Published online November 1, 2004
PEDIATRICS Vol. 114 No. 5 November 2004, pp. 1414-1418 (doi:10.1542/peds.2004-1721D)

This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Stein, M. T. Articles by Kennell, J. H. Search for Related Content PubMed Articles by Stein, M. T. Articles by Kennell, J. H. Related Collections Office Practice Social Bookmarking                         What's this?

SUPPLEMENT ARTICLE

Preparing a 3-Year-Old and His Parents for an Elective Surgery^*

Key Words: preparation for procedures • hospitalization • anesthesia induction • recovery room

	CASE

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
Billy's pediatrician discovered an inguinal hernia and referred him to a pediatric surgeon for a herniorrhaphy. Plans were made for an elective surgery. The pediatrician then received a call from Billy's mother. Although she agreed that Billy (3 years old) needed the procedure, his mother inquired about the risk of general anesthesia: "I heard that some children have a horrible time when they are given anesthesia." She also read about some parents present at the time an anesthesia is given to a child: "Can I be with Billy when he goes to surgery?" In addition, after talking to several parents, she heard that the immediate postoperative period can be difficult for some children. She asked, "Wouldn't it make sense for me to be with Billy when he wakes up after surgery? I'd like to comfort him and let him know that I am there with him."

The pediatrician, only a few years from her training, was comfortable answering the first question but was uncertain about a response to the latter 2 questions. She considered reviewing the literature in this area and investigating local options.

---

 

Preparing a 3-Year-Old and His Parents for an Elective Surgery^,*

Martin T. Stein, MD

Professor of Pediatrics
University of California
San Diego, California

	Dr Martin T. Stein

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
When planning a medical procedure, pediatricians consider the developmental age, temperament, and past experience of the child and the educational level of the parents in order to prepare them for the procedure. This occurs during common office procedures such as a blood pressure measurement, standard immunizations, and a venipuncture. When a surgical procedure is planned with general anesthesia in a hospital setting, there are other considerations advanced by both parents and clinicians. Questions about the effects and risks of anesthesia are prominent among most parents. Many parents are aware that an abrupt and even temporary separation may be associated with fears, sleep problems, and disruptive behaviors following the surgery.

This Challenging Case of a 3-year-old facing surgery is not an unusual encounter in pediatric practice. In this situation, the mother raised specific concerns as a result of reading articles and talking to other parents. The pediatrician provided Billy's mother with an opportunity to discuss her concerns during an office visit. To her credit, the pediatrician recognized that she did not have the necessary objective information to accurately answer the mother's questions. A phone call to the surgeon or anesthesiologist and the nursing coordinator, along with a literature review, would provide the pediatrician with the information and insight to address the mother's questions.

Two commentaries from experienced pediatricians with different training and clinical backgrounds provide the foundation for the discussion. Dr Peter Rothstein is Professor of Clinical Anesthesiology and Pediatrics at the College of Physicians and Surgeons of Columbia University. He directed the pediatric intensive care unit and was Director of Pediatric Anesthesiology at Babies Hospital in New York City. Dr John Kennell is Professor of Pediatrics at the Case Western Reserve University School of Medicine. A developmental-behavioral pediatrician, Dr Kennell has conducted significant research on early mother-infant attachment and the effects of the perinatal environment on newborn and neonatal outcomes.

---

 

Preparing a 3-Year-Old and His Parents for an Elective Surgery^*

Peter Rothstein, MD

Professor of Clinical Anesthesiology and Clinical Pediatrics
College of Physicians and Surgeons of Columbia University
New York, New York

	Dr Peter Rothstein

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
When a young child requires surgery and anesthesia, many questions go through parents' minds. Issues of safety and the risk of anesthesia are at the forefront. When considering the issue of safety and risk, it is important to consider the reason the child is having surgery and the child's health status. Two other issues that impact outcome are the skill and experience of both the anesthesiologist and the surgeon. Whenever possible, the anesthesia should be performed by a pediatric anesthesiologist or one with a large pediatric experience. Similar considerations apply to the surgeon. In 1 of the few studies that show the benefit of subspecialty training, children anesthetized by a pediatric anesthesiologist, as compared with a nonpediatric anesthesiologist, had decreased risk of critical events in the operating room.^1,2

When assessing the risk of anesthesia in children, many studies have looked at all infants and children with all disease categories and have not separated out healthy children having elective procedures. Thus, the stated risk of cardiac arrest or death in the operating room as the result of anesthesia in a healthy child has been significantly overestimated. The use of multiple monitoring modalities, electrocardiogram, blood pressure, temperature, pulse oximetry, and capnometry (breath-by-breath analysis of expired carbon dioxide content) have made the practice of anesthesia much safer, even in the last decade.^3–5 The discussion of risk is a discussion that the anesthesiologist should have with the parents before the operative procedure.

The induction of anesthesia in a child is usually a very rapid event. Most young children will become anesthetized while breathing a mixture of anesthetic agents, as opposed to adults who will usually have an intravenous induction. In the event of emergency surgery such as appendectomy, for safety reasons anesthesia induction in a child will be performed by the intravenous route. The preparation of the child during the time immediately before induction varies in different hospitals and varies depending on the age of the child and the experience and practice of the anesthesiologist. Some children clearly need and benefit from the use of premedication. In most instances, this is accomplished with the use of oral midazolam. (In other situations, rectal methohexital is appropriate.) Oral premedication will usually calm a child and produce some amount of amnesia during the preinduction time period.⁶ A number of hospitals allow parents to accompany their child to the induction area or operating room while their child is being anesthetized.^7,8 Although not all children will benefit from parental presence at induction, parents who are questioned state that their presence is helpful for themselves.^9,10

Most procedures such as herniorrhaphy employ local anesthetics for postoperative pain relief. The local anesthetics may be placed by means of a variety of regional nerve blocks administered by the anesthesiologist or may be instilled locally by the surgeon. In the recovery room, should additional analgesia be needed, intravenous analgesics can be administered. A number of hospitals allow parents to be with their child in the recovery room shortly after surgery. Parental presence in the postoperative period provides reassurance and comfort to the child. In our hospital, where parents join their child immediately after surgery, children who are frightened and upset by the strange surroundings and events are calmed by the presence of a parent, and in many instances, decreased use of postoperative medications is possible.

Many pediatric procedures are performed on an outpatient basis. Postoperative vomiting may occur; however, the major determinant of postoperative vomiting is the surgical procedure that is performed and not anesthesia. It is not unusual to see behavioral changes, particularly in younger children, after surgery. These behaviors may include sleeping difficulties, changes in eating habits, or difficulties with separation. These changes seem to occur independently of any other events such as pain or upset stomach in the immediate perioperative period. Most of these behavioral changes resolve themselves in the weeks following surgery.

	REFERENCES

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 

1. Keenan RL, Shapiro JH, Dawson K. Frequency of anesthetic cardiac arrests in infants: effect of pediatric anesthesiologists. J Clin Anesth. 1991;3 :433 –437[CrossRef][Medline]
2. Keenan RL, Shapiro JH, Kane FR, Simpson PM. Bradycardia during anesthesia in infants. An epidemiologic study. Anesthesiology. 1994;80 :976 –982[Web of Science][Medline]
3. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology. 1990;72 :828 –833[Web of Science][Medline]
4. Morray JP, Geiduschek JM, Ramamoorthy C, et al. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology. 2000;93 :6 –14[Web of Science][Medline]
5. Rothstein P. Bringing light to the dark side. Anesthesiology. 2000;93 :1 –3[CrossRef][Web of Science][Medline]
6. Kain ZN, Hofstadter MB, Mayes LC. Midazolam: effects on amnesia and anxiety in children. Anesthesiology. 2000;93 :676 –684[CrossRef][Web of Science][Medline]
7. Schulman JL, Foley JM, Vernon DT, Allan D. A study of the effect of the mother's presence during anesthesia induction. Pediatrics. 1967;39 :111 –114[Abstract/Free Full Text]
8. Hannallah RS, Rosales JK. Experience with parents' presence during anaesthesia induction in children. Can Anaesth Soc J. 1983;30 :286 –289[Web of Science][Medline]
9. Kain ZN, Mayes LC, Caramico LA. Parental presence during induction of anesthesia: a randomized, controlled study. Anesthesiology. 1996;84 :1060 –1067[CrossRef][Web of Science][Medline]
10. Kain ZN, Mayes LC, Wang SM, Caramico LA, Krivutza DM, Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology. 2000;92 :939 –946[CrossRef][Web of Science][Medline]

---

 

Preparing a 3-Year-Old and His Parents for an Elective Surgery^*

John H. Kennell, MD

Professor of Pediatrics
Case Western Reserve University School of Medicine
Cleveland, Ohio

	Dr John H. Kennell

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
Mrs Brown, Billy is a healthy, happy boy who is trusting and securely attached to you, thanks to your thoughtful consideration of his developmental needs from the time he was born. Your questions show that you are concerned with his emotional as well as his physical needs. You want him to feel he can manage his anesthesia experience and continue his trusting relationship. Perhaps you and I can make certain arrangements so that Billy's experience may result in more positive medical and emotional outcomes.

Let me explain what I consider the best plan. The pediatric surgeon who saw Billy operates at 3 hospitals and will support what I am recommending in whichever hospital you choose. For Billy's sake, we want to select a hospital that has pediatric anesthesiologists who will let you stay with Billy up to the time he has anesthesia and falls asleep (called the induction) and then again when he begins to wake up (recovery). During the surgery, you will wait in the room outside the operating room. As soon as the surgeon finishes, he will come and talk with you, but it may be a half hour or so before the anesthesiologist brings Billy into the recovery room outside the operating room. The nurse will call you to stay with Billy until he is alert and able to take oral fluids and to void and until his pain, if any, is under control. For the hernia repair, the surgeon may use internal dissolvable sutures or sutures that will be removed later. Billy will see a medium-sized bandage where the doctor "fixed his bump" below the belly button, and this area may be sore for a day or two. You can explain to Billy that the area will heal similarly to when he fell and hurt his knee.

Further, I recommend that, if possible, you choose a hospital that has a Child Life Program that prepares children having ambulatory surgery and then supports them and the parents. The Child Life Specialist, let's call her Becky, would advocate for you to be with Billy, as we have just discussed, during the induction and until his discharge home several hours later. She can also be an advocate for your needs as well as Billy's during your stay.

Becky will set up a preadmission meeting for you, your husband, and Billy. She will prepare you to be with Billy until he falls asleep and explain how you can best help him in recovery. She may provide a therapeutic cloth doll (which Billy can keep) that allows her to prepare Billy for his operation. This preparation may include taking his blood pressure and identifying body parts, including the "bump," as well as showing him the mask used for anesthesia. She will encourage Billy to play doctor with the doll, giving him an active roll. Billy will also be encouraged to touch and handle the mask that will be used for his anesthesia. He will also be allowed to choose a flavored ChapStick to provide his induction mask with a pleasant smell. You and Billy may practice breathing with the mask through play activities, for example, pretending to blow bubbles a certain number of times.

Becky will provide additional training for you and your husband so you can work as part of the team in caring for Billy. For example, because you recognize his cry when he is in pain, you can alert the nurse when he may need medication. Becky will explain that, in the early excitement stage of the anesthesia, Billy may move around and talk in his sleep in a way that you have probably observed at home. She will ask you to talk to him in a soothing voice or sing a familiar tune that will comfort him as he gradually falls asleep. She will also describe the recovery period for you. For example, Billy may be agitated when he first awakens. This is normal and is due to a child's inability to feel in control as he awakens from anesthesia. Becky will explain that it takes time for his stomach to wake up and begin to function after anesthesia, so you should observe Billy's behavior closely and be alert to when he is ready for some ice, fluids, or a Popsicle. Check out the 3 hospitals and let me know what you have learned and which you will choose.

---

 

Preparing a 3-Year-Old and His Parents for an Elective Surgery^*

	Web Site Discussion

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
The case summary for the Challenging Case was posted on the Developmental and Behavioral Pediatrics Web site (www.dbpeds.org.list) and the Journal's Web site (www.lww.com/DBP). Comments were solicited.

	Ramona Kearney, MD, FRCPC, Pediatric Anesthesiologist

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
Parental presence at induction of and emergence from anesthesia has been a hot topic for some time. I have reviewed the recent literature on the topic of parental presence at induction of and emergence from anesthesia in children. A summary of some of the work follows:

1. Looking at infants only, parental presence had no impact on infant behavioral distress during induction. Parents had comparable anxiety levels and levels of satisfaction whether or not they were present.¹
   
2. Children who are anxious during induction have an increased likelihood of developing negative behaviors such as nightmares, separation anxiety, and aggression toward authority postoperatively.²
   
3. Extensive preoperative preparation programs (including operating room tour, video, and Child Life Specialist) have limited anxiolytic effects localized to the preoperative period and did not extend to the induction of anesthesia or postoperative recovery period.³
   
4. In a comparison of 2 groups, each of which received preoperative sedation and 1 of which had parents present in addition, parental presence had no additive effects in terms of decreasing the child's anxiety. Parents, though, were less anxious and more satisfied.⁴
   
5. Oral midazolam is more effective than either parental presence or no intervention for managing a child's and parent's anxiety during the preoperative period.⁵
   

I was unable to find any studies on presence at emergence. As a result of this information, each institution has its own policy. As you can see, the evidence is far from clear that children benefit from this practice. From a personal point of view, I have had parents present at induction for nearly 10 years, and it appears that some children do benefit and parents can be used to strategically distract their child during an intravenous induction. If a parent is very concerned about the child's anxiety, I do give oral midazolam, which is an effective sedative that does not make the child very sleepy. Children rarely require a parent during recovery, as they leave as soon as they are awake, and children with good pain control in recovery are seldom upset due to the lingering sedative effects of the anesthetic agents.

The decision to permit parental presence is a policy unique to each institution. The only way to find the answer is to contact the hospital where the child's surgery will occur. In many hospitals, literature regarding the perioperative routine is available either through the surgeon's office, the department of anesthesiology, or the hospital itself.

Many hospitals have preoperative tours for prospective pediatric patients, preoperative anesthetic clinics for consultations with children and parents, or simply access to an anesthesiologist over the phone.

	REFERENCES

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 

1. Palermo TM, Tripi PA, Burgess E. Parental presence during anaesthesia induction for outpatient surgery of the infant. Paediatr Anaesth. 2000;10 :487 –491
2. Kain ZN, Wang SM, Mayes LC, Caramico LA, Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg. 1999;88 :1042 –1047[Abstract/Free Full Text]
3. Kain ZN, Caramico LA, Mayes LC, Genevro JL, Bornstein MH, Hofstadter MB. Preoperative preparation programs in children: a comparative examination. Anesth Analg. 1998;87 :1249 –1255[Abstract/Free Full Text]
4. Kain ZN, Mayes LC, Wang SM, Caramico LA, Krivutza DM, Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology. 2000;92 :939 –946
5. Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology. 1998;89 :1147 –1156[CrossRef][Web of Science][Medline]

---

 

Preparing a 3-Year-Old and His Parents for an Elective Surgery^,*

	David Farris, MD, Pediatric Anesthesiologist

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
Studies have shown that parental presence at induction of anesthesia does not affect most children during induction. As you might expect, some children are calm with their parents and others act out. Some parents like it; for others it increases their anxiety.

Early studies used the child's behavior during induction as the outcome. While I like a quiet induction, really, who cares how that went when the child has nightmares and behavioral regression for weeks afterward? (This is a known, though poorly quantified occurrence.)

Better that the child's memory banks are temporarily suspended—he/she does not need to "be there." Amnesia is safely induced with oral midazolam 25 minutes before the induction. Sorry to be old-fashioned (ie, pharmaceutical), but studies are beginning to show that chemical amnesia will improve psychosocial outcomes.

---

 

Preparing a 3-Year-Old and His Parents for an Elective Surgery^,*

	Morris Wessel, MD

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
Regarding preparing for hospitalization and surgery, early in my practice in l953, I visited a child (age 8) preoperatively and took her for a walk down to the surgical suite. I stopped at the door, and she asked, "Why can't we go in? Isn't this where I will be going tomorrow?" I had no ready answer so I pushed the door open. It was in the evening and the nurses were very gracious when I said, "This is Suzy. She is going to have surgery tomorrow and I thought it would be nice if she could see where she was going and meet you." The nurse was quite gracious.

This became a regular routine in my practice the night before elective surgery. Many surgeons approved and appreciated this role. However, over the years the anesthesiologists took offense, saying that the preoperative preparation of the child was their responsibility. They seemed to be unaware that, as good as they were, they were newcomers to the child and family, where, as a primary pediatrician, I already had a relationship with them. I kept this up throughout my practice.

I cannot measure the success of my intervention, but it was satisfying to me, and when I retired, this intervention was mentioned by many children and parents. I don't think one can measure the "success" of an intervention, but it certainly was satisfying for me to observe how appreciative parents and children were when I took on this task.

I am quite certain many nurses and anesthesiologists today are more thoughtful about playing a comparable role than their counterparts were 50 years ago, but still, the primary pediatrician who has a long relationship with parents and children is unbeatable.

---

 

Preparing a 3-Year-Old and His Parents for an Elective Surgery^,*

	Dr Martin T. Stein

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 

"Parents only may visit their child between 12:30 PM and 1:30 PM"

I was a resident in a New York City hospital that cared for children throughout most of the 20th century when I came across these barely readable words etched into a small, aging brass plaque on the wall at the entrance to the pediatric ward. Nurses and doctors were the healers; the parental role was temporarily suspended.

During the past 50 years, an enormous amount of attention has been given to the psychosocial effects of medical and surgical procedures carried out on children. The films and writings of John Robertson illustrated the potential for disruptive and withdrawal behaviors among young children during hospital experiences in England. John Bowlby's attention to attachment focused our awareness on the predictable effects of a temporary separation between a young child and her parents. He demonstrated that, when toddlers experience abrupt or prolonged separation from parents, they undergo a progression of behavior patterns from protest, to despair, and finally to denial.¹

With the growth of the child advocacy movement and children's hospitals, pediatricians, nurses, surgeons, anesthesiologists, child psychologists, and social workers combined their talents and unique perspectives to develop programs to ensure a child-focused hospital experience. In Working With Children in Hospitals,² Emma Plank observed that the child and family experience during a hospital stay is strongly influenced by medical and surgical procedures and the professionals who care for the child. The Child Life Program, referred to by Dr Kennell, was an outgrowth of this movement. In addition, experience showed that attention to the architectural design of a modern children's hospital may affect the well-being and healing capacity of children and their parents.

This particular Challenging Case was chosen to highlight the opportunities for child and parent education at the time of a medical or surgical procedure. The goal is always to demystify the procedure through the acquisition of knowledge. To be effective in this role, pediatricians need to assess the developmental age and temperament of the child, the educational level of the parents, their past experience with medical procedures, and their anxieties about the present procedure. The cultural beliefs of the family should be assessed, especially when the family's "explanatory model"³ for understanding the condition or treatment may be different from the explanatory model of the health care professionals. Drs Wessel and Kennell, both experienced pediatricians in the application of developmental and behavioral principles to patient education, provide practical guidelines for carrying out this role.

Pediatricians can apply many of the recommendations made by Dr Rothstein and the 2 pediatric anesthesiologists from the Web site discussion when they counsel parents. An emphasis on the experience of the surgeon and anesthesiologist may lessen anxiety. A statement that recent technical innovations in anesthesiology (eg, oral midazolam as a premedication to manage a child's and parent's anxiety during the preoperative period) and the standardization of extensive physiological monitoring of children during the procedure will usually bring comfort to parents.

When we isolate a particular event during a hospitalization for evaluation, it is extraordinarily difficult to know whether that event alone has an impact on a child's subsequent behavior. For that reason, it has been a challenge to determine the potential benefit from the presence of a parent during induction and during the emergence from anesthesia. Although the studies that have evaluated these events have not substantiated their benefit to the child (some parents are less anxious and more satisfied when present during induction), it is interesting to learn from the discussants that many pediatric anesthesiologists continue to find them useful in some situations. Thankfully, the practice of pediatrics strives to individualize treatment strategies as we learn more about each child and family.

	FOOTNOTES

 
^* Originally published in J Dev Behav Pediatr. 2002;23:37–41.

	FOOTNOTES

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 
A bimonthly discussion of an upcoming Challenging Case takes place at the Developmental and Behavioral Pediatrics Web site. This Web site is sponsored by the Maternal and Child Health Bureau and the American Academy of Pediatrics section on Developmental and Behavioral Pediatrics. Henry L. Shapiro, MD, is the editor of the Web site. Martin Stein, MD, the Challenging Case editor, incorporates comments from the Web discussion into the published Challenging Case. To become part of the discussion at the Developmental and Behavioral Pediatrics home page, go to www.dbpeds.org.

	REFERENCES

TOP CASE Dr Martin T. Stein Dr Peter Rothstein REFERENCES Dr John H. Kennell FOOTNOTES  Web Site Discussion Ramona Kearney, MD, FRCPC,... REFERENCES  David Farris, MD, Pediatric... Morris Wessel, MD Dr Martin T. Stein REFERENCES

 

1. Robertson J. Young Children in Hospitals. 2nd ed. London, United Kingdom: Tavistock; 1970
2. Plank E. Working With Children in Hospitals. Cleveland, OH: Case Western Reserve University Press; 1971
3. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88 :251 –258

---

PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Stein, M. T. Articles by Kennell, J. H. Search for Related Content PubMed Articles by Stein, M. T. Articles by Kennell, J. H. Related Collections Office Practice Social Bookmarking                         What's this?