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Below: Dr. Epstein, pediatric intensivist, discusses when to seek medical care for your child with regards to delirium and the definition of lethargy.

(This is the 4th in a series of articles of the same title. Read the 1st article here)

 

As parents, we are always concerned about the health of our children. One of the most common questions that I get is:

“When should I seek medical care for my child?”

My simple response is:

”Whenever you feel the need!”

This is part 4 in continuation of “When to Seek Medical Care for Your Child”. I will discuss changes in behavior in this current posting.

 

Changes in behavior are definitely a normal part of childhood.

If you want to hear stories about behavioral issues, just ask any parent with a toddler…or a teenager, for that matter. Children are allowed to change their emotions or activity levels. However, there are certain behaviors that should raise concern for a parent and these are usually found at the extremes of the emotional or activity level spectrum.

For an infant, change in behavior is an interesting concept because most of their behavior is centered around sleeping, eating, and interacting at varying degrees as they grow.

They can’t verbalize their needs, so their interactions are limited by their emotions, manifested by being calm, happy, or crying.

If they are well fed, their diaper is clean, and they are comfortable, infants are often happy or calm. If they are hungry, have a dirty diaper, or are uncomfortable, infants often cry.

There are infants with varying degrees of being able to be consoled. However, if an infant is unusually irritable, crying, or not able to be consoled or not interactive and is lethargic, then there is cause for concern.

Of note, the term, lethargy, is often defined as a sleepy or less active infant by parents. However, in medicine, when an infant is described as lethargic, we envision an infant who is barely or not interactive or arousable. So, sometimes, picturing what a lethargic infant looks like differs from parents to the medical team.

 

Sometimes, picturing what a lethargic infant looks like differs from parents to the medical team. Click To Tweet

 

Severe infections, intestinal damage, brain injury, toxic ingestions, or other pathologies can cause an infant to act very differently than their normal behavior.

It should not be lost on anyone that parents play a crucial role in alerting the clinician to these changes because they know their infant better than anyone else. So when a parent is concerned, the medical team should be concerned.

The burden of proof is on the medical team to provide the proper reassurance (through a thorough history taking, exam, and necessary testing) to let the parent know that there is nothing wrong with their infant.

 

The burden of proof is on the medical team to provide the proper reassurance (through a thorough history taking, exam, and necessary testing) to let the parent know that there is nothing wrong with their infant. Click To Tweet

 

As children grow, become more verbal, and can explain what they are feeling, it may be a little easier to understand what is bothering them or at the root of their changes in behavior. There are more intricacies and complicated interactions that can stem from mental and physical health.

If there is any concern about behavioral changes in older children, these concerns should be brought to the attention of the child’s medical provider to assess and direct the course of exploration. These changes may be mild in nature or more severe.

 

At the more severe end of the spectrum for behavioral changes is delirium.

This is usually defined as a reversible toxic or metabolic brain pathology that is characterized by a disturbance in consciousness that ranges from extreme hyperactivity to coma (not being able to be aroused).

The ability to converse may be affected and the ability to sustain attention is limited in children with delirium.

The causes of delirium range from various severe infections to drugs and poisonings to low oxygen levels, metabolic derangements, head trauma, migraines, heat stroke, mental disorders, and other illnesses or injuries. If a child is experiencing delirium, an urgent visit to a medical provider is warranted.

 

Most behavioral changes in infants, children, and adolescents may not be related to an illness or injury; nevertheless, there are extremes of the behavioral spectrum or even subtle changes in behavior that should be taken a bit more seriously.

It bears repeating how important a parent’s role is in identifying these changes and bringing them to the attention of the medical team. It also bears repeating how important it is for the medical team to carefully listen and take a parent’s concerns seriously because they know their child better than anyone else.

Have you ever witnessed a child with altered mental status or significant change in behavior before?

Was there a particular reason for the altered mental status or significant change in behavior?

If you have any questions about this or other topics, please feel free to find me via my profile.

Stay tuned for a future discussion about suspected poisonous ingestions to follow.

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David Epstein, MD, MS, FAAP

Dr. Epstein is board certified in pediatrics and pediatric critical care medicine. He has a passion for community education and advocacy online and focuses on acute care pediatric topics.

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