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Cow’s Milk Allergy

What is cow's milk allergy?

Cow's milk allergy is an allergic reaction triggered by a protein in cow's milk. Like any allergic reaction, it represents an abnormal response by the immune system to a specific protein. It is one of the most common allergies in babies, some studies suggesting that up to 7% of infants may suffer from it.

Cow's milk allergy should not be confused with lactose intolerance, another common milk-related problem in which the sufferer may lack an enzyme needed to digest milk sugar. Many babies who are allergic to cow's milk eventually outgrow the problem. However, lactose intolerance tends to worsen as children get older. Many babies develop it as a temporary condition lasting for just a few weeks after a bout of gastroenteritis.

What causes cow's milk allergy?

Any allergic condition is the result of an over-reaction of the immune system, which normally protects the body from outside invaders, such as viruses or bacteria. Special cells produce antibodies that attack specific proteins identified as potentially harmful. In an allergic reaction, however, these antibodies seek out proteins in normally harmless substances known as allergens, such as a protein in cow's milk. A baby with cow's milk allergy can tolerate breast milk, but when fed a formula containing cow's milk, it triggers a sequence of events that results in the allergic response.

Symptoms In babies:

  • Frequent vomiting.
  • Blood in stools.
  • Unexplained skin rashes.
  • Slow growth rate.

In older children:

  • Itchy rash.
  • Breathlessness, coughing, wheezing.
  • Diarrhoea, vomiting.
  • Runny or blocked nose.

How is cow's milk allergy diagnosed and treated?

Symptoms such as a rash, diarrhoea, or blood in the stools should raise suspicion of cow's milk allergy, especially if they occur after a baby has been switched from breast milk to a bottle. The allergy usually shows up after a baby is put on a formula feed containing cow's milk proteins. In most cases, it disappears on its own by the time the baby is 1-2 years old.

The diagnosis can be confirmed if the symptoms disappear after cow's milk is eliminated from the baby's diet, then reappear when the baby is given a trial feed containing cow's milk protein.

Treatment consists of replacing cow's milk formula with one that does not contain these milk proteins. After the age of six months, some babies can tolerate milk from other animals such as goats. More often, the baby will be transferred to a soya formula.

What can I do myself?

By giving a baby only breast milk for the first few months of life, you can often prevent cow's milk allergy from developing. Babies who are not exposed to cow's milk for the first 6-9 months of life are not as likely to develop cow's milk allergy as those who are given it at an earlier age.

If there is a family history of allergies, some pediatricians advise women to avoid drinking cow's milk both while they are pregnant and

while breast feeding, so that the baby will not be exposed to cow's milk proteins at the age when most likely to develop antibodies against them.

 

When should I see my doctor?

If your baby is consistently experiencing diar­rhoea, vomiting or passing blood in stools you should visit your doctor.

You should also see a doctor or health visitor if the baby does not seem to be growing normally, or begins to lose weight after changing to a formula using cow's milk proteins.

What will the doctor do?

Your doctor will examine the baby and check to see if growth rate has been normal. You will be asked about feeding patterns and episodes of diarrhoea, vomiting and other symp­toms. If cow's milk allergy is suspected, cow's milk will be substituted with a soya formula, which is available from chemists and may be obtained on prescription. The symp­toms usually disappear almost immediately.

To confirm the diagnosis, the baby may then be given a 'challenge feeding' of cow's milk to see if the symptoms return. If so, it is clear that the problem has been correctly identi­fied as cow's milk allergy and the baby should not be given cow's milk until the age of 18 - 24 months.

For those infants who remain allergic to cow's milk beyond the age of two, a dietitian or doctor will be able to advise on which foods to exclude. In addition to obvious milk-based products, cow's milk may be present in bread, soups, cereals and instant mashed potato. The key ingredients to look out for on food labels are casein, lactose and whey, although hydrolysed casein should not cause an allergic reaction.

Is cow's milk allergy dangerous?

Not usually. However, it may affect the baby's growth rate; and frequent bouts of vomiting and diarrhoea can weaken an infant and increase susceptibility to infections and other illnesses.

WARNING

Do not exclude milk or milk products from your child's diet without medical supervision by a doctor or qualified dietitian. There may be a risk of nutritional deficiencies.

Ordinary cow's milk, as opposed to bottle or formula milk containing cow's milk proteins, should never be given to babies under six months old.

It contains high levels of sodium and potassium which immature kidneys cannot cope with. Ordinary cow's milk also contains proteins which infants are unable to digest.

Depression in Children

What is depression in children?

Depression in children is a state of mind in which the child feels consistently unable to acknowledge and enjoy the better aspects of life.

All children have times when they feel sad or anxious. Usually, these are outnumbered by the times when the child feels happy, positive and cheerful. These 'down' periods are often called 'depression'. In fact, they are very different from true depres­sion, which is very rare in young children, but slightly more common in older children and adolescents.

What causes depression in children?

Many cases have no obvious reason. Causes which can be identified usually involve a situation where the child feels a lack of control.

Parental separation, or a death in the family may bring about sadness that, rather than fading with time, grows stronger until it dominates the child's life. A child that feels unable to match parental or teacher expectations can also become depressed.

Some experts believe true depression can be traced to a metabolic (relating to body chemistry), or a hereditary cause.

Symptoms

  • Constant tearfulness.
  • Unwillingness to participate in social situations.
  • Eating much more or much less than usual.
  • Repeated aching head or stomach.
  • Repeated complaining of feeling generally unwell.
  • Changing sleeping patterns.
  • Loss of concentration.
  • Disruptive behavior.

How is depression in children diagnosed and treated?

Parents are generally the first to notice signs of depression in their child, but these are occasionally brought to their attention by friends, relatives, or schoolteachers.

Sometimes, the child becomes withdrawn to the point of being unable to cope with school or family life, or becomes so disruptive that the school or family feels unable to cope with the child.

Children's behavior is seldom constant, and one or two symptoms occurring over a period of a few days or even weeks is rarely a cause for concern.

However, help is required if your child exhibits several of these symptoms over a longer period of time, or if the symptoms are very severe over a short period.

Treatment rarely involves hospitalization. In most cases, the child, or even the entire family, may talk to a family therapist to try to identify and eliminate the cause of the depression.

If possible, treatment solely involves talking through the problem, but in very severe cases medication may be given, usually for short-term use.

In extremely rare cases, the child may be admitted to hospital until the condition has stabilized.

Talking through the situation and suggesting changes in lifestyle and behaviour may be enough to help but, if not, the doctor will probably either refer your child to a child psychiatrist or the entire family to a family therapist. In severe cases, especially if the child is thought likely to harm him- or herself, the doctor may recommend hospital admission until the condition has improved.

SAD - A SEASONAL DEPRESSION

Seasonal Affective Disorder (SAD) is a depressive condition that is triggered in susceptible people when the hours of daylight drop below a certain level. It is therefore more common in winter and can be distinguished from other forms of depression by the fact that it disappears once spring comes.

The condition can affect adults and children alike, but it is easily treated by controlled exposure to ultraviolet light.

When should I see my doctor?

Consult your doctor if the cause of your child's depression is not obvious, if talking through the problem is not enough, or if your child refuses to discuss the subject.

If a child is obviously unwilling or unable to confide in you, do not press the issue. Instead, ask your doctor for help.

What will the doctor do?

Your doctor will first ask questions to try to establish the cause of the depression, usually talking to you and your child individually.

FURTHER INFORMATION

The Institute of Family Therapy, 43 New Cavendish Street, London, W1M7RG. 071-935 1651

What can I do myself?

If you notice that your child is behaving in an uncharacteristic fashion and is showing some of the signs of depression, your first move should be to try to identify the cause.

It may be obvious: the death of a family member or friend, for instance, or tension within the family. The cause could lie in any area of the child's life, in or outside of the home, perhaps at school or among friends.

While you may not be able to remove the cause, discussing the situation with your child is, in some cases, enough to help resolve the problem.

Make sure to approach your child in the right atmosphere, when you are not likely to be disturbed, so that the child feels free to talk openly.

If you suspect that you may be unwittingly adding to your child's depression, try to modify your behavior. If symptoms persist, seek professional help.

Is depression in children dangerous?

Depression affects children's quality of life, causing them to miss out on its enjoyable aspects.

A depressed child is indicating that something is very wrong, and if the problem is not eliminated, depression can worsen. In extreme cases, a child may try to physically harm him- or herself, or even to attempt suicide.

However, if signs of depression are recognized, most children respond well to treatment. A sense of perspective quickly returns, and the child is soon able to enjoy life to the full once more.

Depression In Children's Literature

Anxiety in Children

What is anxiety in children?

Anxiety, like fear, is the normal response of the body to any situation perceived as threatening, and affects adults and children alike. When faced with a situation that provokes fear or anxiety, individuals have reacted in the same way since the earliest times, by preparing to fight or flee.

This response is involuntary, but can be modified by adults in their conscious mind. However, children are less able to control or understand their feelings in this way. All they understand is fear, which causes them to become anxious. Unless that fear is removed, the child will continue to be fretful and manifest the physical symptoms of anxiety.

A degree of anxiety can be beneficial (for example, before an exam or sporting event it may even enhance performance), but a more generalized feeling of anxiety over a period of time may affect the child's outlook on life and even lead to physical illness.

What causes anxiety in children?

Anxiety in children can have many causes, some of which may seem irrational or even absurd to parents.

Common causes include the arrival of a new baby, who may be seen as supplanting an older child in their parents' affections; fear of going to school, perhaps because of bullying or worrying about being unable to keep up; a change in the normal daily

routine, such as moving house or spending a night with relatives or friends.

Worrying about other people (for example, if the parents' relationship is going through a sticky patch or if there is illness in the family) can lead to anxiety, particularly if the child does not fully understand what is going on. Sexual or physical abuse will make a child feel isolated and anxious, and this will be heightened if the abuser has threatened terrible consequences if the child speaks out.

Symptoms

  • Disruption of normal sleeping and eating habits.
  • A change in energy levels.
  • Unwillingness to leave parents, or mix with others.
  • Personality change.
  • Reversion in behaviour such as bedwetting.
  • Frequent headaches and stomach aches.

Parents may cause anxiety in their child by expecting too much in the way of good behavior, achievement at school, or staying dry at night. They can also pass on their own fears through their behavior and reactions, (perhaps a fear of spiders or of visiting the dentist).

A lively imagination can lead to anxiety as children imagine getting lost, their house burning down, or a parent being killed. This type of fear may be induced by watching certain television programmes, or overhearing part of an adult conversation.

How is anxiety in children diagnosed and treated?

Parents or other adults close to the child are usually the first to notice any signs of anxiety. These vary from individual to individual, but may include changes in behaviour, par­ticularly in sleeping and eating habits; changes in energy levels; an unwillingness to leave parents or to mix with other children; and changes in personality, with the child often becoming more with­drawn or aggressive.

A child may also develop aches and pains and nervous mannerisms that cannot be explained by the doctor and may revert to more babyish behaviour such as bedwet­ting or wanting to be fed.

Treatment is ideally by removing the cause of the anxiety, although it may take time before the child is reassured. If you cannot determine the cause and the child continues to show signs of anxiety, you should see your doctor, who may recommend that your child sees a child psychologist, or that the whole family undergoes counselling.

When should I see my doctor?

If you cannot find the cause of your child's anxiety after talking with him or her and perhaps also school teachers, or if it persists or becomes worse, see your doctor, especially if the child develops any unexplained physical symptoms.

What will the doctor do?

Your doctor will ask questions about what is happening in your child's life and to the family in general. Often just talking to a sympathetic outsider and acting on the doctor's

suggestions is enough to resolve the situation but, if not, the doctor may either refer the child to a child psychiatrist or psychologist, or recommend that the entire family see a therapist.

Treatment is by trying to resolve the problem; only in exceptional cases is medication recommended.

What can I do myself?

The cause may be obvious to you as soon as you stop to think about what may be worrying your child, or they may be able to tell you. If the child cannot express what is causing the fear, try not to push, as this can result in more anxiety. Clear explanations and reassurance, a change in routine, or talking to a teacher or playgroup leader may be enough to remove the cause.

If you suspect your behavior may be adding to the child's anxiety, try to modify it, for example by not arguing or discussing your own worries in the child's presence. Never tease or mock your child. If there is no improvement, make an appointment to see your doctor.

Is anxiety in children dangerous?

As anxious behavior is a child's way of calling attention to something that is wrong, ignoring the signs may lead to greater problems. Always seek help sooner rather than later.

Your  doctor will be able to put you in touch with the local child guidance clinic, if necessary.

 

Bedwetting (Enuresis)

 

What is bedwetting?

Bedwetting is a lack of night-time bladder control in a child who is otherwise completely toilet trained.

Most children under the age of seven wet their beds occasionally, but bedwet­ting that occurs regularly over a long period is less common and more likely to be a problem.

About 1:4 children aged 4-5 years regularly wet the bed. The problem is slightly more common in boys than in girls.

What causes bedwetting?

The nerve centres that allow a child to recognize when the bladder is full and hold back urine until reaching the bathroom are not fully developed until around the age of two. In some children, slowed development of these abilities is the cause of bed wetting; they just need time to develop control.

Small bladder capacity can also contribute to the problem, as can other factors such as an abnor­mality of the urinary tract that is present from birth; the presence of a urinary tract infection; a defect involving the nervous system, such as damage to the spinal cord, or spina bifida (a congenital mal­formation of the spine).

Bedwetting can also be caused by uncontrolled diabetes mellitus (a deficiency of the hormone insulin, leading to large amounts of urine being passed, among other symptoms) or diabetes insipidus (deficiency of a substance called anti­-diuretic hormone, which is produced at the base of the brain, and which slows urine output).

However, in many of these conditions the child is likely to be incontinent during the day as well as wetting the bed at night.

The tendency to wet the bed runs in families; about 50% of bedwetting children have a close relative who has had the same problem.

As children get older they generally outgrow bedwetting. In the 6-10 age group, only 10% of children wet the bed, and only 3% continue to have problems as teenagers.

Emotional disturbances can also lead to bedwetting.

A previously toilet-trained child may start wetting the bed after the arrival of a baby brother or sister, a move to a new house, or when parents are having marital difficulties, such as bitter rows or living apart.

How is bedwetting investigated and treated?

Parents usually report repeated episodes of bed wetting to the family doctor, who tries to find the cause of the problem.

If overnight bladder control is not achieved by the age of four or five years, the problem is called primary enuresis, and physical causes are usually suspected.

Children who have been dry at night but who have reverted to bedwetting are said to have secondary enuresis; in these cases, emotional factors are more likely to be involved.

In most cases, time and parental patience, support and understanding are the only treatments necessary.

Some parents report success with special alarm systems that are designed to wake the child when he or she starts to urinate. These devices have been particularly effective with children aged over seven.

Occasionally, a drug that may decrease the dream stage of sleep and reduces the sensitivity of the blad­der muscle is prescribed for older children.

New evidence shows that some bedwetters can benefit from the adminis­tration of artificial anti­diuretic hormone which, if given at night, may reduce urine output.

When should I see my doctor?

You should see your doctor if a child's bed-wetting continues after the age of five and occurs more than twice a month, even after you have tried the measures described here.

What will the doctor do?

The doctor may carry out urine tests to rule out urinary tract infection or diabetes. If either of these conditions is present, treating it should clear up the bed-wetting.

Investigations may be arranged to see if it is caused by abnormalities of the bladder or urethra (the passage through which urine exits the body). For example, urography (X-ray imaging of the uri­nary tract), or ultrasound scanning (in which images are produced by sound­waves) may be performed.

Most of the time, such tests and examinations fail to uncover a simple cause for bedwetting. Therefore, the doctor's role is generally to offer support to parents and children until time solves the problem.

What can I do to avoid bed-wetting?

  • Limit your child's evening intake of fluids.
  • Wake the child for a trip to the toilet at 10 or 11pm.
  • Try not to rush toilet training.
  • Do not expect your child to achieve bladder control at night as soon as he or she is trained in the daytime

What can I do myself?

Exasperating as bedwet­ting may be, parents should not punish a child for wetting the bed, or say things that will increase the child's embarrassment, or focus undue attention on the problem.

Instead, it is far better to take practical measures.

For example:

  • Limit the child's fluid intake in the evening and wake the child for a trip to the bathroom before going to bed yourself.
  • Try training the child to increase the length of time he or she can go without urinating during the day, a strategy that may lead to greater control at night.
  • Use a plastic mattress cover under the bed sheets.

Younger children can continue to wear nappies, but you should avoid using nappy-wearing as a humiliating punishment.

Some children respond to a system of behaviour modification in which they get points or gold stars for every night they are able to stay dry.

Is bedwetting dangerous?

Bedwetting is not dangerous in itself. The main risk is the damage it can do to a child's self-image, which can be avoided if the parents handle the episodes of bedwetting with patience, understanding and sensitivity.

Amniocentesis

What is amniocentesis?

This test may be performed on a pregnant woman to find out whether the unborn baby has certain genetic characteristics or birth defects.

It involves withdrawing fluid from the amniotic sac in which the foetus floats. This fluid contains waste materials and cells shed by the foetus, which can be analysed to reveal several things about the baby's genetic make-up.

While amniocentesis is not necessary for every pregnancy, it is often recommended for women over age 35, if there is a history of miscarriages (lost pregnancies), or if there is a family history of certain genetic diseases, chromosome defects, or mental retardation. It may also be done towards the end of pregnancy to determine whether the foetal lungs are mature enough to allow the baby to be delivered early, should this be advised for the health of mother or baby.

In addition to showing the presence of some abnormalities, amniocentesis can also identify the sex of the foetus, which is important if one or both parents are carriers of a sex-linked disease such as hemophilia.

It can rule out certain conditions like Down's Syndrome (a chromosomal abnormality causing mental handicap) and Tay-Sachs disease (a serious inherited metabolic disorder). It cannot detect all birth defects, but it helps to discover spina bifida (open spine), and other neural tube disorders. In all, about 80 of the possible 400 anomalies of the foetus can now be detected by amniocentesis.

What happens during amniocentesis?

You lie on a table with your hands folded on the upper chest to avoid touching the sterile area. The abdominal area is carefully cleansed, then an anesthetic is injected where the needle will be inserted to withdraw the amniotic fluid. The procedure will not begin until the area is numb.

Ultrasound is used to find the position of the foetus. This is a painless, risk-free technique that uses sound waves and their echoes to visualize internal organs such as the uterus, and the foetus. Your skin in the area to be examined is covered with a lubricant. The transducer, a machine that looks like a microphone and sends out and receives the sound waves, is passed over your skin. A computer translates these echoes into a picture on a television screen. Ultrasound is not harmful to the foetus.

The amniocentesis procedure itself involves inserting a sterile, hollow needle through your skin, the wall of the uterus, and into the amniotic sac. The doctor watches the ultra­sound monitor to make sure the needle does not puncture the baby. The needle suctions off a small quantity of amniotic fluid and is then withdrawn. A small bandage is placed on the skin. The sample of fluid is sent to the laboratory where it may be grown in tissue culture and analysed.

Does amniocentesis cause discomfort?

You will not feel anything during the test because of the anesthetic. Afterwards you may feel faint or nauseous, or perspire profusely. These aftereffects can usually be relieved by turning to lie on your left side.

How long does amniocentesis take?

The total time taken for all the procedures described above is about half an hour. The actual amount of time taken to insert and withdraw the needle is only a few minutes.

You will not be able to leave for at least an hour after the procedure is completed, so your breathing rate, blood pressure, and pulse, as well as the foe­tus' heart rate, can be monitored for any changes that may signal problems.

When will I get the results?

Some results are available almost at once, while others take a few days. Growing the cells in tissue culture for chromosomal analysis takes several weeks to complete.

Since amniocentesis cannot normally be done until the 15th week of pregnancy and all the results are not normally known for another 3-4 weeks, this precludes an abortion within the first three months should a problem like Down's syndrome be detected. An abortion can still be done if the parents so desire, but the decision is often difficult if the pregnancy is more advanced.

Is amniocentesis dangerous?

Amniocentesis is generally safe for both the mother and the foetus. But in a very small number of cases, the test precipitates a miscarriage. There is also a slight risk of infection or damage to the foetus if it is accidentally hit by the needle, but this is uncommon. The placenta may also be damaged, which can in turn cause harm to the foetus.

In addition, certain fac­tors can produce false test results, although this is rare. These include foetal blood or faeces in the test specimen or the presence of certain diseases in the mother, including certain types of cancer, viral infections like glandular fever (infectious mononucleosis), and liver disease.

Amniocentesis is not, therefore, undertaken lightly; for example, just to find the sex of the foetus. The doctor will only recommend amniocentesis if the potential benefits from the information to be obtained outweigh the risks of the procedure.

WARNING

After the test, notify your doctor if you feel:

  • Abdominal pain, cramping, or contractions.
  • Chills and fever.
  • Bleeding or fluid loss from the vagina.
  • Unusual activity or lethargy of the foetus.

Phenylketonuria (PKU)

What is phenylketonuria?

Phenylketonuria (PKU) is an inherited metabolic disorder which causes serious brain damage and other abnormalities if it is not diagnosed soon after birth, and the necessary diet followed.

The condition affects 60 - 70 new-born babies each year. It appears to be more common in Scotland and Northern Ireland. Boys and girls are affected in equal numbers.

PKU is thought to be an autosomal recessive disorder. This means that not only must both parents be carriers of the defective gene, but that the gene must also be passed onto the child from both parents to cause the disorder.

The parents are usually unaffected. Each of their children has a 25% chance of inheriting PKU.

What causes PKU?

Phenylketonuria (PKU)Phenylketonuria (PKU)PKU occurs when there is a defect in the activity of a metabolic enzyme (substance which brings about chemical change) called phenylalanine hydroxylase. This is the enzyme that facilitates the conversion of one of the amino acids (the building blocks of protein), called phenylalanine, into tyrosine, another amino acid.

In PKU, phenylalanine cannot be broken down normally. If it is not excluded from the diet, it builds up in the spinal fluid and bloodstream. An abnormally high level of phenylalanine prevents normal development of the brain and nervous system. If unchecked, this can lead to severe mental impairment.

How is PKU diagnosed and treated?

In order to detect PKU early, all newborn babies are routinely given a blood test called the Guthrie test. In the UK, this is usually done between 6-14 days after birth. It measures the amount of phenylalanine in the blood. If it is higher than normal, other specialized tests may then be performed to confirm a diagnosis of PKU.

PKU is effectively treated by restricting the intake of phenylalanine in the diet. Once diagnosis is confirmed, babies will be prescribed a special milk substitute or feed. The baby is carefully monitored by the doctors to ensure the level of pheny­lalanine is dropping.

After weaning, babies are given a very low protein, mainly vegetarian, diet. This is done to exclude phenylalanine, as it is a natural constituent of most protein containing foods, such as meat, fish, cheese and eggs.

Ordinary bread, flour, cakes and biscuits are also generally not allowed. Foods such as cereals and milk contain some pheny­lalanine and can be given only in limited amounts.

There are a number of special food products available for PKU sufferers, and your doctor, dietitian or health visitor will be able to give advice.

In addition to strict dietary control of protein intake, phenylalanine-free amino acid supplements may be taken to avoid deficiency of these vital nutrients, which are necessary for normal growth.

In general, a normal diet is introduced when the child is about 10-13 years old, apart from some restriction of protein intake.

Blood tests are carried out regularly to monitor the level of phenylalanine in the blood.

When should I see my doctor?

You should see your doctor if you notice that your child is not develop­ing properly. Your doctor will be able to coniirm whether or not the Guthrie test was carried out and, if it was, will inform you of the result.

A child with PKU will be monitored regularly by the doctor to ensure that the blood levels of phenylalanine do not get dangerously high. This is especially important when the child starts to eat a more normal diet.

If you, your partner, or a close member of either family has PKU, you should consult your doctor before attempting to have a child (see box above).

What can I do myself?

If you or your child has PKU, you should closely follow your doctor's dietary instructions.

Is PKU dangerous?

Yes. If left untreated, PKU can cause severe mental impairment, physical abnormalities, and neurological disorders.

However, when it is effectively treated from a very early age, there is little risk of damage.

Can a person with PKU have healthy children?

A woman with PKU can have a healthy baby as long as she goes back onto the phenylalanine-free diet before pregnancy. This is necessary because a baby is at a high risk of congenital heart defects, brain damage and other abnormalities if exposed to high concentrations of phenylalanine before birth.

The child of a person with PKU can only inherit the disorder if the other parent is a PKU carrier.

If you decide to have a family and you or your partner (or a close member of either family) has PKU, ask the doctor to refer you for genetic counselling. The counsellor will be able to help in making an informed decision, based on the risks involved.

What will the doctor do?

If your baby is diagnosed as having PKU from the Guthrie test, the family doctor will work closely with the hospital dietitian to advise on the proper diet for your child to ensure no long-term damage occurs.

 

Speech Problems

What are speech problems?

A childhood speech problem is regarded as present when a child's level of speech understanding or speech production is below the normal range for its age, regardless of the cause. Such a problem may be part of a wider learning difficulty; or specific to speech articulation, or to the normal understanding or use of language. Speech problems tend to run in families, and they afflict males up to 10 times more often than females.

What causes speech problems?

Speech is normally learnt by hearing and imitating, so that any failure of hearing at an early age, may have an important effect on speech. Many speech problems relate to hearing difficulties which may be due to otitis media (middle ear infection), or glue ear (accumulation of fluid in the middle-ear cavity), for example. Congenital (from birth) hearing loss is particularly serious, as severely affected children will not acquire intelligible speech unless they receive remedial training.

Other causes of speech problems include cleft lip and/or cleft palate (fissured lip and/or palate from birth); delay in mastering the fine muscular movements needed to articulate sounds; difficulty in remembering the sequence of sounds to make words; problems with producing speech fluently, such as early stuttering; and hoarse voice, often due to constant shouting.

Delay in speaking is usually due to slow development rather than to disease or damage to the brain. Sometimes, such delay is wrongly put down to laziness,  emotional disturbance or learning difficulty. Even so, many children with speech problems do show some degree of learning difficulty; but this may be the effect of the problem rather than its cause.

What can I do to avoid speech problems?

  • Make sure your child is not suffering a hearing impairment.
  • Ensure that your child receives adequate verbal stimulation from the earliest stage.
  • Avoid baby talk. Use normal, simple, one-syllable words at first, whether or not the child seems to understand them.
  • Gradually increase the complexity of vocabulary spoken to the child.
  • Start reading your child stories at a young age.

How are speech problems diagnosed and treated?

Speech difficulties are assessed by comparison with the average child; and it should be remem­bered that the normal range at any age is wide. Typical stages are as follows:

  • 3 months: Pleasurable babbling begins.
  • 9 months: Real speech is echoed without using recognizable words.
  • 22-28 months: First simple words produced.
  • 18-24 months: First short telegraphic phrases, such as, 'Go now'
  • 2-3 years: Longer sentences with adjectives, such as, 'I like hot pie'.
  • Over 3 years: Progressive but uneven advance to fluency, usually reached by age 6-7

Hearing problems are assessed by simple tests of response to sounds and, in older children, by an audiogram test (tone test using headphones which allows the severity of hearing loss at different pitches to be charted).

The treatment of speech problems depends on the cause. Remediable hearing loss should be corrected at the earliest opportunity. Hearing aids, often used on both sides, can be helpful. Cleft lip and/or palate should be repaired as soon as it is thought medically advisable. Referral to a speech therapist may be made to help treat developmental speech problems.

When should I see my doctor?

At the slightest suspicion that your child may not be hearing normally, or that progress in speech development or fluency is delayed, see your doctor, speech and language therapist or health visitor. Babies with normal hearing will always respond in a startled way to unexpected loud noises, but be sure the child has no visual clue as to the source of the noise. Mothers are seldom in any doubt about the normality of the hearing

of toddlers. However, older children may be taken as inattentive or lazy when, in fact, the problem is hearing loss

What will the doctor do?

The doctor will perform simple tests of hearing and try to assess speaking ability by prompting conversation. If satisfied that there is a problem, a paediatric (concerning childhood disorders) appointment will be arranged to carry out a full investigation.

Are speech problems in children serious?

It is interesting to note that some highly gifted adults were late in learning to speak as children. Even so, persistent speech prob­lems may deeply affect social and personal devel­opment, making early recognition and treatment essential to bring about all possible improvement.

Symptoms

  • Baby babbling may not progress to word utterance.
  • Failure to reach normal speech milestones.
  • Unnatural silence.
  • Failure to understand what is said.
  • Defective pronunciation of words.
  • Defective articulation.
  • Noise production not resembling language.
  • FURTHER INFORMATION

    The following organization can provide the names of your local NHS and private therapists, and information for parents of affected children:

    College of Speech and Language Therapy.

     

Undescended Testicles (Cryptorchidism)

What is an undescended testicle?

An undescended testicle is one that fails to move into the scrotal sac (external skin pouch located behind the penis) from within the abdominal cavity, where it is positioned in the foetus.

Normally, the two testicles descend into the scrotum before birth. However, in about 1% of all male infants, and in 10% of premature baby boys, this development has not occurred by the time of birth. One or both sides of the scrotum are empty, indicating either that the testicles have not descended to their appropriate place, or are missing entirely. If both testicles are present, but not in their proper place, the baby is said to have undescended testicles. This condition, known as cryptorchidism, can affect either, or both, testicles in a particular individual, although normally only one testicle is affected.

Symptoms

  • The scrotum is flat and empty on one or both sides of its midpoint.
  • Gentle touching or pushing with a finger high up on the scrotum does not detect the presence of the egg-shaped testicle.

Are there different types of undescended testicle?

There is no agreement amongst developmental biologists as to the cause of the disorder. An unde­scended testicle may result from a shortened spermatic cord (structure from which the testicle is suspended in the scrotum); or a blockage on the testicle's route to the scrotum. Even so, not all testicles that are absent from the scrotum are classified as being undes­cended.

The following variations in type are generally recognized:

Ectopic testicle:

This is a misplaced testicle which has developed normally, but has been diverted to

the wrong location as it descends the inguinal canal (passage connecting the abdominal cavity with the scrotum in the developing male foetus). The commonest of such abnor­mal locations are the groin and the root of the penis.

When this misplace­ment occurs, a tube called the epididymis (sperm conduit), which is attached to the testicle, is also misdirected in its descent. One theory holds that the downward move­ment of both testicle and epididymis is directed by a tissue structure called the gubernaculum. This structure swells in the inguinal canal, under the influence of the male sex

hormone testosterone, creating space for the testi­cle to follow it into the scrotum. When something goes amiss in this process, the testicle becomes wrongly located.

  • Cryptorchidism: This refers to a testicle which remains inside the abdomen. It is regarded as the 'true' condition of unde­scended testicle. The term derives from the Greek crypto, meaning hidden. This is a more serious condition, as the testicle is likely to be poorly developed. Unlike an ectopic one, such a testicle will never produce adequate amounts of viable sperm and may have a restricted blood supply.
  • Retractile testicle: In this case, the testicle may be felt in the scrotal sac, although it is liable to sporadically retract up into the abdomen in response to cold or touch.
  • Noonans syndrome: This is one of several inherited defects, in which the child's body does not produce adequate male sex hormones. When both testicles are undescended, such a cause will often be suspected and appropriate investigations made.

How is the condition diagnosed and treated?

The empty scrotal sac will be apparent upon examination. Some doctors may examine the baby in a warm bath, in order to rule out retractile testicles. The

warmth relaxes the cremaster muscle (muscle that lines the scrotum), which sometimes tightens in response to a stimulus such as cold, thrusting the testicle upwards into the inguinal canal or the abdomen. This condition is usually harmless since the testicles eventually descend permanently, and the sperm they produce will be normal.

If the cremasteric reflex is not the problem, the doctor will try to locate the missing testicle.

In the case of unde­scended testicle, over half the affected testicles will descend without treatment within a month, and a total of about 80% will descend within the first year. The decision must be made whether to wait and see what will happen, or to operate to reposition the testicle. Surgery is usually recommended.

When a testicle remains undescended, the situation is more complicated and genetic tests may be ordered. The testicle can be moved down to the scrotum surgically, but may not produce sperm. It will be abnormally vulnerable to testicular cancer, so some experts recommend that such testicles be surgically removed if they do not produce sperm. These males may need injections of male hormones as they reach the age of puberty.

The outlook for a boy with cryptorchidism is

less clear-cut than that for a child with ectopic testicles. He may or may not develop normally, and continuing care from a pediatric urologist (specialist in conditions of the urinary tract in children) will probably be needed.

When should I see my doctor?

If one or both sides of the baby's scrotum appears empty, part or all of the time, consult your doctor.

What will the doctor do?

Your doctor will examine the baby, and is likely to refer you to a paediatri­cian, or to a specialist in paediatric urology.

Is an undescended testicle serious?

The retractile and ectopic forms of this disorder are not likely to be dangerous. However, true crypt­orchidism may indicate potential problems in that the abnormal testicle is more susceptible to developing cancer.

For the child's psycho­logical well-being, which may be significantly threatened, it is advisable to deal with problems relating to the testicles as early in life as possible.

WARNING

Do not, under any circumstance, attempt to re-position a young baby's testicles.

Teething

When does teething take place?

Teeth start to develop in the jaw before a baby is even born, but the first tooth usually appears at about six months of age. However, this will vary from child to child, and a very few children are even born with one or more teeth already visible. The final tooth has usually come through by the age of two and a half years.

Teeth usually come through in the same order, although the age at which they appear may vary:

  • The first to show, usually at 5 - 7 months, are the two lower central incisors (front teeth), followed by the two top central incisors at 6 - 9 months.
  • The upper two lateral incisors (either side of the central incisors) are usually next, from 9-12 months, followed by the lower lateral incisors, again between 9-12
  • From 12-16 months, the molars (back teeth) appear, most often beginning with the two upper first molars, and then the two lower first molars.
  • Sometime between 15-20 months the gaps are filled, first by the upper canines (eye teeth), one on each side, and then usually the lower canines.
  • At 24 - 30 months, the second molars emerge.

What is teething?

Teething is the term used to describe the period when each of a baby's 20 first, or milk, teeth appear.

What are the signs of teething?

You may notice that your baby's gum is sore and red over the emerging tooth, and the child may dribble more than usual. When a molar is coming through,

the corresponding cheek may be warm and flushed. Some babies are more irritable and clinging than usual when cutting their teeth and try to chew on their hands, fingers or any other hard object to relieve the discomfort.

You may also spot the emerging tooth itself as a small whitish bump in the gum, which feels sharp when you touch it. It can take several days for each tooth to emerge and the symptoms usually come and go over this time.

What can I do myself?

As the teeth are formed before birth, you can help to ensure that they will be strong and healthy by eating a good balanced diet during pregnancy, containing plenty of calcium (from dairy products) and vitamin D (from margarine, and oily fish, such as herrings and sardines).

Once the baby is born, try to minimize the amount of sugar in the child's diet. Above all, do not let the baby suck on a sweetened dummy or a bottle of sugary drink as the gums and teeth will then be bathed in sugar for long periods, which can cause severely decayed teeth.

Do not give sweets to babies.

If at all, young children may be given sweets at the end of a meal, or encouraged to eat them in one go, rather than making them last, as the teeth will then not suffer a prolonged acid attack.

If your baby shows signs of discomfort while a tooth is coming through, offer something hard to chew on, such as a sugar-free rusk, toast crust, or a teething ring.

The baby may also find it soothing if you gently rub the gum with your (clean) little finger. Try to avoid using teething gels containing a local aesthetics as, on rare occasions, they may cause an allergic reaction in some babies.

Fluoride strengthens teeth and reduces decay. If your water supply does not contain the recommended level of fluoride (ask your local dentist), you may prefer to give your child fluoride drops, available from the dentist, chemist, or health center. You will be given advice on the correct dose.

Supplements are usually given from birth until about 13 years old. Never give more than the recommended dose as an excess can cause mottled teeth. Brush the baby's teeth with a fluoride toothpaste, but tell your dentist or health visitor that you are doing so as they may recommend reducing the dose of supplements.

As soon as the first tooth appears, get into the habit of regular cleaning. Although these first teeth

will fall out from the age of about six years to be steadily replaced with the second or permanent set, they still need to be looked after carefully.

If any first teeth have to be removed early because of decay, the other teeth may move to fill the gaps, and the permanent teeth may not come through in the correct positions.

At first it is often easier to use a piece of gauze to clean the baby's teeth, before progressing to a baby-size toothbrush and a pea-size blob of toothpaste. Toddlers will be keen to try to clean their own teeth, however children are likely to need supervision, until the age of at least seven years.

Advice on Teething

  • Offer the baby something firm to chew on, such as a crust, teething biscuit or slice of carrot.
  • Offer the baby a water-filled teething ring, cooled in the refrigerator (never cool a teething ring in the freezer).
  • Gently rub the baby's gums with your little finger.
  • If the baby is not very hungry, offer frequent drinks or pureed food.
  • Give the baby lots of cuddles and extra attention.
  • Cold can make teething pain worse; dress your baby in a hat and scarf for outings.

When should I see my doctor?

Some discomfort is normal while the baby's teeth are emerging and it is quite likely that the child will be a little unwell. However, teething does not cause high fever, or persistent diarrhoea, or vomiting.

If your baby has these or any other symptoms of illness, consult your doctor.

WARNING

If potentially dangerous symptoms are attributed to teething and ignored, this can lead to a baby becoming seriously ill.

Always see your doctor if you are worried about your child.

Croup (Acute laryngotracheobronchitis)

What is croup?

Croup is a condition in which inflammation of the respiratory tract causes narrowing of the airways. It is very common in young children. However, older children and adults do not suffer from croup because their airways are wider and stiffer, making them less vulnerable to the effect of swelling due to inflammation.

Croup is characterized by a barking cough, breathing difficulty that is most pronounced when breathing in, and by a harsh and high-pitched sound when breathing out, due to swelling in the area of the vocal cords.

It is primarily a disease affecting children between the ages of six months and three years, although it may occur earlier or a little later. Croup is usually mild, but in severe cases it can produce extreme swelling that blocks the airway. Croup then becomes life-threatening and requires emergency treatment.

What causes croup?

that branch off from the trachea). The swelling and discharge from the inflammation may cause obstruction in the region beneath the vocal cords.

Symptoms often come on rapidly, preceded by several days of a cold with a cough, runny nose and perhaps a mild fever.

A croup attack most frequently occurs at night, waking the child up. The hoarseness and barking cough can be frightening for parents and child.

The pattern of the condition fluctuates rapidly and unpredictably. The child may have extremely labored, harsh breathing and then be breathing normally within an hour. Symptoms may disappear in the morning, only to recur at night.  Croup usually runs its course in three or four days.

How is croup diagnosed and treated?

Diagnosis is based on the characteristic barking cough, hoarseness, and stridor (noisy breathing). These problems are generally worse at night.

Humidification (increasing the amount of moisture in the air) will often bring prompt relief. Breathing in steam-moistened air is one of the quickest ways to ease the coughing and breathing difficulty.

You can do this by producing a mist with towels over a pan of hot water, or you can run a hot shower or hot taps in a closed bathroom.

Mild croup can usually be treated at home, but a child who has severe breathing difficulties needs to be hospitalized. Hospital treatment involves giving moist air, either in a special room or with a face mask or a tent. Oxygen may be needed.

If breathing is severely obstructed an endotracheal tube may have to be passed down the throat into the trachea.

If this is impossible, because of the obstruction, a tracheostomy will have to be performed. Here a tube is passed directly into the trachea via an incision made in the throat below the obstruction.

Symptoms

  • Laboured breathing.
  • Grunting noise during breathing (stridor).
  • Barking cough.
  • Rapid breathing.
  • Sore throat.
  • Blue lips or nails (cyanosis).

When should I see my doctor?

You should consult your doctor immediately if a child in your care is having difficulty breathing. If the symptoms are severe and unrelieved by steam, or the child starts to turn blue (cyanosis, due to lack of oxygen in the blood), call an ambulance or take the child to the nearest hospital accident and emergency department.

What can I do to relieve croup?

  • If your child is susceptible to croup when he or she has a cold, use a humidifier to keep air moist, especially in the child's bedroom.
  • Encourage the child to drink plenty of fluids when he or she has a cold, and also use a vapour rub to reduce congestion in the airways.

What will the doctor do?

The doctor will examine the child to make sure that the problem is not due to a foreign object which is causing the blockage. If epiglottitis (a bacterial infection with similar symptoms) is suspected the doctor will prescribe antibiotics.

The bacterial infection diphtheria also causes breathing difficulties in young children, although it is now very rare in the UK as babies are routinely immunized against the disease. However, if the child has not been immunized against diphtheria the doctor will need to ascertain whether this may be the cause of the breathing problem.

To do this the doctor will take a throat swab so that any bacteria present can be grown in a laboratory and identified.

What can I do myself?

The child should be reassured and treated with moist air. A humidifier in the bedroom is helpful, and the child should be encouraged to drink plenty of fluids and to rest. If coughing becomes severe, get the child to breathe steamy air, for example in a bathroom.

Is croup dangerous?

If the child cannot breath, he or she will need urgent medical attention.

However, although croup can be frightening it is rarely dangerous. Even severe cases that need intubation (the insertion of a breathing tube) usually rectify themselves completely within a few days.

WARNING

Epiglottitis, a serious condition caused by a bacterium, may be confused with croup. It is caused by infection of the epiglottis (a tiny protuberance at the back of the throat that prevents food from going down the windpipe). When this happens, breathing is completely obstructed and the condition can be life-threatening.

 

 

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