Repeated vomiting in a 7-year-old

Our 7-year-old son has repeated episodes of frequent and severe vomiting. He has just been seen by a paediatrician who diagnosed cyclical vomiting. Our boy is often hospitalized, as he needs a drip to treat dehydration. Can you tell us more about cyclical vomiting?

Cyclic or cyclical vomiting is a most unpleasant condition, the cause of which is unknown. To accept this diagnosis, your child should be completely well between episodes. Cases due to psychological upset have been described but are very much in the minority. Rarely the use of preventative anti-migraine therapy has proved beneficial suggesting that the episodes are due to abdominal migraine – again these are very much in the minority.

So what can be done for the majority of cyclic vomiters for whom no underlying cause is found? Dehydration is the life-threat in these patients and if it occurs an intravenous drip is necessary. To try and stop this from happening a very powerful anti-vomiting agent ondansteron is given. It is a very expensive drug but is worth it if it can reduce the vomiting so that a drip &/or hospital admission is avoided. Sometimes corticosteroids are also given. Despite these measures the patient still has to be hospitalized in many instances in my experience.Fortunately most children (but not all) “grow out” of the condition, so that it ceases after some years without any reason for the cessation. This condition is very frustrating for the patient, the parents and the conscientious medical practitioner who spends much time considering other possible causes, trying anti-migraine and other treatments while feeling very sorry for the families

Inhaled corticosteroids for asthma

Our 2and a half-year-old son has repeated asthma attacks that usually respond to nebulizers at home but he has been hospitalized twice this year. His doctor and the hospital want to put him on a steroid preventer twice a day. I am concerned that the steroids will stunt his growth and give him other problems. What do you think?

Your concern is very common. So much so that a term “Steroid Phobia” has been coined for it. The term phobia is a bit harsh because corticosteroids can cause serious and minor side-effects if given in big doses. However, the dose of steroid given by puffers is so small that it will not cause these side-effects. The great beauty of the inhaled steroids is that they are delivered to where they are wanted – into the airways. They do not go to the rest of the body as they would if swallowed or injected. Any inhaled steroid that is absorbed from the lungs or accidentally swallowed, is 90% destroyed by the liver in 1 second. This means it does not get to other parts of the body and cannot cause side-effects.

Thus, if the correct dose is given, an effect on growth or side-effects is very unlikely. Occasional patients (I have only seen 1 in my career) are unduly sensitive and this will first show up as excessive weight gain. In this case some other preventer is tried. The other group of preventers are also inhaled and stop the release of chemicals in the airways that cause asthma. These are very safe but unfortunately only work in 75-90% of patients. You will need a 4-week trial of giving them twice a day before knowing if they will work or not. Yet another class of drugs called leukotriene inhibitors are relatively new and again seem not to work in everyone.

You specifically mentioned concern about stunting of growth. This has been well looked at by a 25-year trial in which 3 groups of children were followed. These were normal children, asthmatic children not given inhaled corticosteroids and a 3^rd group with asthma who were given inhaled corticosteroids. The normal group grew best but importantly the asthmatics on steroids grew better than the asthmatics not given inhaled steroids. Also, the children with asthma given steroids were only a little bit shorter (about 1 inch or 2.5 centimetres) than the normal children.

As he has been hospitalized twice this year your son should be on a preventer.

Toddlers Diarrhoea

My 2-year-old boy has loose bowel actions and is filling his diaper very frequently. He seems well and our doctor says he is growing ok. A number of tests have been done and none show a problem. What do you think is causing this?

Your son’s problem is quite common. Sometimes it is due to a persistent infection in the bowel and I imagine your doctor has sent off bowel actions to exclude this. One bowel infection that can be difficult to pick up in this way is due to a bug called Giardia and often treatment for Giardia is given even if it is not detected.
A persistent infection elsewhere in the body can also cause diarrhoea and one that is often hard to find just by looking at the child is a urinary tract infection. If not already done, it would be worth sending a urine sample to the laboratory to exclude infection.
As he is growing well it is unlikely that his gut is having difficulty in absorbing his food which is another cause of large quantities of bowel action. For the same reason and his young age he is unlikely to have inflammatory bowel disease such as Crohn’s Disease.
Sometimes an allergy to cow’s milk can cause diarrhoea. You might like to try him on a milk free diet (that is no milk, ice-cream, cheese, dairy products or manufactured products that contain milk such as bread and biscuits) for 3 weeks. Then put him back on his normal diet. If there is a dramatic improvement in the milk-free period followed by a resumption of diarrhoea when milk is taken then he probably has milk allergy. You should then consult a dietician for advice on a long-term milk free diet with calcium supplements. He will need to be on the diet for months before another milk challenge.
The commonest cause of persistent diarrhoea in an otherwise well toddler is called “Toddler’s Diarrhoea”. We do not know the cause of this condition and there is no treatment but the good thing is that it gets better by itself. Because there is no test for the condition, we like to exclude the known causes of diarrhoea that I have described before diagnosing Toddler’s Diarrhoea. The use of agents to slow down the bowel can be dangerous in that there is only a very narrow gap between the effective dose and the dose that is toxic in children. This makes it very easy to “poison” the child accidentally – a sorry outcome for a nuisance condition rather than a true health threat

Caesarian Sections

Why are Caesarian Sections so frequent these days and do they harm the baby?

Caesarian Sections are done more frequently now compared to 40-50 years ago. This is happening all around the world and the major reason is to protect the baby. Natural (i.e. vaginal) childbirth is heavily promoted these days and in general the mother recovers more quickly than a woman who has had a Caesarian. However, while it is the right of any patient to refuse treatment for themselves, the rights of the baby need to be considered in the decision as to Caesarian Section.

Caesarian Sections can be life saving for the baby and sometimes for the mother. At other times they may be necessary to prevent permanent brain or other damage to the baby (and/or the mother). An example of this is the fact that caesarean Section for babies who would otherwise been born in the breech position (that is bottom first) has markedly reduced the risk of damage to the nerves of the baby’s arm and other problems.

Having a discussion as to the need for a Caesar when you are in labour and the obstetrician is worried for you and/or your baby is definitely not optimal. You should discuss this with your doctor and/or midwife during pregnancy, well before delivery.

Babies born by Caesarian Section are more likely to have a short period of breathing difficulty than are vaginally born babies. This Transient Tachypnoea of the Newborn is only for a few hours and much less serious than the condition being avoided – usually some form of brain damage for the baby.

One of my children was born by Caesarian Section because he stopped kicking. He turned out to have a severe ankle deformity. He has done very well, sailing through his University course and now holding a prestigious position in his profession. Ironically he was the best kick at football of all my children but he did spend the first 18 months of his life in night plasters to correct the deformity

Attention Deficit Hypertactivity Disorder

Our doctor has diagnosed our 6-year-old son as having Attention Deficit Hyperactivity Disorder (ADHD) and has prescribed a stimulant (Ritalin). What is ADHD and what causes it?

Attention Deficit Hyperactivity Disorder (ADHD) is a relatively common disorder which affects more boys than girls although girls certainly can have it. It causes the child to have difficulty in concentrating, be overactive and disruptive.

It is easily confused with behavioural problems due to stress from the child being upset by events at school (such as being bullied) or at home (for example warring parents or parental separation).

It is really known what causes ADHD but there is some evidence that the frontal lobes of the brain (which are behind the forehead) are slow to gain their function. The frontal lobes generate intelligence and help regulate our emotions. In a bid to stimulate the function of the frontal lobes doctors try stimulants – which seems strange in a child who is already overactive. However, the giving of these stimulants can be spectacularly successful.

Whatever the cause of ADHD it should be managed because it will interfere with learning at school and make it difficult for the child to make friends. This in turn will lead to the development of Oppositional-Defiant behaviour in late childhood or early adolescence.

Psychological counselling can also be effective in ADHD but waiting lists to see a Child Psychologist are often long. Thus, a child’s doctor may decide on a trial of stimulant medication.

One of the reasons ADHD appears to be a modern plague is that we feel the need to protect our children so much. I think that if I was a child now, I might wear that label. In my case my behaviour was related to my parents unhappy marriage. I was a child when it was easier for such children with such behaviour. From a young age I was able to leave home after breakfast to visit friends with whom I spent much time playing physical games with considerable enthusiasm but limited talent. I returned home for meals or going to bed only. So my behaviour and that of others like me caused little concern for our parents. Yes it did affect my schooling and to this day I find it difficult to stay on task for more than half an hour and one hour is tops. However, I found ways to cope and ADHD usually improves in adolescence if the Oppositional-Defiant problems have not occurred.

There is also Attention Deficit Disorder (ADD) which is like ADHD but without the hyperactivity. The inability to concentrate interferes with doing schoolwork. This may not become evident until primary school; its management is much the same as that of ADHD.

Both ADHD and ADD overlap with Auditory Processing difficulties. In Auditory Processing difficulties the child can hear normally but has a lot of difficulty to in processing the messages from the ear to the brain – it is similar to listening to a foreign language. If given complex instructions such as “Go outside, rake the leaves and put them in the rubbish bin”, the child will go outside but no be able to remember what to do once there. This condition is tested for by hearing experts using specialised techniques and information given to school teachers and parents about how to help the child.

Breastfeeding

I have noticed a lot of argument about the advantages of breastfeeding what are your views, Dr. Robinson?

Breastfeeding is best for babies until 4 to 6 months of age. This does not mean that a baby who is bottle-fed will suffer disadvantage for the rest of their life. A bottle-fed baby will take more work but a perfectly healthy baby can be obtained by bottle-feeding.

The 4 main advantages of breastfeeding are:

Nutritional

Infection Prevention

Allergy prevention

Emotional.

NUTRITIONAL

Breast milk contains substances that are not in formulas. Gradually these are being measured and many are being put into formulas. It is not enough just to put the same amount of them into formula as is in breast milk. A good example of this is iron, which is needed to avoid anaemia and has other beneficial qualities. It was discovered that the baby’s gut would take up iron from breast milk at a greater rate than it will from any formula. Thus more iron has to be put into formula than is naturally in breast milk.

Poly-unsaturated fatty acids (PUFAs) are another example. PUFAs are essential because humans cannot manufacture them – they have to be eaten. Breast milk contains them in significant quantities while, until recently, formulas did not.As these PUFAs are found in brain as well as other tissues, and the brain grows rapidly in the first year of life, trials of supplementing baby formulas with PUFAs have been undertaken. Once again it is not simply a matter of putting in the same amount as is found in breast milk. The ratio of the PUFAs to other fatty acids that are found in formula is critical.

Science around the world is trying to make formulas as similar as possible to breast milk. This work is slow and clinical trials need to be conducted with each change. The cost of this work is reflected in the cost of baby formulas which makes them a much more expensive option than breastfeeding.

INFECTION PREVENTION

Breastfeeding will make a baby less likely to pick up infections than a bottle-fed baby. The reason for this is that breast milk contains a number of substances that fight germs (bacteria and viruses).

One class of these germ-fighters are live cells from the mother. There are several different types of cells. Perhaps the most important are called macrophages. Macrophages attack any germs that enter the baby’s gut helping to prevent infection such as gastroenteritis (“gastro”). The cells will be particularly effective if mother has recently had an infection that she has passed on to her breastfeeding baby. This is because they instantly recognise that it is the same germ and know how to fight it.

Another class of germ-fighters are called immunoglobulins. If we have an infection such as measles we generally never get it again. One of the reasons for this immunity is that the cells in our body that make immunoglobulins that circulate in our blood and help to destroy the measles virus. We keep the ability to make this immunoglobulin against measles for the rest of our lives. Immunoglobulins are present in mother’s breast milk and help protect the baby from infections to which she has been exposed.

There are other protective agents in breast milk. Do all these substances really help in practice? Yes – it has been shown that baby’s who are breastfed are less likely to develop gastroenteritis than bottle-fed infants. Also if a breast fed infant does catch ‘gastro’, they will recover more quickly if breast-feeding is continued.

ALLERGY PREVENTION

Exclusive breast-feeding might help prevent the development of allergic diseases such as cow’s mill allergy, atopic eczema and asthma. The reason for this potential protection is that until 4 months the baby’s gut allows whole proteins (taken in any form of food) through into the blood stream where they can cause allergic reactions.

Scientific studies on whether there is an actual benefit from exclusive breast-feeding in the first 4 to 6 months are contradictory with some showing that it does help prevent the development of eczema and/or asthma and other studies saying it does not. Part of the reason for this is that exclusive breast-feeding is rare – a recent British study found that only 1% exclusively breastfed for 6 months (The target they set). Breast-feeding alone does not supply sufficient nutrition after 6 months of age. The infant gut has matured enough to block the uptake of whole proteins by 4 months. Hence it is recommended that solids be started between 4 and 6 months.

EMOTIONAL

Another advantage of breast-feeding is the promotion of emotional attachment between mother and child.

All mammals are breastfeeders of their young and all develop a unique bond between mother and baby soon after birth. This bond is called emotional attachment.There are many accounts of how determined mother mammals are to protect their young. Human mothers are the same in most instances.

A number of studies in non-human mammals have shown that breast-feeding promotes the formation of this powerful bonding process. Are there consequences if this unique emotional attachment does not occur? Harlow showed that the answer in monkeys is “Yes”. He took the babies of monkeys away at birth and bottle-fed them. When they were returned the monkey mothers showed few “mothering instincts” and were often violent towards their babies. Of course in the wild, mammalian babies that are not breastfed die from starvation and dehydration.

In humans, where the baby is separated from mother and not breast fed (e.g. due to prematurity) the early studies suggested that emotional attachment was slower and more difficult to achieve.

This led to considerable concern among those in child health and welfare. But we came to realise that the emotional attachment did eventually occur in nearly all cases. Also the separation was part of the problem, not just the absence of breast-feeding. Most neonatal units now allow unlimited parental visiting of premature babies or any other baby that has to be there. It is hoped that this will foster emotional attachment.

Thus the conclusion is the same as it is for nutrition and infection prevention: emotional attachment is easier to achieve if breast-feeding is undertaken but it can be achieved along with adequate nutrition and infection prevention in babies that are bottle fed. It is just quicker and easier in breastfed babies.

Childhood Illnesses

Childhood Illnesses

My 4-year-old gets his colours confused. Could he be colour blind?

It is unlikely that your son’s difficulty in correctly naming colours is because he is colour blind. It is not unusual for a 4-year-old to have this problem.

Sophisticated testing has shown that the ability to distinguish colours develops quite early. The problem for the toddler is being able to attach the right name to the colour. A 4-year-old is 3 times more likely to make this error than a primary school child is.

Development of colour naming shows wide variation between individual children and generally occurs earlier girls than in boys. My wife still corrects me on the names of colours I use!

Colour naming problems are much more likely to be the reason than colour blindness in your son and this will become better with time.

Colour blindness can be tested at this age. Not all doctor’s consulting rooms have the booklet that is needed to do the testing. So, it would be a good idea to check if your doctor has the equipment to test for colour blindness before making an appointment.

Remember that the problem is more likely to be difficulty in naming the colours rather than in seeing them and that the naming process will come with time.

Children learn what they are taught. I used to think that my older children were all very smart because they knew their colours early. Their mother pointed out that when they said a word incorrectly (EG “ird” instead of “bird”) I would reply “Yes there is a brown bird”. I did this so they would hear the word correctly but not in the way that was a put-down. An unintended result of this was that they learnt their colours early.