10 FAQs and pitfalls on children in the sun


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10 pitfalls & FAQs leading to kids’ sunburn – big ouch!

Ouch – that’s gotta hurt!

For an Emergency Medicine Doc, I’m pathetically squeamish about sunburn (I come over all faint and it’s all a bit embarrassing!). Despite factor 30 – I got burnt in the early May sunshine yesterday. How? I’m paranoid – how could I get caught out?

1.We try to catch a tan at the start, using inadequate protection. It doesn’t work, and often it wrecks the holiday due to pain or needing to keep covered up.

2. It’s windy – doesn’t make the sun much stronger, but you don’t feel yourself burning (this is what caught me out). Solution is to take note that risks are higher, and to spend less time in it.

3. Water – washes off suncream, but more easily forgotten is the reflection from water surfaces which magnifies the rays.

4. Not putting cream on early enough. It wipes off if you slap it on and then sit on a towel that wipes it all off. It takes a good 30 minutes to start to work – you can burn in strong sunlight in the time it takes to work.

5. Time of day. Most folk know to avoid middle of the day but can forget to use any protection at either end of the day. You can still burn at either.

6. Damage from burning is more intense the earlier in childhood it happens, partly as it’s still developing, but also DNA damage has more time to develop into something nasty the longer it’s there. If it happens really early or you get to live to a ripe old age, it is more likely to cause problems.

7. We tend to remember cream for short intense bursts, but forget in the daily cumulative exposure. Damage early on just using UVB protection leads to wrinkles and other forms of sun damage – skin care ranges have cottoned on to this and push for daily SPFs

8. We forget that burnt skin becomes more fragile and more likely to burn again.

9. We don’t manage burns well. We forget to use tepid or cool showers / baths. Often 8 hr cream (Elizabeth Arden) is a great treatment (don’t wear it out in the sun!). Moisturisers are important for when burnt skin becomes itchy or peels.

10. We try and max out on the rays on the last day – or worse still, dilute the dregs of the cream in moisturiser to make it stretch. It doesn’t work. It doesn’t mix evenly so though some parts may be partially protected – others burn badly.

Good luck – enjoy the warmth of the sun. Lap up the Vitamin D, but please be careful. And if come to me with a sunburnt child I’ll ask a colleague to see you because I’ll likely have turned green!

The Aussies are the pro’s at this, SLIP, SLAP,SLOP, SLIDE is a great slogan. You can’t buy less than factor 30 there and people berate you in the street if you are burnt. A culture change – but their melanoma rates have fallen dramatically.

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Food & other allergies – a fantastic resource


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An excellent site with a lot of practical fact sheets to download – take a look and send them some feedback!
10 FAQs in allergy / anaphylaxis still to come

http://www.childrensnational.org/DepartmentsAndPrograms/default.aspx?Type=Program&id=100016&SubType=ResourceForFamily&SubId=341&Name=Food%20Allergy%20Program&Subname=Downloadable%20Brochures%20about%20Food%20Allergies

Childhood constipation – drawing attention to a neglected area of child health


Childhood constipation – drawing attention to a neglected area of child health.

Teenage bedwetting – there’s nothing to be ashamed of


Teenage bedwetting – there’s nothing to be ashamed of.

How fast does Movicol work? How long does Movicol take to work?


 

Check out my no-nonse ebook - Kid's Constipation - Crack It!

Check out my no-nonse ebook – Kid’s Constipation – Crack It!

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With thanks to http://www.quickcare.org/gast/constipation.html – their site is great for general info – though laxative dependency isn’t something we really see – their site shows a fantastic animated version of this diagram.

this is by far my most asked question!

FAQs? No – wordpress tells me this is almost the only question people search for that finds my blog

So, Movicol, how fast does it work, or at least how long does Movicol take to work?

Problem with constipation is that by the time anyone realises, there’s already some build-up. It’s that that makes people feel so – yuk!

This is because the amount of stool inside makes you feel sluggish and bloated. If you drink clear fluids that often helps, but eating fibre at this stage seems to just make you feel more bloated. This is why people who feel constipated eat simple carbs like bread and rice as these tend to be almost fully absorbed so they don’t add any more to the bloated feeling.

We forget this when trying to treat it. Movicol is like dynamite – if you give enough for the job it will work (though in most cases you should be in close liaison with your healthcare provider).

When to try it – relax!

When you know it will work, relax, find a time when you won’t need to worry too much how it affects you – time off or school holidays or Bank Holiday weekends. You never know if you’re going to be quite sensitive to it, or need bucket loads. Nobody does until you try it.

Bowel transit times and other ‘medical’ factoids

The normal bowel transit time in adults is a couple of days, in toddlers only about 12 hours. For this reason, it doesn’t work straight away. Because it is a starch attached to water it is a bit like food rather than fluid and it takes time to work through. If you think of cooking rice when there is the gloopy rice water before you rinse it – Movicol works like this – you couldn’t squeeze the water out of it even if you tried. But equally, the bowel doesn’t absorb it. While you always think of the bowel as your ‘insides’ ironically it sort of outside. It is open at the top and open at the bottom. If something goes in at the top and is not absorbed, it will come out at the bottom. This is how it works. When you make up the sachet, that minimum volume will all reach the end of the bowel, you can add more fluid, but that original amount all reaches the end.

Now the less lovely part – what happens then?

Ok, deep breath, here goes!
The food & drinks you eat all mix with fluids in the stomach. The clear fluids are absorbed quickly there as are simple sugars like glucose, most of the rest pushes along to mix with more enzymes to help absorb it. At this stage each Movicol molecule is still attached to its water.

They continue like that through the small bowel and enter the large bowel at the same level as the appendix (the caecum). This is inside your abdomen (of course) just above your right hip. It then passes in an inverted ‘U’ shape along to the end of the large bowel. Some nutrients are absorbed here but generally water is absorbed so that the stools get drier and drier as they get to the end.

Now the action bit!

The Movicol molecules continue being pushed along attached to the same water molecules. When it reaches the impacted stool (the stool that’s backed-up) it can do a number of things:
1) form a normal stool and by weight of this push that ahead of it out (‘rocks’)
2) remain loose and build-up a head of pressure sufficient to push that ahead of it out
3) remain loose and effectively break-up the stool ahead of it out as small bits or loose stool rather than expected ‘rocks’

It seems to be a variable proportion of these which varies from person to person.

I hope that this makes some sense – and makes taking this medicine easier.
It is hard to remember now, but in the days of lactulose and senna alone, treatment was much more difficult.

10 FAQs on GOR / GERD – reflux in babies


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http://lapsurgerybrisbane.com.au/gastro-oesophageal-reflux/

Special thanks to: lap surgery.brisbane.com.au

10 FAQs on GOR / GERD – reflux in babies
It’s just plumbing really!

1) What is GOR/GERD?

If we think of babies stomachs as being machines, we want to put fuel in and have the finished product (use your imagination at this point!) come out. We don’t want to have some of the fuel rejected and spat out, and we don’t want to have a machine which makes unhappy unhealthy noises before it’s topped-up, when it’s topped-up or anytime after it’s topped-up. These things happening are essentially in essence how reflux is.

Essentially the stomach contents (which have acid in them) flow back up into the gullet where either they cause pain from the acid, or go as far as vomiting.
It stands for Gastro-Oesophageal Reflux or Gastro-Esophageal Reflux depending on whether you are in the UK or USA.

2) Why does it happen in babies?

It can actually happen at any age, but usually is in this age group. Most of us would assume that when we eat, food passes via gravity through the gullet (oesophagus) into the stomach and then it stays there, closed off by a valve or sphincter. In fact the bowel doesn’t work this way – you can eat standing on your head for example!

All of the bowel works by gently having waves of pushing which start at the top and work right down to the anus at the end. These are the same waves that cause ‘tummy rumbles’ by pushing fluid around in the small bowel, and spasms in constipation as the bowel pushes harder and harder in waves to try to pass stools – doctors call these waves peristalsis and these ‘tummy rumbles’ borgorymi.

There is no sphincter as such, but the whole bowel contains muscle to push its contents along. Between the gullet and the stomach, the area of muscle is thicker and is effectively narrowed compared to the rest of the bowel, though it stretches when food passes through.

After birth the thickening of this seems to happen at different rates, but certainly GOR is very common in babies either as pain and/or vomiting. Interestingly later in life adults may suffer with a similar condition, hiatus hernia which means that a small amount of stomach has slipped up through the diaphragm into the chest. The symptoms are much the same.

3) What ages do you see it at?

Pretty much any age, but generally babies in the first few months of life. Inexplicably it doesn’t appear to be there from the first days or week or so. While I cannot think of an obvious explanation for this, certainly breast feeding tends to be quite small volumes at this stage so there is much less to come out. Acid secretion in the stomach may also be quite immature in the first few days or weeks.

It generally settles within a few months but most babes have long-settled by 1 year and very few continue up to their 2nd birthday.

4) My baby used to just posset or dribble. Now the vomiting is projectile – why?

Posseting is generally very normal when it is just a small amount of milk ‘dribbling’ or ‘leaking’ from the mouth. It just comes with no effort at all and no retching beforehand. Vomiting in reflux is also like this – it just comes – often with little or no warning. Some parents report hearing gurgling in the starch first or hearing milk going up int the gullet first.

If it seems to be more than that, or your baby is otherwise unwell they should be taken to see a doctor or midwife / health visitor or similar. Vomiting like this can be due to an ear or urine infection amongst others, or to something like ‘pyloric stenosis’ (a narrowing of the outlet of the stomach to the rest of the bowel which allows virtually no milk to pass through).

5) Ok, so we’ve decided it’s reflux – what are they still putting on weight?

I know! It seems like every drop of milk you made up ends up on their clothes, your clothes or the carpet. The washing pile is never-ending and they seem to ‘waste’ a lot of milk.
Somehow because it’s not the same as normal vomiting which makes you feel pale shaky and faint ( the so-called vagal response) babies are keen to feed again and get enough overall to keep on growing.

6) How about simple measures?

Propping up the mattress head end of the cot helps, as does holding the baby upright for some time after a feed to allow milk to pass through before it is regurgitated.

7) If it’s just plumbing, how do we treat it?

First, like many machines there are different ways of approaching the same thing!

In the Gaviscon advert, firemen hose down the inflamed walls of the stomach which settles it. Broadly this us how infant powered Gaviscon works. It forms a layer on top of the stomach contents to stop any acid causing inflammation. It also thickens the milk if allowed to stand initially which means that is more likely to stay down.
In these cases there needs to be a balance struck between making the milk thick enough to stay down, but thin enough to get through the teat.
Many babies become quite constipated on it and may require suppositories or laxatives to settle the constipation.

Babies can only have Gaviscon sachets and not adult liquid because the adult version has large amounts of salt in it which small babies kidneys can’t process adequately.

For many this is the mainstay of treatment.

8) What if vomiting is still a big issue?

A further thickener can be tried (instead of Gaviscon). There are options such a over-the-counter ‘Stay-down’ milk. This is much more expensive than normal milk (it’s small sales volume compared to the others). Another alternative is Carobel which comes as a powder which thickens the milk – it is the same stuff as in chocolate carob biscuits – bit like sawdust. One advantage is that you can titrate it to effect so that you can thicken the feed as much or as little as you need. The same proviso about thickness nod the teats applies as with Gaviscon.

A further alternative is a medicine that works not by thickening the milk so that it stas down, but by emptying the tummy quicker so that there’s less milk there able to be regurgitated. These medicines include Domperidone (invariably quoted as ‘Dom Perignon’!) and erythromycin. Both of these have a drawback that they are 3/4 times per day. Interestingly, the erythromycin is a normal antibiotic (often used in penicillin-allergic patients) used at a very lw dose for its side effect of driving the waves in the bowel harder.

9) What if the problem is more pain than vomiting?

In that case, if Gaviscon has not been sufficient or has been replaced by Carobel, the normal treatment would be to reduce how much acid the stomach makes since if this settles there is little or no acid to cause pain. The medications to do this are Rantidine (or Zantac) which partly reduces acid secretion but works within a few hours and Omeprazole (Losec) which markedly reduces or stops the acid production.

Ranitidine is 2/3 times per day and Omeprazole once per day.
This potentially means that a baby on Domperidone (Dom Perignon) and ranitidine may be having 7 doses of medication at different times of the day.

10) Which will work for me?

Nobody can really know that for any given baby – they’re all different. There are two strategies though – going in hard with lots of medicines and then reducing or starting with one and working up. Sometimes certain medicines are just not right for some babies so a bit of tinkering of medicines and doses may improve things.

It’s never clear when things are under control whether your baby was just outgrowing the reflux or if the medications really helped.
This leads me onto 11) Is there good evidence for this treatment approach?

In fact there is not – quite the opposite in fact

click here

Most Paediatricians do however treat it as the constant vomiting meaning babies and mums always smell of ‘sick’ and the constant piles of washing in an already exhausted mum wears them down. In terms of the acid, babies can be completely inconsolable for hours on end – nothing the parents do help. I am constantly amazed just how much of this parents live with on a daily basis.

Bonus question 12) What about changing the milk?

There is little evidence for this, and generally parents will have already tried a number of over the counter milks and teats. There are different options – lactose free milks, soya milks (used later as thought to affect hormones), Nutramigen for those who can’t have cow’s milk, and Neocate for those who REALLY can’t have cow’s milk.

While these specialised milks are available on prescription they are very expensive, smell awful in some cases and taste even worse in others. However, for those who need them they are miraculous often.

Going for one of these means that being labelled milk-allergic means that no-one an even give your baby a chocolate button, or biscuit unless dairy-free. It’s very restrictive. For that reason, medicines are often tried first.

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Special thanks to: Amazon.com

10 FAQs on Gillick Competence ( Fraser Competence / Guidelines)


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1) First of all which is it?

It is absolutely Gillick Competence – there are Fraser Guidelines with respect to Gillick Competence but there’s really no such thing as Fraser Competence – whatever Mrs Gillick thinks or wishes to happen, the legal folk and some doctors have tried to make this point (see below).

2) What is it all about?

I keep hearing it bandied about but don’t think folk bandying it about even know what it’s really about!

It’s about whether some children who are particularly mature but under 16 should be able to give consent to doctors themselves for treatment without their parents needing consent or even being involved. It didn’t concern itself with children who refuse to consent – that came later.

Although the case itself involved contraceptive advice & was quite emotionally charged, it actually applied to all aspects of child age of medical consent equally. While it concerned medical advice it also involved family law and medical law.

3) Who were Gillick & Fraser then?

Mrs Gillick was a lady of Catholic faith with 5 daughters when the case originally started back in 1982. Later she had a total of 10 children some of whom are pictured above. All of her daughters were well below the age where their possibly giving consent themselves was likely to be an issue – one was a newborn.
Fraser was one of the judges of 5 in the House of Lords who made the final judgement. 9 judges altogether were involved, but it was his setting out of these guidelines in his decision that was adopted. Lord Scarman ( famous for other cases too) also wrote similar guidelines but added a further condition which was not formally adopted).

4) Gillick competence is the law right?

The decision in the case of Gillick is not written in a specific law (Statute) but is part of what’s called the Common Law – a decision made on a particular issue taken in this case all the way to the House of Lords which effectively sets a precedent. That s, where the same question comes up again, where no area of the law elsewhere has changed, this decision will be the basis for the new decision.

There are a number of ‘laws’ which apply in this area however

The Family Law Reform Act 1969

( reduced the age of majority from 21 to 18 – before that your parents ad to consent for you to any operation until your 21st birthday – it also allowed 18 yr olds to vote)

Children Act 1989

This concerns whole raft of child issues but many of the areas where local authorities alter guardianship of children or mandate certain things happen for the child

5) Why did it concern contraception?

Doctors and lawyers were certainly not looking to explore this area n this way. I was a time however when control of pregnancy was an increasing issue and abortion statistics showed this was becoming an issue.

The whole case started because the Local Health Authority in Cambridgeshire where Mrs. Gillick lived had put out a circular advising it’s staff that they could provide under 16s with contraception not necessarily requiring a rental consent.

It is unclear how Mrs Gillck came by this information as her children were too young to be exposed to it, and she herself was a devout Catholic who had 10 children so is presumably unlikely to have come across it at a family planning centre.
Interestingly, we never hear of Mr Gilick apart from one judge expressing that e assumed that Mr Gillick was in agreement with his wife’s position.

There were many advantages to this however – no time pressure. There was no real child requiring a rapid decision to enable them to have treatment. The whole legal process in he event took around 4 years. It was also convenient in that there was something specific t challenge – the written guidance circular.
The issue of contraception was a real one where these dilemmas existed and not providing treatment was perceived to risk unwanted child pregnancy, abortions and other problems.

How did Mrs Gillick set about starting this whole process?6)

Mrs Gillick wrote to the Health Authority seeking an assurance that no such advice would be provided to her own children without her involvement. The Health Authority refused to give such an assurance.
She then brought a case against the Local Health Authority challenging their position on 2 fronts. The first was that doors providing contraception to these girls were partly guilty of rape since by providing contraception they were condoning it and it was legally rape because the girl was under 16. This part was rapidly thrown out.

Secondly she claimed that parents had complete responsibility nod authority over their children at that age. This part was pursued.

7) We would always have reached this position at some stage wouldn’t we?

Possibly, but not necessarily. It’s very easy to think it all looks obvious in retrospect – it so wasn’t. The furore at the time was huge,and the md-80s was a very different time to now. Many parents of children that age were very supportive of Mrs Gillick – my own and many f my friends’ parents too.

If a particular case had led to examination and exploration of the law on this issue, the pressure to make timely decisions would not have allowed the time given here to make reasoned decisions. (Naturally even urgent & rapid legal decisions are well-reasoned, but having no time pressure makes the process easier.)

8) The judge did not support Mrs Gillick did he?

It seems strange now, but actually more judges supported Mrs Gillick than were against her. Our legal system is a bit odd in that one judge alone makes the initial decision – in this case against Mrs Gillick. 3 judges sit in the Court of Appeal, and all 3 supported Mrs Gillick. At the final hurdle following appeal by the Health Authority, the case was considered by 5 judges. 2 supported her and 3 were against. So of 9 judges, 5 were supporting her and 4 were against. It is easy to see why there are always an odd number of judges at each level! It is also notable that the burden of decision is spread more in number as the level of appeal increases.

Wouldn’t things have been different if the judges were spread differently? A rhetorical question and one FAQ I’m not sure I can answer!

9) What was the decision in a nutshell?

Essentially that children were recognised as maturing at different rates such that they would reach ‘genuine’ competence to make decisions at different ages. Until this point they were ‘pre-competent’ rather than ‘incompetent’ (the preferred legal term).

It was envisaged that a few children would be so demonstrably mature that they could demonstrate their abilities by looking at Lord Fraser’s guidelines. It was also felt hat the number of children it would apply to would be very much a minority.

This hasn’t been the case. Many healthcare professionals seem to start from a position of assuming that young people are competent ( often resulting from a ‘mature’ appearance rather than pure decision-making ability). Certainly the numbers are not few.

10) What were Lord Fraser’s guidelines?

The Fraser guidelines refer to the guidelines set out by Lord Fraser in his judgement of the Gillick case in the House of Lords (1985), which apply specifically to contraceptive advice:

“…a doctor could proceed to give advice and treatment provided he is satisfied in the following criteria:

1) that the girl (although under the age of 16 years of age) will understand his advice;

2) that he cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive advice;

3) that she is very likely to continue having sexual intercourse with or without contraceptive treatment;

4) that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;

5) that her best interests require him to give her contraceptive advice, treatment or both without the parental consent.

Lord Scarman added that the child had also to understand what was involved. This in addition to meeting Lord Fraser’s guidelines was said to be ‘Gillick Competence’.

Decision can be read here

http://www.bailii.org/uk/cases/UKHL/1985/7.html

Gillick v West Norfolk & Wisbech Area Health Authority [1985] UKHL 7 (17 October 1985)
URL: http://www.bailii.org/uk/cases/UKHL/1985/7.html
Cite as: [1986] AC 112, [1985] UKHL 7, [1986] 1 FLR 229

Always at least one bonus question!

11) What did Mrs Gillick do after this?

Raise a family certainly. There have been rumours over the years that Mrs Gillick would strongly like her name to be removed from this concept. While sympathetic with Mrs Gillick particularly as her name is attached to something she fought to stop, we have her to thank that this issue was raised and debated and considered fully. Without her, the issue may have evolved very differently.

Over the years Mrs Gilick has also campaigned on anti-abortion and has stated that the number of abortions local to her in 12 years would have filled the whole nursery school. She also campaigns on local issues.

The story of this case is as interesting as the result.

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