Doctorweblog. About Health & Medicine

Use ‘time-out’. This removes the child from the action and ensures he will not get attention. Here are some strategies for time-out:

• Pick a room for time-out. Usually the child’s bedroom is used, though it can be any room where he will be safe. Sometimes you can use the time-out technique in a chair in the corner of the room, although this is more difficult and used more in older children.

• If your child is doing something of which you disapprove, warn him that if he doesn’t stop immediately, you will put him in his room.

• Only warn him once — then act. Never warn and then fail to act on your warning. This undermines your whole strategy by creating uncertainty as to whether you are serious.

• If he does not stop after the warning, take him to his room immediately. Do not explain to him why you are doing this — explanation at this time is a form of reinforcement.

• Leave him there for 5 minutes, then go and tell him he can come out of his room. Treat him normally after the time-out — do not talk to him about the event.

Time-out is especially effective for aggressive behaviour such as hitting or biting.

Have appropriate expectations that are relevant to the age of the child, and remember that children differ from each other in temperament. Some children will inevitably be more active and curious than others, and may be more likely to test limits more often.

Do not blame yourself for your child’s behaviour. While it is true that some parenting practices may reinforce undesirable behaviour, parents do not cause a child’s behaviour problems.

Behaviour is always more difficult to manage when you are not in your home. Parents often report that their child plays up when they are visiting friends and relatives, or out shopping, for example in the supermarket. The principles of behaviour management are exactly the same as outlined above, although it is much more difficult to carry them out consistently. It is understandable that parents may feel embarrassed in front of friends or strangers, and be reluctant to maintain the principles of behaviour modification.

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Betty had worked extremely hard on her recovery. She had been able to return to work three months ago and was really happy to be back in the workforce. Although she’d had the occasional bad day, Betty was able to work through them and she had begun to feel that she had finally recovered. That was until last week. Now Betty was beginning to think the disorder was returning. Her anxiety was increasing and the attacks had returned. She knew that returning to work had been stressful, but she was happy in her job. She couldn’t understand why the anxiety and the attacks were back. To all intents and purposes life was normal. Her husband and children were fine. Although Betty realised it was hard to run a household and work at the same time, she felt it was worth the extra effort. Her father’s death two months ago had been traumatic but she felt that couldn’t be the reason. Betty wondered if it was the argument she had had with her mother and sisters. The issues had still not been resolved and each time they were together the atmosphere was quite tense. She knew the anxiety and the attacks were making her feel tense, but she couldn’t understand why they had come back. Betty thought that she needed to be more aware of what was causing stress in her life!

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The purpose of looking at norms is not to say that all children have the same needs and can be neatly categorized. Because you are reading this book, it is safe to assume that your child does not fit the pattern outlined. It is also safe to say that you are not pleased and you sense something is going wrong. The purpose of this section is not to make you feel worse about yourself or your child.

Norms are very useful to pinpoint problem areas—to help you establish where you are now. Using the norms, you can begin to look at your situation realistically. You will have something to compare your experience to besides, “When you were a child…” and “None of my children….”

Norms are also useful in setting realistic goals. When the problem is solved you will have clear comparisons for determining how far you have come. Read this section with these thoughts in mind.

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Breathing extra oxygen will make you feel easier, whatever the reason for your breathlessness. Ask about this if the reason for your breathlessness cannot be corrected, or if you feel that the cost of trying to correct it is too great for the likely benefit, or while you are waiting for treatment of the cause to work. It is quite feasible to have an oxygen cylinder at home and it also comes in small cylinders which can be fixed to a wheelchair or carried around fairly easily.

Feeling very breathless can be extremely frightening and stressful. You may find it very hard to relax or to sleep, even with oxygen. Having somebody sit with you may help. Taking a sedative is another possibility. In considering whether to take sedatives you should understand that they could make your breathing and coughing less efficient. This is a cost that you may well be prepared to accept, especially if your cancer cannot be cured and the reason for your breathlessness cannot be relieved. Some doctors take this choice out of their patient’s hands, either by prescribing a sedative without telling them or by refusing to prescribe one even when the patient asks for it. The choice should be yours. Insist that your doctors prescribe nothing without your agreement. Tell them if you would prefer to be either more alert or more drowsy than you are. You have the right to choose, even if the choice to be more drowsy could mean that you don’t live quite as long.

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Headache is probably the commonest symptom from which we all suffer. It may be due to physical and emotional causes.

Some headaches can all be classified and singled out as having a specific name, such as migraine.

There is often an overlap between the different types and sometimes two or three different forms may be present in the one individual.

Many headaches are caused by stimulation of the pain-sensitive nerves in the wall of the blood vessels both inside the brain and in the scalp.

These are vascular headaches and include migraine, cluster headache, the headache due to a hangover and even that associated with toxic states, such as fever.

Some are due to muscle contraction and this includes the common tension headache and the very rare headache due to eye strain.

It also includes pains around the temple due to spasms of the masseter muscle which moves the jaw when we chew and is caused by an imbalance of the bite.

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Menstruation — that most intimate part of every woman’s life — is still, despite modern education, often misunderstood.

So let’s consider exactly what this function is, and the parts of the body involved.

The organs concerned with menstruation are the womb, the ovaries, and the fallopian tubes.

The womb, or uterus, is a pearshaped organ roughly 7.6 cm (3 inch) long and 3.8 cm (IVi inch) wide, and it lies low down in the pelvis.

The womb is mostly thick muscle, but it is lined with several layers of cells known as endometrium.

The ovaries are two almond-shaped organs lying either side of the womb about 5 cm (2 inch) away. The fallopian tubes connect to the top of the womb, and their open outer ends lie very close to and partly enclose the ovaries.

The womb thins down to a narrow neck, the cervix, and sits on top of and projects into the vagina.

The beginning of a woman’s menstrual cycle really begins at the end of menstruation, or bleeding.

A hormone, oestrogen, is produced by the ovaries and causes the lining of the womb to thicken, to become soft and spongy.

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Taking care with what you eat is essential if you have diabetes. For some people with type 2 diabetes, this is all they have to do to keep their blood sugar levels in the normal range of between 4 and 8 millimoles per litre. Others also need to take tablets or injections of insulin. People with type 1 diabetes must have insulin injections. But no matter what the treatment, everyone with diabetes must take care with what they eat in order to keep their blood sugar levels under control Keeping the blood sugar near the normal range helps prevent complications of diabetes such as blindness, heart attacks, kidney failure and amputations.

For over a hundred years, people with diabetes have been given advice on what to eat Many diets were based more on unproven (although seemingly logical) theories, rather than actual research. In 1915, for example, the Boston Medical and Surgical Journal advocated that the best dietary treatment for someone with diabetes was ‘limitation of all components of the diet’. This translated into a very low kilojoule diet interspersed with days of fasting. Unfortunately, malnutrition was often the result!

In the 1920s doctors began recommending high fat diets for their patients. Ignorant of the dangers of a high fat diet, they knew that fat, at least, didn’t break down to become blood sugar.

It was not until the 1970s that carbohydrate was considered to be a valuable part of the diabetic diet Researchers found that not only did the nutritional status of patients improve with a higher carbohydrate intake, but their blood sugar levels improved as well.

The only part of food which directly affects blood sugar levels is carbohydrate. When we eat carbohydrate foods, they are broken down into sugar and cause the blood sugar levels to rise. The body responds by releasing insulin into the blood. The insulin clears the sugar from the blood, moving it into the muscles where it is used for energy, so the blood sugar level returns to normal.

Some people think that because carbohydrate raises the blood sugar level, it should not be eaten at all by people who have diabetes. This is not correct. Carbohydrate is a normal part of the diet and at least half of our total daily kilojoules should come from carbohydrate. In fact, the more carbohydrate you eat the better because it automatically reduces the proportion of kilojoules you get from fat.

The secret to the diabetic diet is not so much the quantity but the type of carbohydrate.

Traditionally sugar was excluded from diabetic diets because it was thought to be the worst type of carbohydrate. The simple structure of sugar supposedly made it more rapidly digested and absorbed than other types of carbohydrate, like starch. This assumption was simply not correct. Even in the late 1970s, test meal studies showed that there was a great deal of overlap between the blood sugar responses to sugary and starchy foods. Fifty grams of carbohydrate eaten as potato caused a similar rise in blood sugar as 50 grams of sugar. Ice cream resulted in a lower blood sugar response than potato! Findings like these sparked research into the G.I. factor in an effort to learn more about how the body actually responds to different carbohydrate foods.

The emphasis through the 1970s and for much of the 1980s, was on the quantity of carbohydrate in the diet. ‘Portion’ diets were used to prescribe a set amount of carbohydrate to be eaten at every meal. (A carbohydrate portion* is an amount of carbohydrate-rich food which contains 10 to 15 grams of carbohydrate—depending on which country, or State of Australia—you lived in. So, not only was the portion system complicated, portion sizes varied throughout the world!).

An underlying assumption of the carbohydrate portions theory, was that equivalent amounts of carbohydrate, irrespective of the type, cause an equal change in the blood sugar level. This reasoning had no scientific backing and has since clearly been shown to be incorrect. Fortunately, good quality scientific research supports today’s dietary recommendations for people with diabetes. While the G.I. factor research has not negated the significance of the quantity of carbohydrate in the diet, it has shown us the importance of considering the type of carbohydrate food that we include.

The G.I. factor has shown us that the way to increase the quantity of carbohydrate in the diabetic diet, without increasing the sugar levels in the blood, is to choose carbohydrate foods with a low G.I. factor.

Our research has shown that blood sugar levels in people with diabetes are greatly improved if foods with a low G.I. factor are substituted for high G.I. factor foods.

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The following lists some basic tasks and resources which can be used by the fat loss counsellor in exploring the psychological component of excess body fatness. More detailed therapy should be referred to a qualified professional psychologist.

Current attitudes.

1. Identify current thoughts, feelings and attitudes to fat loss: What for? Why now? How long for? What then? Ensure clients recognise that permanent fat loss means lifestyle change.

2. Clarify expectations of fat loss: What problems are anticipated that it will solve? How else could these problems be dealt with? If any of these expectations are perceived negatively, how else could the problem be managed?

3. Clearly define a lifestyle which is both acceptable and achievable, which will maintain a lower level of both fat intake and body fat level.

History.

1. Explore previous experiences of fat/weight loss: What worked, What didn’t? What lasted? How were relapses dealt with? Understand what went wrong or right and how this time is different.

2. Deal with family leftovers, experience of fatness in the family, food messages, how eating, drinking and exercise played a part in the family life and what impact these still have.

Obstacles.

1. Identify which important aspects of lifestyle keep the client from losing fat: food choices, feelings/experiences which seem associated with inappropriate eating, time pressure, stress, lack of regular exercise, food knowledge?

2. Identify times during the day/week which represent the most difficult times to control eating: Mealtimes? Snack times? Going to work? Going home? Eating out?

Knowledge.

1. How good is the client’s knowledge of what is in food? How is this used? What else is happening at times when fattier food is deliberately chosen?

2. Increase knowledge of low-fat shopping, cooking, recipe modification and food skills associated with developing palatable, low-fat foods.

Stress management.

1. Identify possible connections between perceived stress and eating behaviour.

2. Develop effective stress management techniques which do not involve the use of food, in conjunction with other regularly used ’self-nourishing’ activities.

3. Plan and use time consistent with lifestyle aims (i.e. incorporating deliberate and incidental exercise, food choices and meal planning).

4. Develop and practice assertiveness, with self and others.

Habit management.

1. ‘Reframe’ eating habits which contribute to overfatness as ‘curious and interesting’ as opposed to ‘immoral or bad’.

2. ‘Stalk’—describe eating, drinking, exercise avoidance habits or routines and develop strategies for interrupting these. Monitor self-talk, identify triggers for over-eating and thinking patterns associated with these. Challenge beliefs about self body image.

3. Evaluate social environment for social support. Develop ways to protect self from ‘high risk’ situations.

Relapse management.

1. Identify and develop a clear strategy for dealing with relapses. This includes strategies for dealing with celebrations and festivities, times of high stress and pressure, times of boredom alone and negative mood states.

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There is some inter-conversion between nutrients such as protein being converted to glucose (gluconeogenesis) for release into the bloodstream, but under normal conditions, the capacity to convert one nutrient into another for storage is very limited. Also, humans have little capacity to ‘waste’ extra energy by burning it off. This process, which has been termed luxuskonsumption, is common in animals such as rats but is very limited in humans. Therefore, the examination of each macronutrient as a separate entity is necessary and is summarised below.

Alcohol. There is an inconsistent relationship between reported alcohol intake and body mass index, with many studies showing that drinkers of large amounts of alcohol have lower body weights. This has led to hypotheses that alcohol calories may be subject to inefficient oxidation, thereby diminishing the impact of alcohol calories on energy balance. In heavy drinkers, there does seem to be an inefficient burning of alcohol because the addition of alcohol to a weight maintenance energy diet does not result in weight gain. Virtually all ingested alcohol is metabolised in the liver and this process produces energy. None of it is converted directly into fat. The main pathway is via the enzyme alcohol dehydrogenase and this should theoretically produce 7kcal/g of alcohol. However, alcohol also appears to induce another series of liver enzymes to burn it and this pathway produces far less energy for use than the usual one.

Alcohol, perhaps because of its toxic potential, is the top priority fuel for burning and, if present, displaces fat and, to a lesser extent, carbohydrate and protein as fuel sources for energy needs. Hence, while alcohol does not directly turn into body fat, it will certainly send any spare fat in the diet into storage. So it appears that the so-called ‘beer gut’ may not be full of beer calories, but rather full of the chips and nuts that accompanied the beer which have been sent to the fat cells for storage. A sobering fact though is that although alcohol does stimulate its own burning, it does not satisfy hunger, and indeed may stimulate appetite. The nature of beer is such that the type of food that is likely to be eaten with it will probably be high in fat (can you imagine beer and fruit rather than beer and nuts?). The sugar which is in the beer, wine and mixes may have an effect on reducing appetite and therefore counter the stimulation of appetite by the alcohol. Overall, we could consider alcohol as ‘half-balanced’ as a form of energy in the body and a potential promoter of weight gain.

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Bronchiectasis means that large infected cavities have developed in the lungs. It is a chronic disease, often starting during childhood and following on from an infection. Whooping cough, measles, bouts of influenza or pneumonia may have been the predisposing infection. Small cavities of the lung are infected, and this usually spreads gradually. Although the general health of the child may originally have been good, a chronic loose cough becomes established. At first it may be apparent only in the mornings or the evenings. When the child runs or exerts himself, there may also be some breathing difficulty. He gets out of breath easily. Gradually, as it develops, he may lose weight and also lose general health and vitality.

Older children tend to develop a cough and bring up large quantities of foul-smelling sputum. Often there is a mild fever which waxes and wanes. In long-standing cases the doctor notices that the fingers become clubbed. (This means the normal ends of the fingers are more rounded.) Many children become anaemic, pale and obviously in deteriorating health.

Treatment

Most doctors believe that bronchiectasis can usually be prevented by adequate treatment of any respiratory disorder. Upper respiratory tract infections, bouts of the flu, coughs and colds, bronchitis, pneumonia, removal of foreign bodies—whatever the cause and nature of the respiratory disorder—if this is treated adequately and completely until a full recovery has taken place, then the risk of this hapless and debilitating chronic disease is not nearly so high. It is salutary advice which parents would do well to follow.

Treatment must be under the proper care of a doctor or hospital where full facilities are available, and where ongoing care and advice can be offered. Lengthy hospitalization is usually not needed, and much of the care can be given at home by the parents.

In the early acute stages, when diagnosis is being established, hospital care may be needed. Antibiotics, aerosol bronchodilators, postural drainage and breathing exercises all form an important part of treatment. Adequate nutrition is also important. Sometimes diseased tonsils or adenoids may require surgical removal, or sinus drainage undertaken. In severe cases, when the disease is confined to a particular lobe of the lung, removal of the lobe may be advisable.

The crux of ongoing home treatment is the postural drainage and breathing exercises routine. This is aimed at removing as much debris from the lungs as possible, and opening up the air passageways to enable as much oxygenation as possible of the lung tissues. The routine may be continued for many months, for years, or possibly for a lifetime.

There is often no simple do-it-yourself cure for bronchiectasis. It usually is diagnosed in hospital, and treatment and ongoing care must often continue for a considerable period of time. Parents should make certain they carry out full instructions to the best of their ability. They should also explain to all their children (especially older ones) the nature of the problem and the need for continual co-operation. Without this, it becomes an even more difficult medical problem.

In early stages, moderate bronchiectasis is often completely curable. However, some cases continue for many years and require ongoing management under the experts.

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