The earsplitting scream turned every head. D, an otherwise healthy and robust 2-year-old boy, had arrived for his checkup and was having a superhero-size tantrum.

Of course, routine visits to the pediatrician can trigger discontent in toddlers, but this boy's reaction was lasting an unusually long time. None of the staff's usual interventions were working and it was becoming clear he was fast approaching an inconsolable stage.

His mother said that lately, D's meltdowns were getting worse; he was less talkative and not sleeping well at nap time or bedtime. He had lost all interest in potty training. The temper tantrums were taking control and bringing the house down.

At previous checkups, D had been described as pleasant and cooperative. He was growing and developing well, and, until recently, had been a loyal playmate to his older brother.

What had changed?

Despite the ongoing tantrum, an attempt was made to take a history.

D's mother disclosed that she hadn't been able to interact with D as much as she used to. A hardworking, stay-at-home mother, she used to spend hours sitting on the floor, playing with her two boys.

Over the course of recent months, however, she had been suffering with severe back and neck pain, and three weeks before this visit, was hospitalized seven days for surgery.

During that time, the boys' father stayed home with them. When D's mother returned, she immediately noticed that D's disruptive behavior had escalated and was more dramatic than ever; he was barely sleeping at all during the night.

On physical exam, D's facial features appeared coarser compared with previous visits. When asked to walk, D crossed the exam room floor on tiptoe.

When the allotted time for the visit passed the hour mark and D continued to scream, the physician's concerns increased. Had D suffered an emotional trauma? Was he being abused? Were his behaviors signs of developmental regression or autism? The decision was made to admit him for further evaluation.

Solution

Once admitted to the inpatient pediatric ward, the child-life specialist accompanied D to the unit's playroom while the admission interview with the mother took place.

She further explained that on a good night, D had no more than five hours of uninterrupted sleep. At bedtime, he struggled with her before relenting and usually woke up unhappy and demanding to play.

Asked about the tiptoe stance, his mother clarified that he walked on his toes only when the floor was cold. On carpeted areas, D walked normally.

A few months ago, D's mother tried to potty train both boys at the same time, thinking there might be strength in numbers. Her older son accomplished the task almost immediately, and D initially showed interest and tried hard to comply. Now he adamantly refuses to participate in potty training and prefers diapers.

When D returned to the hospital room, the tantrum resumed immediately and with vigor. He stopped crying only long enough to take a breath.

With his mother's assistance, a physical exam was completed and no physical signs of injury or abuse were noted. His gait was normal.

Without any focal source of concern on D's exam, it was decided to attempt an appropriate night's sleep. Melatonin is both a hormone made by the pineal gland affecting sleep and a safe supplement often used to promote sleep. D's mother agreed he would be given a small dose of melatonin, but in the end, he fell asleep before taking it. Exhaustion from the day's adventures turned out to be the better medicine.

What was causing this profound change in behavior?

Many toddlers and preschool-age children have significant bedtime behavior problems or night waking, and these are often improved by establishing bedtime routines and "sleep hygiene." Such routines may include taking a bath, reading a book, and maintaining a consistent bedtime.

"Sleep hygiene" is giving a person a quiet, dark place to sleep without electronics like TVs, cellphones, or computers to stimulate the sleeper.

For D, who already suffered from poor sleeping patterns, the absence of his mother may have set off a habit of sleeplessness that culminated in the frenzied tantrum the medical staff witnessed.

The coarseness to his face observed in the office could be attributed to his constant crying.

The toe walking, while sometimes a concerning sign of abnormal muscle tone or cerebral palsy, was a likely red herring brought about by the cold, hard floors at the clinic. In the hospital, D was with his mother, and the room was quiet and dark without a television on and he could finally sleep.

That night, D slept soundly for 10 hours. His mother was elated and said he had never slept so long. When he awoke, D was smiling and playful. He made eye contact, was interactive and cooperative. After his respite from constantly crying, his handsome facial features were again obvious. D was back and the worrisome and frenzied child we saw the day before was gone.

Margaret Lafferty is senior pediatric resident at Thomas Jefferson University / DuPont Hospital for Children.