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PE5.1-4 | Behavioural Problems — PBL Case

CLINICAL SETTING

You are a final-year MBBS student posted in the Paediatric OPD of a district government hospital in semi-urban Tamil Nadu. It is a busy Monday morning. A 42-year-old agricultural labourer, Mr. Raju, arrives with his wife Meena (38 years) and their youngest child, Arjun, a 5-year-old boy. Mr. Raju has had to take unpaid leave to bring the child, and his expression is tense. Meena carries a cloth bag with the child's school report card and a list of complaints she has written in Tamil. The family lives in a joint household with grandparents. Arjun is shy but physically active in the waiting area.

Trigger 1: The Opening History

Meena speaks first: 'Doctor, Arjun has been eating chalk from the walls of our house and soil from the courtyard for over six months. His teacher also complained that he eats the chalk from the classroom blackboard tray. We have scolded him many times but he keeps doing it. He also wets his bed every night — he is 5 years old and has never had a single dry night in his life. The teacher says he smells of urine and his classmates are teasing him. He is becoming quiet and withdrawn at school.' Mr. Raju adds: 'And doctor, last week he had a frightening episode at home. He fell and hurt his knee, started crying very hard, then suddenly went completely blue around the mouth, went limp, and fell unconscious. My mother thought he was dying. He came back to normal in less than a minute. No fever, nothing. Should we do an EEG or a brain scan?' On observation: Arjun is thin but active. His conjunctivae are pale. He does not look anxious. Growth parameters: weight 14 kg (15th centile), height 104 cm (25th centile).

DISCUSSION POINTS

  • How would you define pica? Does Arjun meet the diagnostic criteria? What features of his pica are specifically concerning and why?
  • What is the most likely diagnosis for the episode described by Mr. Raju? Construct the differential diagnosis and identify the clinical features that distinguish these conditions.
  • How do you classify Arjun's enuresis (primary vs secondary, nocturnal vs diurnal)? What does this classification imply about aetiology and workup?
  • What are the mandatory investigations you will order before the end of this OPD visit, and why is each one critical?
Click to reveal Trigger 2: Investigation Results (discuss previous trigger first!)

Trigger 2: Investigation Results

You order the following investigations, results return within 2 hours: - Haemoglobin: 8.2 g/dL - Peripheral smear: microcytic, hypochromic red cells; occasional target cells - Serum ferritin: 5 ng/mL (reference 12-150 ng/mL) - Serum iron: 38 mcg/dL (low); TIBC: elevated - Blood lead level: 48 mcg/dL (reference <5 mcg/dL) - Urine routine: no RBCs, no nitrites, no casts; specific gravity 1.018 - Urine culture: no growth after 48 hours (you review this result retrospectively) - Renal ultrasound: normal bilateral kidneys, no hydronephrosis, bladder wall not thickened Arjun's house was built in the early 1990s; the walls have old distemper paint that the family says is 'peeling in places'. The grandmother, who has come to join the family, says: 'All children eat soil. In our time, we all did. It builds immunity. Do not give him medicines — just give him good food.'

DISCUSSION POINTS

  • Interpret the blood lead level in the context of the clinical guidelines. At this level, what is the management plan for lead toxicity — be specific about thresholds, the chelating agent of choice, dose, and duration.
  • How does iron deficiency relate to both the pica and the lead poisoning? What is the mechanistic link between iron deficiency and increased lead absorption?
  • How would you address the grandmother's belief that soil-eating builds immunity? What communication strategies would you use to counsel the family about the lead exposure, given their trust in traditional practices?
  • The urine is normal and renal ultrasound is normal. Does this change your workup for enuresis? What further assessment is required before managing Arjun's enuresis?
Click to reveal Trigger 3: Management Decisions — Navigating Complexity (discuss previous trigger first!)

Trigger 3: Management Decisions — Navigating Complexity

You explain the findings to the family. Mr. Raju is shocked about the lead level: 'Doctor, we cannot afford to do more tests or buy medicines every month. I earn ₹300 a day and work only 20 days a month. The public pharmacy does not stock the chelation medicine. How will we manage?' Meena is also worried about the bed-wetting: 'He is starting Class 1 next month. His teacher says if he smells of urine he will be sent home. My mother-in-law says we should wake him up at midnight to urinate — she does this every day. My husband says we should scold him when he wets — maybe shame will cure him.' Regarding the episode last week: after further questioning, you confirm: Arjun was running, fell and hurt his knee, cried very hard for 15-20 seconds, then there was total silence, perioral cyanosis for about 30 seconds, and brief loss of consciousness lasting less than 1 minute. He was walking and asking for water within 2 minutes. No post-ictal phase. No fever. This is the third episode in 6 months. EEG has not been done.

DISCUSSION POINTS

  • Formulate the complete management plan for all three conditions simultaneously: (a) pica/lead toxicity — treatment steps in order, explaining to the family in plain language; (b) iron deficiency anaemia — dose in mg/kg/day of elemental iron; (c) nocturnal enuresis — behavioural strategies first, pharmacological options with hierarchy, and specifically what to tell Meena about the midnight awakening and scolding strategies.
  • Is an EEG indicated for Arjun's breath-holding spell episodes? Justify your decision and outline what you would say to Mr. Raju who is convinced his son needs 'brain tests'.
  • How do you manage the socioeconomic barrier to DMSA chelation? What government programme resources (ASHA, community health centres, Jan Aushadhi scheme) could you mobilise? What is the role of identifying and remediating the lead source in their house?
  • Design a follow-up schedule: what do you assess at each visit, what milestones would indicate improvement, and what are the 'return immediately' red flags you communicate to the parents?
Click to reveal Trigger 4: 6 Weeks Later — Follow-Up (discuss previous trigger first!)

Trigger 4: 6 Weeks Later — Follow-Up

Arjun returns 6 weeks later. Haemoglobin has risen to 10.1 g/dL. Blood lead level has dropped to 32 mcg/dL after the first course of DMSA (obtained through the district hospital pharmacy after your escalation to the CMO). The peeling paint sections of their house walls have been covered with fresh plaster arranged through the local panchayat. Enuresis: Meena reports that she stopped waking Arjun at midnight and stopped scolding him. They have been using a star chart. He has had 8 dry nights in the last 6 weeks — a major improvement from zero. He is now less withdrawn at school. Breath-holding spells: there have been two more episodes. The family followed your advice (stayed calm, placed him on his side) and both resolved within 1 minute. The grandmother now says 'the doctor was right — no fit medicine needed'. Arjun's teacher asks for a medical note explaining the enuresis and requesting she not shame him in front of classmates.

DISCUSSION POINTS

  • Interpret the improvement in Hb and BLL. Does Arjun need a second course of DMSA? What is the criterion for repeat chelation?
  • Evaluate the enuresis management: 8 dry nights in 6 weeks is a good response to behavioural therapy. At what point would you consider adding desmopressin? What formulation and dose would you choose and why (oral tablet vs nasal spray)?
  • Draft the medical note for Arjun's teacher in plain language. What key points must it include to protect the child from stigma while educating the school?
  • What does this case illustrate about the interaction between organic (iron deficiency, lead exposure) and behavioural (pica, enuresis, BHS) conditions in Indian paediatric practice? How does addressing the organic root cause modify the behavioural outcomes?

Group Task Assignments

Group 1: Collaborative Task

Group 2: Collaborative Task

Group 3: Collaborative Task

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PE5.1] What are the organic causes of feeding problems in infants and toddlers, and how do non-organic/behavioural causes present differently? What is the evidence base for responsive feeding?
  2. [PE5.2] What is the pathophysiology of cyanotic and pallid breath-holding spells? How are they distinguished from epilepsy, and what is the role of iron deficiency in their pathogenesis and treatment?
  3. [PE5.3] What are the diagnostic criteria for pica, its organic associations (iron deficiency, lead poisoning, ASD, intellectual disability), and the management protocol for lead toxicity at different blood lead level thresholds?
  4. [PE5.4] What is the classification of enuresis (primary/secondary, nocturnal/diurnal), what organic causes must be excluded, and what is the evidence-based management hierarchy (alarm > desmopressin > imipramine)?