Children and tummy aches.

Children of all ages often complain about having tummy aches. Frequently it's just one of those things that disappears by itself. (When my 3 year old complains of having a tummy ache, it's normally because he needs to do a poo.) But how do you know if it's something serious?  Or, what most people want to know is, why? What is causing my child's tummy ache?

Well, the interesting thing about medical science is that it may be able to do amazing things like face transplants and brain surgery, but often it can't tell you why your child has a tummy ache. Even if children are admitted to hospital and lots of tests done on them, often we don't find out what the cause is. What you as a parent wants to know is 'what is it' but what your doctor wants to know is 'is it serious'? Two slightly different questions.

So, let's start by thinking about things that might make us think it's serious. Firstly, how is your child? Are they well or unwell? If they're unwell, fever, not eating, vomiting, that sort of thing, your doctor will want to know if they have appendicitis. Appendicitis is an infection of a little bit of your gut that sits in the lower right hand bit of your tummy (in the majority of people). The appendix isn't really thought to be used for much in humans, apparently rabbits have large appendices, something to do with digesting all that grass but don't quote me on that.  Anyhow, the point is it can get inflamed and infected and then it needs to be removed with an operation. Your doctor will do lots of prodding and poking your child's tummy to help them decide if they may have appendicitis.

What else would make your doctor concerned? If the tummy pain had been going on for a long time, if your child wasn't eating or growing well. If it was associated with symptoms such as diarrhoea (over a long period of time, not just for a day or two) or blood in your poo.

There are lots and lots of causes of tummy ache and some are easily diagnosed. For example, constipation, urinary tract infections and diarrhoea are all common causes of tummy ache. Sometimes children get inflamed lymph nodes in their tummy when they have an infection somewhere else ('abdominal lymphadenitis'). But sometimes it has to be put down to 'one of those things' and hope that it doesn't last too long.

Getting children to eat fruit and vegetables.

Most parents wonder how to give their children a healthy diet, how to make them eat fruit and vegetables and how to reduce the amount of cake, crisps and biscuits that they eat. Well, help is at hand. Recent studies by City University and the School Food Trust has found that cooking clubs and classes has a positive effect on children's eating habits. They found that more children ate fruit and vegetables after the classes and were able to recognise healthy food.

Given the growing epidemic of childhood obesity this is fantastic news. Getting children involved in cooking is a 'fablious' idea, as my 3 year old son says. The up sides are huge, learning what goes into food, how long it takes to prepare, giving them skills for later life (not just being able to cook but impressing the fairer sex according to my husband who claims I fell for him thanks to his amazing risotto.) Let's not mention the mess and the amount of extra time needed! When they're old enough, they might even cook the meal by themselves.

From a personal point of view, I find that my children are much more likely to eat something new if they've helped make it. I use the word 'helped' in the loosest sense. My 3 year old 'helped' me to cook mussels the other day. I de-bearded them, passed them to him, he dabbed a few of them with a sponge and put them into a colander. Anyhow, he ate the mussels and was very proud to have helped. A few weeks later I cooked mussels again, this time he was watching tele. He wouldn't touch them. Yuk yuk, I'm not eating those! This 'helping' tactic has also worked with curry and other new and unknown foods. 

In my clinics, I often recommend that children get involved with cooking, especially those who are slightly over weight and constipated (a frequent flyer in many paediatric clinics.) Many parents try to hide vegetables in dishes and this is certainly one way of getting children to eat vegetables in the short term. But I wonder whether it is a good tactic for the long term, when the child is able to decide themselves what they want to eat (which happens very quickly). If they are used to eating fruit and vegetables they will often opt to have a healthy piece of fruit as a snack instead of a piece of cake or a biscuit. (Not all the time I grant you.) I leave bowls of fruit on the kitchen table and both my 1 and 3 year old will help themselves to it. "Norange, norange" grunts my 1 year old.

Feeding children, of what ever age is not easy. Just when you think you've got it nailed, your perfect eater turns into a fussy eater overnight. They don't have to have a perfect diet. Cakes, biscuits and other treats are fine in small quantities. However, it is important that they eat fruit and vegetables, not just today but as they grow and continue into adulthood. If you're having problems getting your child to eat healthily it may feel like a steep slope to climb, but take it one step at a time. Get them involved, don't loose heart and keep presenting them with healthy options.

Molluscum contagiosum or those funny wart things kids often have.

Molluscum contagiosum is a very common childhood viral infection. It is similar to warts, causing  pearly white papules that are shiny and have a little dimple in the middle. It is most common in children between the ages of 2 and 5. The papules may clear up in a few weeks but more commonly they don't go for a couple of years. Eventually they do go by themselves.

Normally no treatment is needed. However, if they cause problems such as rubbing on clothing or becoming painful and inflamed, they can be treated using cryotherapy (liquid nitrogen) or diathermy (often used in surgery to cauterise blood vessels). If the molluscum is really bad, it may be necessary to see a dermatologist.

Children can go to school or nursery if they have molloscum contagious.

Image:  E van Herk

http://nl.wikipedia.org/wiki/Gebruiker:Evanherk

http://creativecommons.org/licenses/by-sa/3.0/deed.en

Urinary Tract Infection in children

Urinary Tract Infections in children are mostly a matter of anatomy. They are normally caused by bugs tracking up the urethra (bit where the wee comes out) and colonising the bladder. Under normal circumstanses the bladder is a sterile environment, meaning that there is no bacteria in it. The bottom end of the urethra however, sits in an area that is not so sterile; quite close to the anus (where the poo comes out.) Needless to say, poo is not sterile. In fact, it has lots of bacteria in it. (But that is normal, it supposed to have some bacteria in it, known as 'commencals' or good bacteria.) If the bacteria stays where it supposed to (i.e. in the poo inside you and not in your bladder) then all is well. Often, however, the bacteria manages to get from the poo, or surrounding area and tracks up the urethra into the bladder, causing an infection, a 'urninary tract infection' or 'UTI', commonly known as a 'wee infection'. Due to anatomy, UTIs are much less common in boys. The bacteria needs to track all the way up the urethra (i.e. the inside of the penis) and into the bladder. This is a much longer length than in girls, in whom the bladder is quite close to the opening of the urethra.

A urinary tract infection can occur higher up in the urinary tract. A kidney infection is a 'higher urinary tract infection', know as 'pyelonephritis'  whereas a bladder infection is a 'lower urinary tract infection' or 'cystitis'.

An anatomical abnormality will also predispose children to having a urinary tract infection, but they are still common in children who have entirely normal anatomy.

Symptoms

Symptoms of a UTI vary with the age of a child. A young child may have a temperature, vomiting, lethargy, irritability and poor feeding. Older children (generally those over 3) may also show signs of being in pain when doing a wee ('dysuria'), they may go to the toilet a lot ('frequency'). (Obviously if they are old enough they can tell you that it hurts.) You may also notice blood in their urine ('haematuria'). Other symptoms include tummy pain, offensive or cloudy urine.

Diagnosis

If your doctor (either your GP or in the hospital) is concerned that your child has a urinary tract infection, they will do a urine sample. This is really easy with older children, you just get them to wee into a sterile pot. With younger children in nappies, it is much more difficult. The best sample to get is called a 'clean catch' and this involves sitting around with your child's nappy off, hoping to catch a drop of urine in a pot when they do a wee. There are other methods, such as a special pad that can be put into their nappy. If your doctor is really worried, they might need to put a needle into the baby's bladder and get some urine. (This is not as bad as it sounds! Sometimes it is easier than getting blood out of a baby.)

Treatment

Urinary tract infections are treated with antibiotics. The antibiotics may be given by mouth or by a drip depending on how severe the illness is. The majority will clear up with antibiotics in a couple of days. Some children will also need follow up imaging such as ultrasounds.

Avoidance

As well as maintaining good personal hygiene (clean genital area) it is important for children (especially girls) to wipe from 'front to back' after going to the toilet. This is so that bacteria from around the anus is not brought forwards towards the urethra. Constipation can also precipitate urinary tract infections (see blog post Kids and Constipation.) Drinking sufficient amounts of water and making sure you go do a wee when you need to (i.e. not holding onto it) can also help prevent urinary tract infections.

Breast fed babies and irritability.

The Medical Research Council (MRC) published an article today in a journal called Plos ONE that said that breast fed babies are more likely to be irritable at the age of 3 months than their bottle fed counter parts. The paper suggests that mothers perceive the irritability as stress when in fact it is a signal of hunger and entirely normal. The authors say that breast feeding is still much better for babies than bottle feeding and that this study is useful as it prepares mothers for the reality of breastfeeding.

One of the researchers, Dr Ong says (to paraphrase) that bottle fed babies may appear more content, but they may also be over-nourished and gain weight too quickly. He points out that as with adults, feeding is comforting. I think this observation is very interesting, especially as breast fed babies are much less likely to suffer with obesity later in life. It is much easier to overfeed bottle fed babies that breast fed babies for several reasons. Firstly, a breast fed baby has to work quite hard to get the milk. It normally takes at least 20 minutes to breast feed a baby whereas a bottle fed baby can devour a bottle in a couple of minutes.

Another reason is that all babies, whether they are formula fed or breast fed will be irritable at some stage. It can be really difficult to know why they are crying or unsettled. It may be because they are tired, hungry, over stimulated, under stimulated, have wind or a bit of discomfort. How are you supposed to know? If they haven't been fed that long ago, parents may give them some more milk. If they are breast fed, they can only get whatever is in breast (i.e. probably not that much if they weren't fed too long ago.) However, with a bottle fed baby, they can be offered a whole new bottle. And no doubt, whatever the original cause for complaint was, they'll be pacified with more food. Lastly, a bottle fed baby's stomach may stretch due to the amount of liquid that they are given at once. This means that they'll want more next time they're fed.

The authors suggest that the extra irritability may be one of the reasons why mothers give up breast feeding. In the UK, we have really low rates of breast feeding compared to other countries. Many women do try to breast fed, but many give up. According to an article in Pediatrics (1), published in 2008, the most common reason cited was that "milk alone didn't satisfy my baby". The authors of the MRC study suggest that in fact, it may not be that the baby isn't satisfied, but that they are naturally slightly more irritable.

They do also point out that other studies have previously had conflicting results (some noted no difference and some noted that that breastfed babies were less irritable.) Both my babies were exclusively breast fed and I found neither particularly irritable. I also found breast feeding really useful when they were unwell as they found it so comforting. (You can continue to breast feed even if your baby has diarrhoea or vomiting.) There is no doubt that breast feeding can be particularly difficult to begin with (both for the mother and the baby) but once established it is normally hugely satisfying for both.

They say that this is part of an ongoing study so hopefully they'll publish another paper telling us what breast fed babies are like when they are a bit older.

(1) Li R, Fein SB, Chen J, Grummer-Strawn LM (2008) Why mothers stop breastfeeding: mothers' self-reported reasons for stopping during the first year. Pediatrics 122: Suppl 2S69–76.

Kids and constipation

I thought I'd write a brief article on children and constipation as it's such a common complaint. I remember when Jamie Oliver did his school dinners programs, he was astounded to find out that a particular hospital in the north had a special clinic for children with constipation. What he didn't mention was that many hospitals in the UK have a special clinic for children with constipation. It is one of the leading complains that children present to paediatricians with.

Symptoms

Typically a child with constipation will have hard, dry stool (poos) and not go to the toilet very often. (It can be difficult to say what is normal in terms of how frequently a child goes to the toilet but I would consider normal to be once or twice a day and constipation to be less than 3 times a week.) When constipation gets bad, there is a back-log (excuse the pun) of hard poo. Behind the hard poo is soft watery poo which can leak down the sides. So strangely, a child with constipation may actually appear to have diarrhoea.

Constipation can also be very painful, so children can present with tummy aches.

Causes

There are many factors that contribute to having constipation: not drinking enough water, not doing enough exercise. Sometimes children get a small cut in their anus (where the poo comes out) which makes it painful to poo, or sometimes they have a bad experience which leads them to 'hang onto their poos' which can lead to constipation. There are also diseases that cause constipation.

However, the most common cause by far is not eating enough fibre (i.e. vegetables). Fibre is the bit of food that our bodies cannot digest. It sits in the bowel, bulking out the poo and making it easier for the poo to pass through the body. When I'm explaining constipation to children, I use an analogy of a tube of toothpaste. When a tube of toothpaste is full, you press it a little and toothpaste comes out easily (a bowel full of fibre). When the tube is empty, you have to squeeze really hard to get just a little bit out. That is a bowel without any fibre.

What can I do to help my child?

The first thing to think about is vegetables. Many people think that their children eat enough vegetables. But chances are, if they are a little over weight or have constipation, that they don't. I ask children what their favourite vegetable is and if they answer 'chips' (which they frequently do) I begin to suspect that they don't enough of the green ones! (That is generally where the fibre is). 

Some vegetables, such as potatoes and cucumber don't have heaps of fibre (it's all in the skin, so if you peel that away, there isn't that much left.) Vegetables that are a bit more woody have more fibre (wood is also fibre but I wouldn't recommend eating it.) Broccoli, sweetcorn, cabbage, beans are all good fibre boosters. 

So how do I get my child to eat more vegetables?? Well, that can be a difficult one. Ideally you start right at the beginning, when you wean them. If they are used to eating vegetables from a young age, they will carry on (ok, they'll probably eat sweets and chocolate too, but at least some of what they eat is the good stuff.)

Leading by example is also a really good way of getting your children to eat vegetables. Young children are desperate to be grown up and considered 'a big boy or girl'. My 3 year old didn't used to eat greens like cabbage or lettuce. I wasn't that worried as he was good with other things like peas and carrots. Then, a few months ago, he started asking for bits of cabbage when I was serving it to the adults. Now he always has a piece of cabbage or beans (still not keen on lettuce).

I also used to grow peas in the garden when he was little (we only had a tiny garden, I didn't manage to grow much else.) I didn't even manage to grow enough to eat them. My little then 1 year old would always be helping himself. But what better introduction to green vegetables that peas picked out of the pod?

If your child is older, how about getting them involved in the cooking. (I know, I know, it's FAR FAR easier just to do it yourself, but it should get them interested in what they're eating and they'll learn how much effort goes into each meal.) Anyhow, make sure you cook something with lots of veggies in…

Other than vegetables, you can encourage your child to go to the toilet. If you put them on the toilet after dinner the chance of them doing a poo is increased (due to a particular reflex that we have.) It's important to sit in the 'poo position' which is back straight (rather than leaning forwards which can make it difficult to poo). If you child is young, they may need a step to rest their feet on. Drinking lots of water and exercise can also help people with constipation.

Summary

Mostly constipation is an avoidable or at least curable illness. It can be very unpleasant and lead to further problems (such as wee infections.) So if you're child has constipation or you think they may have constipation:

Make sure they are active, drinking enough and EATING LOTS OF VEGETABLES.

For more information on what is a portion size for each fruit or vegetable check out this leaflet on the NHS website. Remember the portions published are for adults, they say a child's portion should be roughly what they can hold in their palm.

Cancer and Lifestyle

A supplement in the British Journal of Cancer, entitled "The Fraction of Cancer Attribuatable to Lifestyle and Environmental Factors in the UK in 2010" was published last week. They looked at things that they knew caused cancer (such as smoking and drinking alcohol) and that were things that people could choose to change in their life. Using statistical analysis they worked out how much these exposures contribute to total amount of cancer in the UK. Amazingly they found that all of the factors together account for 43% of new cancer cases in the UK and about 50% of all deaths.

So that means, that if we choose to lead a healthy lifestyle we can significantly reduce our chances of getting cancer. 

The exposures are all things that we know cause cancer, smoking being the number 1 culprit. But what we didn't really know was exactly what a difference all these things make. 

The exposures in order of significance are:

• SMOKING
• BEING OVERWIEGHT
• LOW FRUIT AND VEG DIET (not getting 5 a day)
• ALCOHOL
• OCCUPATION (being exposed to chemicals)
• SUNLIGHT AND SUNBEDS
• CERTAIN INFECTIONS
• RED MEAT
• RADIATION
• LOW FIBRE DIET (having less than 23 grams a day)
• INACTIVITY
• NOT BREAST FEEDING (for up to 6 months)
• EATING TOO MUCH SALT (having 6g or more of salt)
• HRT 

I find it interesting that being over-weight is above alcohol consumption. And that breast feeding is more important than having a low salt diet. Anyhow, the list allows you to see where your weaknesses are and what is the most important point to concentrate on. Obviously there are benefits to a healthy diet other than reducing your cancer risk.

Anyhow, for me, it's reduce alcohol and red meat (again)....

For more informamation check out the actual supplement and the Cancer Research UK website who funded the research. They have a graphic which shows you which risk factors are related to which cancers.