Anti-epileptics are not indicated.

Iron deficiency is a modifiable risk factor for BHS; treating it reduces frequency by up to 50% in studies. Brief tonic posturing in a BHS is caused by cerebral anoxia — it is anoxic, not epileptic. Anti-epileptics should never be started for BHS.

Valproate and anti-epileptics are not indicated for BHS. CT brain and neurology referral are not required for typical BHS with an identifiable trigger and characteristic sequence. Absence seizures have a completely different presentation (sudden staring, no triggering event, no cyanosis).

Red flags for autism (absent eye contact, no pointing/pretend play, language delay) are present alongside tantrums. In this context, tantrums may reflect frustration from communication difficulties rather than typical developmental tantrums. ASD screening (M-CHAT at 16-30 months; CARS for older children) is the priority.

Persistent tantrums in a child with language delay, absent eye contact, and absent pretend play are red flags for ASD, where tantrums often stem from communication frustration. ASD must be screened before attributing tantrums to normal development.

Behavioural counselling alone is not appropriate when ASD red flags are present. Risperidone may be used for severe ASD-related aggression but only after diagnosis. Reassurance is inappropriate given the language delay and social communication concerns.

DSM-5 and ICD-11 define pica as persistent eating of non-nutritive, non-food substances for ≥1 month in an individual for whom this is developmentally inappropriate (i.e., must be >24 months of age, as mouthing/ingesting non-foods is normal in infants up to ~18-24 months).

Pica (DSM-5): non-nutritive substance ingestion ≥1 month, age >24 months. Common substances: soil/mud (geophagia), chalk (amylophagia), paint chips, paper, hair. Associations: iron deficiency, lead poisoning, intellectual disability, ASD. Always check blood lead level and iron studies.

The definition requires duration ≥1 month, age >2 years (developmental appropriateness), and non-nutritive substances; single-occasion ingestion or food refusal are different conditions.

For short-term situations (trips, sleepovers), desmopressin (oral tablet or melt — preferred over nasal spray due to risk of hyponatraemia with nasal formulation) is appropriate for a defined period. The enuresis alarm is the most effective long-term treatment but requires 2-3 months to work — not suitable for 1 week. Imipramine is third-line due to cardiac risks.

Enuresis management is tailored to the goal: for long-term cure, enuresis alarm is first choice (2-3 months). For short-term situational use (trips, camps), desmopressin oral tablet/melt at bedtime is ideal. Nasal desmopressin spray is avoided due to higher risk of dilutional hyponatraemia in children.

The enuresis alarm takes 2-3 months to be effective and is not a short-term solution for a 1-week trip. Imipramine carries cardiac and overdose risks and is not preferred over desmopressin. Deferring all treatment while the family has a clear short-term need is unhelpful.

In a boy with continuous dribbling, poor/no stream, straining, and both daytime and nighttime wetting since birth, posterior urethral valves (PUV) or another structural outlet obstruction must be excluded. This is a surgical emergency that can cause progressive renal damage if missed. Voiding cystourethrogram (VCUG) is diagnostic.

Organic red flags for enuresis that mandate investigation: daytime incontinence + poor stream (obstruction), recurrent UTIs (vesicoureteral reflux), polydipsia/polyuria (DM/DI), neurological signs (spinal dysraphism). Posterior urethral valves = most important structural cause to exclude in boys with obstructive voiding from birth.

Primary nocturnal enuresis is nighttime-only and does not present with daytime continuous dribbling and poor stream — this is a structural alarm sign. UTI causes dysuria and fever but not obstructive voiding pattern. Overactive bladder has urgency and frequency without the obstructive pattern.

Extinction (planned ignoring) is subject to an 'extinction burst' — a temporary increase in tantrum intensity before it decreases, because the child tests whether increasing behaviour will get a response. Parents must be counselled about this, or they will abandon the approach prematurely.

Planned ignoring (extinction) is effective for tantrums but parents must be warned about the extinction burst. Consistent application is key. Positive reinforcement of calm behaviour (catch the child being good) is the paired strategy. Tantrums that start reducing by age 4 and cease by 5-6 years are developmentally normal.

Oppositional defiant disorder requires a pattern of hostile defiance lasting ≥6 months affecting function — not normal developmental tantrums. Consoling during a tantrum reinforces the behaviour (intermittent reinforcement). Tantrums >2 minutes are common and not a referral criterion on their own.

Force-feeding creates a negative feeding relationship, conditions the child to associate feeds with stress, and perpetuates the feeding refusal cycle. Responsive feeding (feeding in response to hunger cues, division of responsibility — parent decides what/when/where, child decides how much) is the evidence-based intervention. This must be addressed before escalating investigation or intervention.

Anxious force-feeding perpetuates feeding refusal by conditioning negative associations. Responsive feeding (parent decides what/when/where; child decides how much) interrupts this cycle. Always assess growth trajectory and rule out organic pathology, but address the interactional feeding pattern first.

NG tube feeding and hospital admission are for moderate-severe malnutrition (SAM/MAM criteria) or unsafe oral feeding, not for a child at the 15th centile with a behavioural feeding pattern. Appetite stimulants are not first-line. Gastroenterology referral may follow if behavioural intervention fails, but it is not the first step.

Blood lead level ≥45 mcg/dL in a child without encephalopathy is an indication for oral DMSA (succimer) chelation. Additionally, iron deficiency (which promotes lead absorption) must be treated, and the lead source (chalk/soil at school or home) must be identified and removed. IV CaNa2EDTA is reserved for ≥70 mcg/dL or encephalopathy.

Lead toxicity management thresholds: BLL 5-44 mcg/dL = environmental + iron; BLL ≥45 mcg/dL (asymptomatic) = oral DMSA (succimer); BLL ≥70 mcg/dL or encephalopathy = IV CaNa2EDTA ± DMSA. Treat iron deficiency before/during chelation; iron repletion can cause mobilisation of lead stores. Identify and eliminate the source.

At BLL 52 mcg/dL, environmental intervention + iron alone is insufficient; DMSA chelation is indicated at ≥45 mcg/dL. CaNa2EDTA alone is reserved for ≥70 mcg/dL or encephalopathy. Deferring chelation at this level risks ongoing cognitive damage.