Posted On: August 30, 2013

Overcoming Bed-Wetting

A recent “explainer” posted on The Conversation will be welcome information for many parents. It’s about bed-wetting.

The writers of the report on The Conversation, an independent source of news and opinion for public consumption by members of Australia’s academic and research communities, are Caroline Walsh, a continence nurse at The Children’s Hospital at Westmead (Sydney), and Patrina Ha Yuen Caldwell, who heads the enuresis service for the hospital. “Enuresis” is lack of urinary control, especially nighttime bed-wetting.

Walsh and Caldwell say that bed-wetting, although embarrassing and traumatic, is common among children. It affects 15-20 out of 100 school-aged children, the vast majority of whom grow out of it. But there are treatments to hurry the evolutionary process.

Like adults, children usually wake up when they have a full bladder, but bed-wetters have a defective arousal response. They can’t wake fully. So when urine production exceeds bladder capacity, a child urinates in his or her sleep.

The disorder has a genetic link, so if you or your spouse had the problem, it’s more likely your kid will too. Bed-wetting is more common among boys, but women are more likely to pass the genetic inclination to their children. Gee, thanks mom!

Because bed-wetting carries such emotional baggage, and can affect a child’s self-esteem, mental health and early peer relationships, parents must handle the issue with sensitivity.

There are several treatments for bed-wetting, primarily alarm training, urotherapy and medication. Treatment is appropriate generally around the age of 6.

Alarm training

Usually, this is the first line of treatment, and the goal is to train the child to recognize the full-bladder signal before urinating in his or her asleep. There are two kinds of alarms:


  • Pad and bell alarms connect a mat to an alarm box placed on the child’s bed. The alarm activates when the mat senses liquid.

  • Personal alarm sensors are secured either in a panty liner or clipped to the child’s underpants. The alarm activates when the sensor detects liquid.

    This method requires patience. It should be used every night until the child achieves 14 consecutive dry nights. It can take two to four months of training before the child reacts consistently enough to the signal to be deemed fully effective.



Urotherapy

This covers a wide range of practices, primarily:


  • ensuring the child has an adequate daily fluid intake (5 to 6 drinks per day that do not contain caffeine, including chocolate milk);

  • avoiding the consumption of fluids late in the evening or close to bedtime;

  • avoiding or readily treating constipation, which can affect bladder function;

  • ensuring appropriate toilet posture, such as adequate foot support when sitting on the toilet (this supports complete evacuation of both the bowel and bladder);

  • taking bathroom breaks regularly throughout the day, and encouraging the child not to postpone a trip to the toilet when the urge occurs.


Medication

This approach should be for a short-term solution or as a last resort. It relies on desmopressin, a synthetic hormone that has an anti-diuretic effect. It acts on the kidneys to reduce overnight urine production. Effective in about 7 in 10 child cases, desmopressin might be useful for sleep-overs or school camps when alarm training isn’t practical. It can also be combined with other treatments to ensure a dry night.

Like all medicines, desmopressin can prompt a negative reaction when combined with some other drugs, so make sure your pediatrician has a complete record of what your child takes.

Imipramine was one of the first medications used to treat nocturnal enuresis, but because of its risky side effects, including thoughts of harming or killing oneself, it’s not recommended as a first-line treatment.

Other Options

Behavioral therapies can be helpful in treating bed-wetting. They include taking the child to the toilet during the night and rewarding him or her when he or she stays dry. “Try to create a positive environment and involve the child in decision-making,” the writers suggest, “so they can take ownership of the problem.”

But given the physiological nature of the disorder, psychological treatments often aren’t as effective as alarm training or medication.

Some complementary and alternative medicine interventions, such as hypnotherapy and acupuncture, have been tried, but the evidence to support their use is limited.

If your child doesn’t respond to common treatments, seek advice from a pediatric urologist. Or try to ride out what usually is a youngster’s affliction that does improve with age.

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Posted On: August 23, 2013

Recognizing and Treating Anxiety Disorders

No parent wants to see his or her child suffering. When the distress is emotional, it can be harder to address because nothing hurts; everything hurts.

Writing on PsychCentral.com, psychologist Marla W. Deibler, a specialist in anxiety and obsessive-compulsive disorders, has some guidance for parents to recognize their child’s anxiety problems, and what to do about them.

Deibler says anxiety disorders are among the most common psychological problems children and adolescents experience—about 13 in 100 U.S. kids suffer from them. Such problems are the greatest predictors of adult problems including substance abuse and a variety of mood disorders. So identifying them early and getting them treated is key to positive long-term outcomes.

Anxiety itself is neither good nor bad—it’s an appropriate response to many circumstances, it’s how our bodies register stress so that we can confront and diffuse it. But if anxiety is excessive, it’s hard to turn off. It can become so overwhelming that we’re unable to function, to perform our regular routines.

Deibler identifies six common anxiety disorders parents should watch out for.

1. Generalized Anxiety Disorder (GAD) is characterized by persistent, pervasive worry that is difficult to control.

Children with GAD are chronic worrywarts. They fret about family, friend and romantic relationships; academic performance; recreational performance. They concerns might be legitimate, but they exaggerate them, and obsess about them.

They worry about not measuring up to the expectations of others. They might have a hard time sleeping, they might constantly seek reassurance. They’re often irritable, and have stomach- or headaches.

2. Separation Anxiety Disorder is expressed by severe distress when kids are separated from their caregivers. Generally, it begins when they are younger than 10.

Separation anxiety is a normal stage of child development from late infancy to several years later. But cause for concern is when it the degree is extreme and acute every time a child is separated from the caregiver(s). Such an extreme is clinically significant if it interferes with a kid’s ability to engage in age-appropriate activities—school, play dates, sports, etc.

Children with separation anxiety might seem excessively clingy, reluctant to do anything requiring separation. They, too, can complain of stomach- and headaches.

3. Social Anxiety Disorder is recognized by excessive concern about being judged by others. It’s not just being shy—it’s being anxious and extremely worried about embarrassing yourself. Kids with this disorder freeze at the prospect of performing or speaking in public; even doing such simple acts as eating or writing if somebody’s watching. And, either imagined or real, judging.

These kids are afraid of being criticized or humiliated. Older kids might avoid situations they believe will make them anxious, and younger kids might act out--crying, or having a tantrum. They also might feel breathless, dizzy, lightheaded, have a racing heart rate or stomachache.

4. Selective Mutism (SM) makes a child unable to speak in certain settings, even though he or she is otherwise able to talk and interact.

SM typically presents in a child as being able to talk freely at home and other comfortable settings, but unable to do so at school or in the presence of strangers. These children might gesture or use other nonverbal efforts to communicate, but can’t seem to speak.

5. Specific Phobias are characterized by excessive and irrational fears about things or situations not usually considered to be dangerous.

The source of the fear might be dogs or other animals, storms, insects, blood/injections or heights. The fear is so strong as to be debilitating. Youngsters might not understand how unreasonable their fear is. Often, they address this by avoiding the stimulus. They also might act out and experience a racing heart, breathlessness, trembling, dizziness, lightheadedness, sweating or stomachaches.

6. Obsessive Compulsive Disorder is recognized by persistent intrusive thoughts, images or impulses (obsessions) and repetitive behaviors and/or mental acts a kid feels he or she must perform as a response. It’s like a rule that must be followed.

The compulsive behavior is done with the goal of reducing or neutralizing anxiety or distress caused by the obsession.

This disorder, which can present in early childhood, may be exhibited by excessive hand washing, locking and relocking doors, touching or tapping items or spots in a certain order, counting, rewriting, rereading or doing anything in a certain sequence.

Common obsessions include a fear of germs or illness, or harm coming to oneself or one’s family if the child doesn’t engage in compulsive rituals.

The time to treat your child’s anxiety disorder is when it interferes with his or her ability to function every day. Your child’s anxiety is excessive when:


  • It’s unrealistic or irrational.

  • The level of distress far exceeds the seriousness of its cause.

  • It results in perfectionism, or the child having unrealistically high expectations of himself or herself.

  • It’s unwanted and uncontrollable.

  • It results in avoidance or inability to engage in activities the child would otherwise enjoy.


Discuss fears with your child. Be open, honest and listen. Ask open-ended, nonjudgmental questions to learn more about how he or she is feeling. An open-ended question is: Why do you think you’re so afraid of dogs? A closed, judgment-laced question is: “You’ve never been bitten by a dog, why are you afraid of them?

Don’t dismiss any of your child’s feelings, don’t express in words or body language that you think their problem is silly or dramatic.

Don’t reinforce the fear by appearing anxious yourself or by allowing avoidance behavior or school absence. That might reduce anxiety in the short-term, but it prevents children from having to learn adaptive coping skills.

Remember, anxiety tends to increase when what causes it is unpredictable, unfamiliar or imminent. So prepare children for anxiety-provoking situations by discussing them in advance, talking about what could happen, how they might feel, what they might do and, if the worst were to happen, how would they manage that.

But if anxiety is excessive and isn’t getting better, seek professional help from a psychologist who specializes in treating children. Sometimes behavioral therapy is sufficient; sometimes medication must be prescribed. (See our blog about combining therapy and medication to treat anxiety.)

To learn more and to find a child psychologist, link to the American Psychological Association.

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Posted On: August 16, 2013

Anesthesia Drug May Cause Brain Damage in Kids Undergoing Surgery

Drugs that fall under the category of “anesthesia” are powerful in their ability to separate you from the sensation of pain, and when you’re on the operating room table you wouldn’t want it any other way. But a recent study suggests that for youngsters, at least one of these drugs can have ominous effects.

As reported by AboutLawsuits.com, the drug ketamine can have a toxic effect on developing neurons that can cause learning and memory disorders as well as behavioral problems.

The association was described in a study published in the journal Neural Regeneration Research. It found that children younger than 3 who underwent surgery for an extended period or repeatedly got ketamine for multiple surgeries, exhibited learning and memory disorders and behavioral abnormalities when they reached school age.

The research, which was conducted on rats, not kids, found signs of neural toxicity and neuron death caused by the drug. In case there’s any doubt of ketamine’s power, it has been implicated as a “date rape” drug that leaves victims unable to move or remember what happened. It’s in the same class of drugs as PCP (phencyclidine), a dangerous “recreational” drug, and propofol, the drug that killed Michael Jackson.

Ketamine is a common anesthetic used in combination with a sedative. Apart from pediatric uses, it’s also common in veterinary medicine. Short term side effects sometimes include hallucinations and elevated blood pressure.

The Neural Regeneration Research scientists replicated results found in other studies. They expressed concern that ketamine might cause long-term neurological damage in children, prompting disabled learning and memory function. Dyslexia, hyperactivity and attention deficit hyperactivity disorder (ADHD) were mentioned specifically.

“Researchers,” said AboutLawsuits, “urge health-care providers and parents to weigh the risks with the benefits when considering using ketamine during surgery.”

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Posted On: August 9, 2013

More Cautions on Kids Locked in Hot Cars

It’s an annual warning some people may tire of hearing, but the problem of kids locked in hot cars endures. According to KidsandCars.org, an advocacy group, 38 youngsters die every year after being left in hot cars—that’s one every nine days.

At this writing, at least 24 children left in cars have died this year from heatstroke, according to data from the San Francisco State University Department of Geosciences. And according to the National Highway and Safety Transportation Administration (NHSTA), an unknown number of children are injured each year because they were left in hot cars. Among those injuries are permanent brain damage, blindness and hearing loss.

Often, heatstroke strikes after a playful child gets into an unlocked vehicle without a parent's knowledge. It strikes when a parent or caregiver who is not used to transporting a child as part of his or her daily routine forgets that there’s a sleeping infant in a rear-facing car seat in the back of the vehicle.

Even when the weather seems mild, the temperature inside a parked car can reach hazardous levels within 10 minutes, even with a window rolled down two inches. So if you plan to leave a kid in a car only for a minute while you run into the store, cleaners, neighbor’s house … don’t—children are more susceptible to heatstroke than adults because they overheat more easily; infants and children younger than 4 are at the greatest risk for heat-related illness.

Last year, we wrote about devices that purport to protect against leaving children in cars, but that were found to be less than effective.

Much better to inform yourself about measures you should take regularly to ensure tragedy doesn’t happen to you. Link here for 13 safety tips about keeping your kids safe from overheated cars. For more information about kids and heatstroke, visit this page from Safe Kids Worldwide.

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Posted On: August 5, 2013

Early Use of Antibiotics May Lead to Eczema Later

Antibiotics are often necessary to treat an infection, but kids who take them before they’re a year old appear to be more likely to develop eczema.

A report published in the British Journal of Dermatology resulted from a review of earlier research. It concluded that children who took antibiotics in their first year were about 40% more likely to develop the itchy skin disorder. As interpreted in a story by Reuters, the study supports the idea that antibiotics destroy intestinal microbes that contribute to the development of the immune system after birth.

Fetuses exposed to antibiotics taken by their pregnant mothers, however, were not at higher risk of getting eczema after birth.

The Dermatology report, the first to consolidate available results from several studies indicating that early-life exposure to antibiotics increases the risk of eczema, reinforces what’s known as the “hygiene hypothesis”—that babies and youngsters who are not exposed to a wide variety of microbes don’t develop immune systems as robust as those who are. The theory has been applied to immune overreactions such as allergies and asthma.

As we wrote a few months ago, the American Academy of Pediatrics issued new guidelines for diagnosing and treating children’s ear infections in an effort to reduce the unnecessary use of antibiotics because, in addition to helping bacteria develop resistance to the drugs, using antibiotics when they’re not necessary can cause stomach problems and allergic reactions.

For some infections, most kids improve within a couple of days without drug intervention.

As many as 2 in 10 kids will have symptoms of eczema; more than half of them continue to have symptoms into adulthood.

The new report analyzed results of 20 studies of antibiotic use, either prenatally or in the first year of life, and their association with later skin problems. The more antibiotics a baby took, the higher the risk. Each round of antibiotics bumped up the risk of eczema by 7%. Broad-spectrum antibiotics, or those that treat a wide variety of infections, like amoxicillin, seemed to have the strongest effect.

Some experts noted the possibility of "reverse causation”—that’s when a baby with eczema has more skin infections that might require antibiotics and confound the results of the studies. But the authors of the new review acknowledged that limitation and said the findings are still valid.

Another possible flaw in the review concerns when eczema symptoms began and when antibiotics were first administered. The onset of eczema often occurs before a baby is a year old, so if symptoms began before antibiotics were given, those children should have been excluded from the studies.

But even outside experts who pointed out that flaw agreed: Antibiotics should be given to anybody only when it’s necessary, and especially for wee ones whose immune systems are developing.

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Posted On: August 2, 2013

Getting Tough on Texting While Driving

Some people are bonded more closely to their smartphones than they are to other people. Sometimes, these relationships are more helpful than harmful or annoying, but when it comes to driving, it’s never a good idea to text when you’re behind the wheel.

It’s essential that parents ensure their teenagers aren’t doing it, either.

We first broached this subject more than three years ago, but with the boom in texters and texting opportunities, the problem endures.

In a discussion posted on KevinMd.com, pediatrician Claire McCarthy from Boston Children’s Hospital states that “I’m not big on spying on teens generally. I think that privacy is important. And by the time they are teens, … we need to let them learn to be independent and make choices without us.

“That said, if you have a teen who drives, there’s some spying I suggest: … check to see when your teen is texting. More specifically: Check to see if he’s doing it while he’s driving.”

Although you might not be able to see the content of texts on your online account, you can review every call or text made. And that’s the point—McCarthy isn’t interested in reading texts, just knowing when they’re happening.

Even if you don’t know exactly when your child is driving, you might be able to detect patterns, and if the child knows you’re checking, that can serve as a deterrent in itself.

McCarthy refers to a study in the journal Pediatrics that found that half of U.S. teens 16 and older reported texting while driving in the previous 30 days. “To be fair to teens,” McCarthy makes clear, “we adults aren’t setting much of an example: According to the Centers for Disease Control and Prevention, a third of adults text while they drive.”

The study also found that teens who text while driving also are more likely to do other risky things while driving–fail to use seat belts, drive with someone who has been drinking alcohol or drive drunk themselves.

So, like so many parent-child lessons, it comes down to role-modeling. If you want your child to eat healthfully, follow a healthful diet yourself. If you want your child to read more and watch TV less, read more yourself. If you don’t want your child to text while driving, don’t you do it.

As McCarthy reminds, the teen brain is not the same as the adult brain, and because of that “under construction” status, behavior that comes more easily to you proves more difficult for a kid. (See our blog, “Teen Injuries in Auto Accidents: Sense of Invincibility May Cause Car Crashes.”)

Teens, as McCarthy says, “are wired to think that disaster will happen to someone else. Their brains are still developing, and the last part to mature is the frontal lobe, the part of the brain that controls our impulses and gives us some common sense. From an evolutionary standpoint, it’s good that adolescents are willing to take risks; as you start out in life, it’s good not to be afraid of your shadow. But that risk-taking can sometimes play out badly–and often does, when they text and drive.”

Set rules for safe driving, McCarthy says, and enforce them. Follow them yourself.

If you do find out that your teen has been texting while driving, impose consequences. “At a minimum,” McCarthy advises, “there should be a loss of driving privileges. Driving truly should be a privilege, not a right–teens need to understand really clearly how their lives, and the lives of those around them, can be on the line every time they drive.”

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