Behavior: Ask the experts


Tantrums to the max. Salt pica?mental or physical problem?



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Tantrums to the max

Q The mother of an 18-month-old girl is concerned about her daughter's recurrent tantrums, which occur several times a week. They lead to breath-holding, cyanotic spells, and, occasionally, loss of consciousness. The child is not anemic but is being treated with supplemental iron. Fearing another breath-holding spell, the mother gives the child everything she wants. I have reassured the mother that the spells are not harmful, but she is still too fearful of more episodes to discipline her daughter. What do you suggest?

Brian Goldstein, MD
Plainview, N.Y.

A The most important points for this mother to understand are that her toddler is manipulating her and that this is not a healthy parent-child relationship. Consider the following strategies:

  • First, reassure the mother that the breath-holding and cyanotic spells are benign. If the parents are unable to accept this information and remain excessively concerned about the health of the child, as in vulnerable-child syndrome, investigate that problem further. In my clinical experience, further discussion is usually unnecessary.

  • Suggest that the parents minimize or eliminate unnecessary frustrations that are triggering tantrums. They should not, however, avoid normal parental discipline and management.

  • Advise the parents to allow the breath-holding spells to happen without paying much attention to them or giving in to what the child wants. Help the parents understand that breathing will resume as soon as the child becomes unconscious. It is reasonable for the parents to remain with the girl during the spell to be sure that she does not get hurt, but it is not reasonable for them to scream at her or plead with her to stop. Afterward, the parents should talk with the child without expressing anger, fear, or guilt. These measures are, of course, the same general ones to apply when tantrums occur without breath holding.

  • Encourage the parents to find ways to teach the child more acceptable coping strategies that will help her abandon this behavior.

The use of iron supplements in case of anemia has sometimes been recommended as an effective way to reduce the frequency of cyanotic spells. In the absence of anemia, the value of this measure is unclear.

William B. Carey, MD

DR. CAREY is clinical professor of pediatrics, University of Pennsylvania School of Medicine, and director of behavioral pediatrics, division of general pediatrics, Children's Hospital of Philadelphia.

Salt pica—mental or physical problem?

Q I have a patient, a 7-year-old boy, who has a history of simple febrile seizure and a learning disability manifested as poor writing skills and hyperactivity. He just finished the first grade. His mother's main concern is his ravenous, implacable appetite for salt. She has witnessed him downing the entire contents of saltshakers. He also enjoys soy sauce (he drinks the whole bottle), salt-containing sweetened beverages, saltine crackers, and chips. His appetite is otherwise poor, and his growth is in the fifth to 10th percentile for his age. I should add that, according to his mother, the boy "drinks and pees" constantly.

The boy's iron studies and electrolytes are normal. (A sweat chloride test is pending.) His mother believes he may be grieving for his father, who left the family a year ago. Could his problem be anxiety? He doesn't seem to have other symptoms of obsessive-compulsive disorder, and his interactions with peers appear to be normal. He was evaluated at our development center and was not thought to have attention deficit hyperactivity disorder (ADHD).

R.Winfred, MD
Grafton, W.Va.

A The major concern here is medical. This child needs to have renal and metabolic evaluations. If he is metabolically normal, eating this volume of salt would certainly require him to drink and pee all day.

Is his salt craving present in all settings? Is there some reward or gain that he gets for consuming so much salt? Is his mother genuinely trying to limit his behavior?

Finally, in my 25 years of practice, I have never seen a child consume large amounts of salt because of a psychiatric disorder, and neither has a colleague who has run a referral center for pediatric gastrointestinal and metabolic disorders at Massachusetts General Hospital for 25 years. So this is a rare bird indeed.

Michael S. Jellinek, MD  

DR. JELLINEK is president of Newton Wellesley Hospital and chief, child psychiatry service, Massachusetts General Hospital, and professor of psychiatry and of pediatrics, Harvard Medical School.

Invited commentary: I agree with Dr. Jellinek that one first needs to rule out a medical cause behind this boy's excessive salt consumption before proceeding to consider behavioral causes. There are medical conditions that result in excessive salt loss and that require large quantities of salt intake to maintain homeostasis of normal sodium and osmolality. In this child's case, salt restriction should be undertaken in a controlled setting. If a medical condition is causing excess salt loss, the serum sodium should decrease because there would still be unchecked sodium losses. If this is an intake problem, in which excess sodium and water intake are driving increased urine output, the serum sodium will not decrease but the urine output will decrease. During salt restriction, appropriate serum and urine studies for electrolytes, osmolality, and possibly certain hormonal levels, such as antidiuretic hormone (ADH), atrial natriuretic peptide (ANP), and aldosterone need to be obtained. They will indicate whether a salt-losing condition exists and, if so, what the underlying cause might be. The table at right lists possible causes.

I do not believe the child has a problem with retaining water, such as you would see in syndrome of inappropriate (secretion of) antidiuretic hormone (SIADH), as the child is constantly "peeing." SIADH would cause the patient to retain water inappropriately with excess volume leading to hyponatremia.

If the cause is medical, I suggest looking into the cause of excess salt as outlined above. If this is an intake problem, then behavioral modification of the diet needs to be started. Finally, keep in mind that all of the diagnoses mentioned in the table above are uncommon and some are rare conditions.

Melanie S. Kim, MD

DR. KIM has a background in nephrology and is associate professor of pediatrics, Boston University Medical School, associate director of residency training, Boston Combined Residency Program, and a member of the Contemporary Pediatrics Editorial Board.

Causes of excess sodium loss

Renal causes

Mineralocorticoid deficiency*

Mineralocorticoid resistance*


Polyuric acute tubular necrosis*

Acute renal failure*

Bartter syndrome or Gittelman syndrome*

Gastrointestinal causes

Secretory diarrhea

Laxative abuse

Intestinal fistula or ileostomy

Transcutaneous causes

Cystic fibrosis

Central nervous system (CNS) causes

Cerebral salt wasting*

This condition occurs in children with acute or chronic CNS damage from head trauma, tumor, meningitis, or CNS surgery. Large renal salt loss occurs because of elevated ANP levels with low levels of renin and aldosterone.

*In these conditions, despite a low serum sodium concentration, urinary sodium levels will remain inappropriately elevated indicating excess renal sodium losses.


Behavior: Ask the experts. Contemporary Pediatrics 2002;11:34.

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