Medsarticles. Medical Weblog

Preschoolers experience the same sleep problems as toddlers. Bad habits and behaviours learned during the toddler period have often become entrenched by this time. During school age most children will have outgrown the problems seen at younger ages, but this is the peak age for nightmares, school terrors and sleepwalking. Some children also have trouble getting off to sleep, or wake very early in the morning. This is often related to stresses in their day to day life, and many children ruminate endlessly about the day’s events or worry about what the next day will bring.

In general, the problems referred to above are those that persist for prolonged periods of time when the child is well and there are no specific family disruptions. It is very important for parents to understand that all children will exhibit altered sleep patterns when they are sick or there are changes to family routine. Even trivial illnesses, such as colds, that do not seem to affect young children much during the day, may affect them at night. They may need more cuddling and become more dependent on parents, and may wake during the night even if they have already established regular sleep patterns.

Similarly, it is quite normal for children to regress at times of stress or family disruption. Children who have to spend time in hospital or have been separated from the parents for some other reason will behave like a younger child for a period of time. One of the commonest reasons children regress, including reverting to more immature sleep patterns, is the arrival of a younger sibling.

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Pinch the patient’s nose between finger and thumb, take a deep breath and apply your lips firmly on the lips of the patient.

If this procedure or blood or vomit around the mouth makes you sick, place a clean handkerchief over the mouth and breathe through that.

If the mouth is injured or if it is difficult to breathe through the mouth, “mouth-to-nose” resuscitation will produce equally good results.

Breathe into the mouth and watch to see if the chest is rising. This will show that your breath is getting into the patient’s lungs. Then sit up and watch the chest collapse. This will show that the air is coming out. Take another deep breath and repeat the exercise.

For a child, breathe at the rate of about 20 per minute, and for adults about 10-15 per minute. As a rule a few quick breaths for a start, then settle into a routine.

If artificial respiration has to be maintained for some time, you may become tired. If there is someone with you, taking turns will make it easier. Keep it up until the patient starts breathing on his own.

If your patient starts breathing, even shallowly, time your breathing to coincide with his.

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Mention gout and people are apt to snigger, yet this common disease is no laughing matter.

My introduction to gout was in the comics of my youth, where the Indian Army colonel with the flushed face had his foot wrapped in a turban and his mood was always irascible.

This comic attitude, unfortunately, still persists, so that the sufferer gets little sympathy. But he himself is also likely to regard it too lightly.

Gout, or podagra, is an ancient disease, being well known even before the time of Hippocrates, the “father of medicine” who lived nearly 500 years before Christ. The list of famous men who have had this disorder reads like an historical Who’s Who.

Gout is mainly a male disease — 20 times as many men get it for every woman sufferer. The first attack usually comes in the forties but it is not unusual in men in their twenties — and it can even occur in children.

The trouble is an inborn error in metabolism — the tendency to gout is inherited.

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The operation which women most fear is removal of the breast.

This is only done for cancer and the fear of that disease is added to the feeling of disfigurement and loss of femininity.

Hysterectomy, or removal of the womb, on the other hand is usually done for non-cancerous conditions. Yet this operation is often misunderstood by women and as a result leads to many problems which are mainly preventable.

The uterus or womb is an organ, shaped like a pear and about the size of a golf ball. It lies low in the pelvis and can’t be felt through the abdomen unless it is enlarged. The neck of the womb, or cervix, projects into the top of the vagina.

From either side of the uterus come the Fallopian tubes and the outer open ends of these lie over the ovaries. The womb is held in place by ligaments.

The inside of the womb is hollow and lined by tissue called the endometrium.

During a woman’s reproductive life, this tissue is acted on by the hormones, oestrogen and proger-sterone, which are produced by the ovaries.

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There are all kinds of worms. Some you find when digging in the garden. They’re usually long, juicy-looking, slimey things but they are useful (so my gardening friends remind me) for aerating the ground and helping plants grow. Then there are cut-worms which always seemed to chop off my new seedlings at ground level (that’s why I gave up gardening). My older brother, an inveterate and fanatical fisherman in his spare time, often searches the beach for worms when holidaying. He says they make good bait.

But I’m getting carried away… I wish to talk about human worms, or rather worms that inhabit the human system. They are commonly called threadworms, or Enterobius vermicularis if you like scientific names you can hardly get your tongue around. They are called threadworms because they look just like that. A bit of white cotton cut up into little lengths. Only they are very active and can turn and twist and crawl around in a most active way.

Worm infestations are common in children. Often the worms, in large numbers, come from the anal canal and crawl around the external part of the back passage. In fact, if examined at night with a torch, many of these creepy crawling things may be seen in a child with a heavy infestation. Personally, they give me the creeps.

In turn, this produces irritation and itching of the back passage. Often the child scratches, and the area may become sore or even infected if the skin is broken and germs start multiplying. Worms are commonly blamed for irritation, nail biting, nervousness and restlessness, especially during the night. Often vague gastric and nerve symptoms are related to infestations, rightfully or wrongfully. And the worms in their merry-making may become lost; cases have been reported in girls where the worms have reached the vagina and set up irritations there. They are also blamed for some cases of ongoing bed-wetting in children. But often there are few or no symptoms.

Commonly all of the children in a family may be infected. The eggs are highly infectious, and transmitted by scratching fingers from the anal region, they may reach toys, school books, writing implements and other objects that are of common interest. Once the eggs have reached the fingers, it is only a matter of time before they reach the mouth, then the bowel. Here they readily and rapidly hatch out, to set up further infestation. Inattention to adequate hygiene is a major factor in their spread. Inadequate hand washing after handling another person’s property, or before handling food or putting the hands to the mouth, is an important factor.

Treatment

Often it is simple to make the diagnosis, and often parents themselves will see the worms in their children. A simple examination of the stools will often reveal their presence; sometimes the doctor will have an examination carried out to discover either the worms or their eggs. These may be collected from fresh stools, or from around the anal margin. A simple test to detect their presence is done by sticking a piece of cellophane adhesive against the patient’s skin, removing it and replacing it on a glass slide which is then examined under the microscope. The doctor or pathologist may do this.

General hygiene is important. All members of the household should be treated at the same time—or the whole class if the disorder is widespread and has come to the general attention of the teachers.

The hand-washing routine after attending the toilet every time, and before handling or eating food, is essential. Soap and hot water should be used. The fingernails should be scrubbed often with a nail brush and soap. Nails should be kept short at all times, and regularly retrimmed. Regular washing of underclothing and bedclothes is important in getting rid of eggs.

Medication is usually very effective. However, although a single dose is often adequate to kill the organism in the bowel, reinfection is common. Ideally, the whole family is treated at the same time, and proper medical supervision is suggested. Pyrantel embonate (commercially known as Combantrin) and viprynium embonate (Vanquin) have been widely and successfully used for several years. Mebendazole (Vermox) in one single dose is also extremely effective.

Roundworms

Infestation by roundworms (Ascaris lumbricordes) is rare in this country. It is common in tropical countries, and may cause abdominal distention, colic, diarrhoea and emaciation. It is diagnosed when the worm or its eggs are located in stools. The egg may be passed in the faeces into the soil, where larvae develop, and are retransmitted to humans via soil-contaminated fingers or feet. Medical treatment is satisfactory.

Tapeworms

Tapeworms (caused by Taenia saginata from beef or Taenia solium from pork) come through eating inadequately cooked infected meat. General abdominal symptoms, diarrhoea and fever may occur. The parasite sucks blood from the bowel lining. Diagnosis is made when parts of the body are detected in faeces. Medical treatment effects a cure.

Giardiasis

A parasitic bowel infestation, giardiasis has been around for many years, but only for a short time, to any appreciable extent, in Australia. It produces loose bowel actions that do not stop within a few days, as do most bowel upsets. Motions are loose, watery, frothy, offensive. Most doctors consider a diarrhoea that has been persisting for a week or more to be most likely caused by this parasite. It is treated with metronidazole, and proper medical supervision is advisable. Treatment is invariably effective, but recurrences may occur. Most cases have been imported into Australia from European and Eastern lands, and it is now firmly entrenched in this country, especially in the eastern states.

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‘Over the years millions and millions of babies have been successfully bottle fed and have come to no harm. If this kind of feeding is necessary, the mother should accept the fact and not have “hang-ups” over it, for the baby will certainly thrive and develop into a happy and healthy child and adult.

‘When bottle feeding the ideal is to hold the baby as close to your body as possible, for close body contact, once more, increases the mother-baby bond which we believe is important to normal development.

‘Is cow’s milk given straight?’ Karen asked.

‘No, cow’s milk must be modified to make it suitable for the baby. Many excellent commercial brands are available which have been modified to simulate mother’s milk as much as possible. Often the proper amount of vitamins and minerals have been added to provide the necessary requirements.

‘Once more, demand feeding may be practised. But, it has been found that overweight is more common in bottle-fed babies. Whereas a baby will automatically gauge how much breast milk he or she takes, a vigilant parent may think it essential that the baby drain the last dregs from a measured amount of fluid in a bottle. Often the baby is best barometer of food needs.’

‘We often hear horrible stories about breast feeding. Some claim it will ruin your figure; your breasts will look terrible afterwards; that you develop fat on the hips and thighs and around the tummy, and so on. What do you say about this?’

‘The breasts certainly increase in size before the birth and during lactation,’ I said. ‘This is inevitable. After it is all over, the breasts tend to return to their previous size. Sometimes, there is a change in the fat distribution of the mother’s body, possibly because of the various hormonal changes that took place during the whole experience. Many women find breast dimensions similar to the time before they were pregnant. Others find them smaller as the fat deposits have lessened.

‘Many women put on from three to six kilograms (6-14 lb) in weight, from the time before pregnancy to the time the baby is a few months old. What’s more, this weight is often hard to dislodge. It tends to accumulate around the hips, thighs and buttocks and abdominal wall. It is often a consequence of the woman’s eating more during these months, perhaps in the hope of producing enough good-quality milk for the baby. But, commonsense eating habits and a sensible diet after it is all over will help her regain her normal pre-pregnancy shape again.’

‘Normally my breasts are quite small,’ Karen said. ‘They are large right now, but will this affect my milk-producing ability?’

‘No, breast size is no indication of how good your supply of milk will be. Often women with small breasts prove to be the most prolific milk producers, whereas many large-busted women are the opposite. Large breasts simply mean they contain more fat, and this has nothing to do with the milk glands and milk production. Aren’t you lucky?’

“What about taking medicines during breast feeding? Is this safe?’

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Sources of minerals and trace elements and their uses

Calcium

function in body: Growth and maintenance of healthy teeth and bones; nerve function; blood clotting; muscle contraction; metabolises iron.

sources: Fish (especially those eaten with bones); soybeans; dairy products; almonds; sesame seeds; sunflower seeds; watercress; fortified cereals. Vitamin D facilitates uptake. effects of deficiency or excess: Deficiency can cause rickets, osteomalacia, osteoporosis.

Chromium (trace element)

function in body: Functioning of skeletal muscles; storing and metabolising sugars and fats.

sources: Unrefined wholegrain and cereal products; fish and shellfish; brewers yeast; beef.

effects of deficiency or excess: Deficiency can cause depression, confusion, irritability. Excess can be toxic.

Cobalt (trace element)

function in body: Component of Vitamin B12 which prevents anaemia.

sources: Meat; liver; kidney; shellfish; green leafy vegetables. effects of deficiency or excess: Deficiency causes lack of Vitamin B12, leading to pernicious anaemia; bowel disorders; weak muscles.

Copper (trace element)

function in body: Formation of red blood cells; growth of bones; absorption of iron; pigmentation of hair and skin. sources: Shellfish; nuts; liver; kidney; pulses; brewers yeast; tap water from copper pipes.

effects of deficiency or excess: Deficiency can cause anaemia, low white blood cell count. Excess can be toxic.

Fluorine (trace element)

function in body: Strengthens teeth and bones.

sources: Fluoridated tap water and toothpastes; fish (especially

those eaten with bones); meat; tea; cereals.

effects of deficiency or excess: Deficiency causes tooth decay,

osteoporosis. Excess causes mottled and discoloured teeth,

increased density of bones in the spine, pelvis and limbs and

calcified ligaments.

Iodine (trace element)

function in body: Production of hormones in the thyroid gland which control metabolism; promotes growth; promotes energy; mental alertness

sources: Iodised salt; Irish moss; kelp; seafood; fruit and vegetables grown in soils containing iodine.

effects of deficiency or excess: Deficiency causes goitre, weight gain, lack of energy. Excess can cause thyroid diseases.

Iron

function in body: Production of haemoglobin; distribution of oxygen and removal of carbon dioxide in body tissues; production of myoglobin (red pigment in muscles). sources: Red meat; liver; kidney; oysters; kelp; pulses; dried fruits; nuts; oats.

effects of deficiency or excess: Deficiency causes anaemia. Magnesium

function in body: Healthy teeth and bones; functioning of the nerves, muscles and metabolic enzymes. sources: Wholewheat cereals and products; eggs; meat; nuts; pulses; seeds.

effects of deficiency or excess: Deficiency causes muscle cramps, tremors, tics, loss of appetite, nausea, insomnia, irregular heart beat.

Manganese (trace element)

function in body: Functioning of the nerves, muscles and many enzymes; bone strength.

sources: Whole grains; nuts; pulses; avocado; egg yolk; green leafy vegetables.

effects of deficiency or excess: Deficiency can cause bone deformities and impede growth rate.

Molybdenum (trace element)

function in body: Metabolism of iron; male sexual function; prevention of dental caries

sources: Oats; barley; pulses; root vegetables; liver.

effects of deficiency or excess: Excess can prevent body from

utilising copper.

Phosphorus

function in body: Conversion and storage of energy; healthy bones; function of muscles, nerves and some enzymes; intestinal absorption of certain foods.

sources: Meat; poultry; fish and shellfish; nuts; seeds; pulses; dairy products; eggs.

effects of deficiency or excess: Deficiency causes bone pain; stiff joints; disorders of the central nervous system; weakness. Excess can interfere with intestinal absorption of calcium, iron, magnesium and zinc.

Potassium

function in body: Maintains balance of fluids and pH in the body; disposal of body wastes; aids in sending oxygen to the brain; function of nerves and muscles.

sources: Fresh fruits and vegetables; whole grains and products; prunes; milk.

effects of deficiency or excess: Deficiency can case muscular weakness and paralysis, low blood pressure; thirst; loss of appetite; sensitivity to noise. Excess can aggravate some heart conditions.

Selenium (trace element)

function in body: Functioning of the red and white blood cells; along with Vitamin E works as an anti-oxidant; detoxifies metals including cadmium, mercury and lead; may protect against some cancers; prevents dandruff and some skin disorders; healthy liver function.

sources: Garlic; onions; whole wheat and products; fish and shellfish; red meat; chicken; broccoli; brewer’s yeast; Brazil nuts.

effects of deficiency or excess: Deficiency causes premature aging, cardiovascular disease and asthma and may be a factor in cancer. Excess can cause neurological disorders.

Sodium

function in body: Along with potassium maintains balance of fluids, especially water, and pH in the body; function of nerves and muscles.

sources: Common salt, baking powder; cured and smoked fish and meats; kelp; beets; artichokes; coconut; figs. effects of deficiency or excess: Deficiency can cause heat prostration, dehydration, low blood pressure and indigestion. Excess causes high blood pressure, heart disorders and oedema (fluid retention).

Sulphur (trace element)

function in body: Synthesis of protein; promotes healthy skin, hair and nails; combats bacterial infection. sources: Meat; fish; dairy poducts; eggs; pulses; cabbage. effects of deficiency or excess: Deficiency can cause skin diseases.

Zinc (trace element)

function in body: Formation of insulin in body; release of Vitamin A; healing; healthy reproductive organs; functioning of growth and development enzymes.

sources: Red meat, liver; egg yolks; dairy products; whole wheat and products; oysters; brewers yeast.

effects of deficiency or excess: Deficiency can cause infertility, enlarged prostate gland, acne and skin disorders, slow healing of wounds, slow physical, mental and sexual development. Excess can cause nausea, diarrhoea, dizziness and dehydration.

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Choking is one of the few true emergencies of childhood in which minutes may determine life or death. A swallowed object is the most common and serious cause of choking. Choking is caused by the obstruction of the airway resulting in an inability to breathe. It is easily identified by two key signs: the child frantically tries to breathe, and the child is not able to cry out or to speak.

If choking continues, the child quickly becomes blue, convulsive, limp, and unconscious. If the object completely blocks the air passage, you have only a few minutes to reestablish an airway before brain damage or death can occur.

The objects that choke children are usually of a shape and size to plug the opening into the throat like a cork. Frequent and especially dangerous causes of choking are peanuts, tablets, glass eyes of toy animals, hard or hard-coated sweets, beads, popcorn, and tiny toys or small parts from toys. Solid particles of food from the stomach may choke a child who breathes in during vomiting. A vomiting baby is safest from choking when lying on his or her stomach.

Choking may also occur in a child who has croup. But choking caused by croup is slightly different and is treated differently. A child choking from croup frantically tries to breathe, but the child is still able to speak or cry. See the article on Croup for treatment of that form of choking.

Signs and symptoms

Choking on an object is easily identified by the two major symptoms. There are frantic, unsuccessful efforts to breathe. The child cannot talk or cry.

Home care

Seconds count! Scream for help. A second adult on the scene should phone the police or paramedic squad for help. (Police are usually more quickly available in most communities than an ambulance, the fire department, or a doctor.)

First, give your child one minute to clear the obstruction by his or her own efforts. If this doesn’t work, place your child’s head down over a chair, table, or your lap and pound hard on his back four times. Broken ribs heal; death does not. Support the child’s head and neck before pounding to avoid fracturing the neck.

Only if safer measures fail should you consider reaching into the child’s mouth with a hooked finger or tweezer in an effort to remove or dislodge the foreign body: there’s a good chance of pushing the object more tightly into the windpipe in your desperation to remove it. If your child is not breathing after the object is removed, give mouth-to-mouth resuscitation until trained help arrives.

Precautions

• Never give mouth-to-mouth resuscitation until the obstructing object is removed; to do so may force the object further down the throat.

• Prevention of choking is most important. Examine all toys for loose eyes or other small parts. Keep tablets under lock and key. Do not give peanuts, popcorn, or hard sweets to toddlers. (Clean up after adult parties before children can wander unattended into a room.)

Medical treatment

When the object completely blocks the air passage, the child seldom reaches a doctor in time. However, the object may only partially block the airway, even though you may not think so. Your doctor will operate, on the spot, to open the windpipe through the neck (tracheotomy). Then oxygen, artificial respiration, and intravenous fluids will be given.

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Scientific studies have rather consistently demonstrated that companionship contributes to good health. The quality of relationships also is a factor, found Xinhua Steve Ren, Ph.D., assistant professor at the Boston University School of Public Health and research health scientist with the Center for Health Quality, Outcome, and Economic Research of the Veterans Affairs Medical Center in Bedford, Massachusetts. Here are some of his other findings.

•     Separation and divorce can actually improve health – but only in cases where there were serious ongoing marital problems. Separation and divorce are most detrimental to health when the marriage had no prior serious problems and the crisis arose with the sudden discovery of infidelity.

•     Being separated is more injurious to health than divorce. The separated were more than 2 times as likely to consider themselves in poor health than were married folks, while divorced people were about 1.3 times more likely to think themselves in ill health.

•     The quality of a relationship-whether marriage or cohabitation-affects the participants’ health. Those in unhappy relationships are at higher health risk than those who are in happy relationships and, surprisingly, even than those who are divorced.

•     Compared to married people, the unmarried tend to have higher death rates from all causes, have higher levels of stress, and use more health services.

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Tonometry

This is a simple, painless method of measuring the pressure of the fluid in the eyeball. It is valuable to be aware of this pressure because an early rise, if caught, can be treated and can save the person’s sight. It is a test worth doing every two to five years after the age of 40.

Sigmoidoscopy (Looking inside the rectum or back passage)

Most cancers of the bowel lie within the view of a special instrument, called a sigmoidoscope. It is generally considered sensible to have a sigmoidoscopy every three to five years following two negative examinations a year apart at age 50. Other experts recommend one examination at age 56 because this is the peak age for this cancer, which is the second commonest.

Testing the stools for blood

Because microscopic amounts of blood can be lost in the stools in people who have bowel cancers this can be a very good way of detecting such cancers early and certainly long before they start to produce symptoms. It is probably sensible to have such a test done every year after the age of 50.

Testing for anaemia

Recommendations for the screening of adults for anaemia range from, every two to every five years. Women are particularly at risk because of having periods and childbearing. Many millions of people, women especially, are walking around sub-clinically unwell with anaemia yet remain unscreened. This is an easy and cheap test to do and the treatment is straightforward and inexpensive.

Blood sugar tests

Whether or not it is worth screening populations for their blood sugar levels to see if they are undiagnosed diabetics is controversial-mainly because there is no evidence yet that the early detection of diabetics without symptoms does anything to alter the long-term outlook. Some experts think that as the test is relatively cheap it is worth doing every five years until 65 and then every two years. Others feel that looking for sugar in the urine (another sign of diabetes) every five years is quite sufficient.

Screening for sickle cell trait

Certain high-risk populations (mainly black) should be screened prior to childbearing so that they can receive genetic counseling about the likelihood of having an affected baby. Some experts recommend that the test be done at the age of 10 years.

Checking for German measles (rubella) immunity

This disease, whilst not serious during normal life, can produce terrible handicaps in the baby of a pregnant woman who catches it. It is estimated that even with rubella vaccinations being widely available, about 15 per cent of women get to childbearing with no immunity to the disease. The most logical time for screening is just before childbearing age. Pregnancy should not be allowed to occur for three months after the immunization. A girl who is not immune can be vaccinated in her early teens. Many authorities think that every pregnant woman should be routinely tested for antibodies to rubella.

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