Paediatric Grand Rounds 1:12 Is Up

Dr Sethi has posted Paediatric Grand Rounds 1:12. Some nice postings but we do seem to have gone a little flat (of course, some of us are hampered by needing to type with one hand). Actually, I found some of the posts irrelevant and impenetrable. Frozen shoulder making me cranky? You think?

Next host is the ever entertaining Kim on October 8, 2006 at Emergiblog.

Shinga Is Off-line

A note from Shinga's husband to say that normal service will be resumed as soon as possible. Thanks to those of you who have sent enquiries.

Shinga has been 'freezing' a shoulder for some time. A while ago she lost most of her range of movement for that shoulder and arm and they became very painful: she finds it very difficult to type etc. On Wednesday, she finally received a couple of steroid injections into her shoulder and we are waiting for the improvements to start. Normal service will be resumed when her arm improves or at least enough of the stiffness slackens off to allow her to type with one hand.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

Non-Pharma Remedies 1:3, smoking cessation education

I've written extensively about the ill-effects of environmental tobacco smoke (ETS) exposure on children and their development. There is a substantial bad news flow about ETS and many studies that lend weight to the notion that children and ETS do not mix.

I thought about this when considering another post for Clark Bartram's Non-Pharma initiative. His latest post is fascinating and about transient tachypnoea in the newborn.

Anita was 7 years old. She had copious mucus in a variety of colours that was regularly bloody. She complained of frequent headaches and earaches: she had a history of snoring and restless sleep. Anita found it difficult to exercise: she was 118 cms in height and around 50 kgs (approx 112 lbs). She was pale and had dark circles under her eyes. She had halitosis that was so bad that it smelt like something had died and been left to moulder for a long time.

Anita also had shoulder-length, densely-curly hair that reeked of tobacco smoke (you know that it was strong if it managed to compete with the halitosis). Taking the history, both adults claimed that they never smoked in the house or in her presence. Little by little, that was modified to, "It's too cold outside. But we never smoke upstairs" to "Well, we don't smoke in her room" and then, "We only smoke in her room if we're sitting by the open window". After some time, the best estimate was that Anita lived in a household that smoked a total of 3 packs indoors in a 24 hour period.

Anita's GP clarified the family history a little. Anita had lived with her grandmother for some time and was still registered for a practice near that address rather than her mother's. The grandmother smoked and he had spoken to her about the impact of ETS on Anita but the grandmother had felt unable to cut down.

The GP had enquired about dental problems but Anita was attending for check-ups (albeit irregularly) and, although she had a number of caries and fillings, there was no obvious dental abcess or other condition that would account for the degree of halitosis. Anita was waiting for a referral to a dietician (about 1 year in that area) for advice about her weight and diet. She had had repeated courses of antibiotics. The GP was concerned that Anita might have some allergies that were being obscured by her reaction to the ETS.

During the workshop, Anita's nose poured out a constant stream of mucus. She had a dramatically loud and unsuccessful nose-blowing technique. She used the nose clearing exercise to stem the tide of the mucus but frequently twitched or rubbed her nose.

We ran through the guidance on helping children to blow the nose (hat-tip to the excellent Flea for this). Anita's nose was obviously irritated so we demonstrated nasal irrigation. We don't usually recommend nasal irrigation for children because it can take some practice but it can soothe outraged nasal membranes and we felt that it might help Anita.

We showed Anita's mother and partner how to make up a buffered saline solution. I then demonstrated various irrigation techniques using a squeeze bottle. Although it is possible to flush the nose by leaning over a sink, it is usually easier for children if they are standing in the tub, prior to a bath, or standing in a shower. I then made sure that both adults could use the technique. This was messy as the saline flowed across the cheek and into the ears and hair for the first few squeezes. When Anita experimented I wished that I had a Sou'wester as the solution, and her mucus, went everywhere.

However, after a few practices, both adults and Anita could irrigate the nose. The adults had been quite shocked at what had come out of Anita's nose. I told them that this might continue for some time and that they should encourage her to irrigate her nose in the morning, before she went to school, and then about 2 hours before bedtime. I don't recommend that people with obviously blocked sinuses etc. should irrigate just before bedtime because some of the water can be retained and then make a spectacular downrush some time later: very messy and disconcerting if you're lying in bed. The adults were given guidance on the remainder of the exercises and asked to practise them with her and they were asked to make some changes to her sleeping arrangements.

I took the opportunity to explain that some of Anita's symptoms were, at best, worsened by ETS, and might even be caused by it. I ran them through the scratched forearm exercise. For this exercise, we ask someone to run the smooth part of the index fingernail down the inside of the forearm with a little force. After a few seconds, there is usually a long, red mark along the forearm. If this mark is left alone, it fades over a few minutes. But, if the mark is irritated further, it remains; if the irritation continues, it can become sore and swollen. We use this exercise to illustrate what is happening in children's airways with ETS and how the constant irritation can contribute to their symptoms.

Luckily, the centre that I was working in had some local smoking cessation literature that I could give them. I also suggested that Anita's mother and her partner might want to talk to their GP or the local NHS Smoking Clinic if they wanted advice about what was available to help them.

I saw Anita on several more occasions. She had some initial objections to the nasal irrigation but her nose felt so much better that she persevered with it. Although her symptoms had improved enough for her to stop, unless she had a cold etc., she still irrigated her nose every evening as part of her bath routine. Her mother had stopped smoking and the partner was no longer allowed to smoke in the home. Anita's mucus production improved and was no longer purulent. Her sleep had improved and she now snored quietly and occasionally. Anita had signed up for an after-school club to encourage activities in unfit children and she was enjoying that and growing in physical confidence.

Anita's improvement was the result of several factors working together but I feel that the most significant one was the reduction in her ETS. It is sad, but true, that for children, the most beneficial health interventions may involve changing the behaviour of people other than themselves.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

Paediatric Grand Rounds Wants Your Post, Please

Yes, it is out with the begging bowl, as I shamelessly rattle the post collection bag and ask you for your contributions to Paediatric Grand Rounds 1:12. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

Dr. Sethi of Pediatrics Info is the host of the next Paediatric Grand Rounds. He invites your recommendations and submissions for the next issue on September 24.

Please send the posts by Saturday 23 September to Dr. Sidharth Sethi of Pediatrics Info:

sidsdoc@gmail.com

You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

More Bad News About Traffic Pollution

Otitis media (OM, inflammation or infection of the middle ear) is common and very unpleasant. 3 in 4 children experience OM before the age of 3. For children, OM is the leading cause of healthcare visits and for antibiotic use or surgery. Recurrent OM is associated with hearing loss, language delay, and cognitive deficits. It is stressful for caregivers and has high direct and indirect costs.

Brouwer et al. have previously established that recurrent OM has an adverse impact on the quality of life of children and their caregivers. Children with recurrent OM have similar quality of life scores to those of children with asthma. The authors recommend that:

[p]rofessionals involved in the care of children with OM should be aware that OM not only affects physical functioning but also general well-being of the child and its family. These outcomes should therefore be included in the evaluation of the child with otitis media both in the clinical and research setting.

Well established risk factors for OM include respiratory tract infections and environmental exposure to tobacco smoke such as parental smoking at home. However, researchers suggest that traffic-related air pollutants contribute to OM. The authors decided to assess the relationship between traffic-related air pollution and OM in two birth cohorts, one in the Netherlands and another in Munich, Germany.

The dutch birth cohort was previously followed for 24 months: the results indicated that exposure to traffic-related air pollutants may be associated with respiratory tract or ENT infections. Earlier analysis of the german cohort highlighted an association between air pollution exposure and (nocturnal dry) cough without respiratory infections. Neither of the evaluations had assessed the relationship of traffic pollution and OM.

The investigators looked at the relationship between exposure to traffic-related air pollution and doctor-diagnosed OM before the age of 2 in both birth cohorts of approximately 3700 infants from the Netherlands and 650 infants from Germany. They obtained individual estimates for home addresses of outdoor concentrations of traffic-related air pollutants — nitrogen dioxide, fine particles (particulate matter with aerodynamic diameters ≤ 2.5 µm [PM2.5]), and elemental carbon.

After making appropriate adjustments for known major risk factors, the odds ratios (ORs) for OM indicated positive associations with traffic-related air pollutants although the ORs were low.

These findings indicate an association between exposure to traffic-related air pollutants and the incidence of otitis media. ..The strong evidence linking otitis media with ETS exposure and the similarities between ETS and ambient air pollution add further support to our findings. The specific air pollutants that affect respiratory infections have not been clearly identified, although some evidence suggests that NO2 and coarse particles may be especially active in this regard...Additionally, the mechanism by which air pollution may lead to otitis media is not known. Air pollution exposure may result in a more severe or persistent infection—for example, by decreasing mucociliary clearance...-making progression to otitis media more likely.

The authors argue that it is important to identify preventable risk factors such as exposure to air pollution for OM, because they have significant implications for health care costs. They stress that because air pollution is not usually considered a risk factor for OM, its associated costs for the health impact and cost–benefit assessments tend to be disregarded. The authors further conclude:

Given the ubiquitous nature of air pollution exposure and the importance of otitis media to children's health, these findings have significant public health implications.

Children can't be expected to breathe through gas masks to protect them from traffic pollution. It would be useful to have a research model that would examine how much protection they obtain from the filtering that comes with, e.g., nose-breathing.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

Does Modern Life Harm Children?

The Telegraph published a letter from 110 signatories that expresses concern that, modern life leads to more depression among children. It is an interesting letter:

we are deeply concerned at the escalating incidence of childhood depression and children’s behavioural and developmental conditions. We believe this is largely due to a lack of understanding, on the part of both politicians and the general public, of the realities and subtleties of child development.

Since children’s brains are still developing, they cannot adjust – as full-grown adults can – to the effects of ever more rapid technological and cultural change. They still need what developing human beings have always needed, including real food (as opposed to processed “junk”), real play (as opposed to sedentary, screen-based entertainment), first-hand experience of the world they live in and regular interaction with the real-life significant adults in their lives.

However, I'm not entirely sure that it is due to "a lack of understanding". A wholesome way of eating and a regular lifestyle with time spent with other people - these are not matters that require subtle understanding. I know parents who are only too aware that their working hours take them away from their children and (through stress and tiredness) have an impact on the quality of time that they do spend together. Hectoring all parents in this manner will wash over some of those who need the advice and may alienate those who are already acting in their children's best interests. These Vera Lynn statements (Dr. Crippen defines this as something so self-evidently right that is beyond criticism) smacks of truthiness.

[T]he quality by which a person purports to know something emotionally or instinctively, without regard to evidence or to what the person might conclude from intellectual examination.

I agree that children's mental health and development are complex socio-cultural problems and that we need a discussion on matters of public policy. However, a lot of money is already being spent on services that are not achieving much in the way of outcomes (e.g., Sure Start). And there are some health issues that are not in the control of parents, such as the contribution of traffic particulates to asthma, poorer lung function and recurrent ear infections. Too many children live in poor housing conditions. Both of these need to be part of any discussion about child development. And any discussion should involve parents, not alienate them.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

My Child Is Ill But the Doctor's Prescribing Something For Me!!!

We have an extensive smoking ban in the UK. Anecdotally, some G.Ps claim there has been an increase in the incidence of asthma exacerbations in children as people spend more hours smoking at home, rather than doing this at their local pub. A number of the adults who attend the Breath Spa workshops with the children, tell me that at the last emergency visit for (typically) an asthma exacerbation, the doctor advised them to give up smoking: they shake their heads ruefully as they say, "My child is ill. And the doctor's prescribing something for me!". I don't know what to say.

Like most of their generation, my parents both smoked. A layer of tar and cigarette ash seemed to coat every surface in the house. All of the furnishings and most of my mother's clothing had at least one cigarette burn in it. Until I moved away from home I'd never had a meal without at least one person smoking as we ate. Of course, it wasn't until I moved away that my 'putrid ears' (as my ENT consultant so aptly referred to them) started to clear up. And I realised that my sinuses did not have to feel as if they were being scoured with a drain cleaner and wire brush.

The sophistication of tobacco advertising was extraordinary. Cigarettes and alcohol were socially approved methods of self-medication. Everybody smoked back then. Even people like my parents who had both had several bouts of tuberculosis. People were admired for their stoicism and their power to endure. Psychotropic drugs were unheard of and the notion of stress was disdained no matter how hard the routine of your life or the blows that threatened to fell you to the ground and break up your family.

When the public health message about the personal health impacts of smoking gained credence, my mother tried to give up. She may have lasted longer when I was very young; but, as I grew older, her attempts at smoking cessation did not go beyond three hours. And, yes, I mean that. She always did wake up during the night and smoke. But when she was "giving up smoking" her anxiety level was so great that she would wake up even more frequently and need to soothe herself with 'just one more'.

My mother did stop smoking eventually, but it was almost by default. She had had surgery but something had gone awry and she spent almost five weeks in an intensive care unit. She was unconscious for most of that time. She said afterwards that she must have gone cold turkey because by the time she remembered anything again, she had been without a cigarette for more than a month and had lost her craving. She never did start smoking again. When she returned to her home, she couldn't believe the smell, or the stains on the ceiling over her favourite armchair. She was so angry that at one point she accused us of putting cigarette burns over her furniture just to embarrass her.

So, I have every sympathy for people who find it hard to give up smoking. I witnessed the struggle for many years and I know the heartache it causes. But it is because of this that I don't know what to say when adults accompany children to the Breath Spa workshops, give me an overview of the child's sleep problems, ENT issues or respiratory conditions, say "I'd do anything for my kids", but then reveal that they are smokers. They hold the children tight to protect them from all other sources of harm, but either they can not bring themselves to accept that smoking really has that much of an impact on the child or their lives are so chaotic that smoking seems better than any alternative. Some of the adults have made repeated attempts to give up. A fair number claim that they don't smoke in the house, or "never upstairs": or they smoke in some subtle way that defies the law of physics and means that children never come into contact with the smoke. It's usually at this point that the listening child makes some artless comment that contradicts the adults' account.

It's not political correctness or a fear of causing offence that puts a scold on my tongue: it's the memory of my mother's struggle and the awfulness of the solution to it. Plus, much as I believe that a smoke-free home is in the best interest of the children with whom I work, it is really not appropriate for me to comment. But I admire the doctors who do address the issue. Researchers interviewed parents in four paediatric practices in the US and asked them what their reaction would be if a paediatrician addressed the issue of parental smoking in the outpatient setting.

Only 3% of the sample felt their smoking status was not the pediatrician's business, 89% stated they believe it is an important part of a pediatrician's job to ask about their smoking status, and 8% stated it wouldn't matter if the pediatrician asked...Among 187 smokers, 177 (95%) would appreciate or feel okay about the physician's concern if advised to quit and 57% reported wanting some kind of smoking cessation help from the pediatrician's office.

However, another study reports that when smoking parents accompanied a child on a visit to the doctor, only 15% had pharmacotherapy recommended to them and only 8% received a prescription for a smoking cessation medication although smokers who use such medication double the likelihood of their success.

Part of the reason for this may be explained by a recently published survey* of paediatricians and their smoking cessation activities, namely the 5A's of ask, advise, assess, assist, and arrange. The authors report that the clinicians were not confident that they could carry out all five steps.

• 83% felt that they could appopriately explain the effects of smoking on the child
• 57% thought that education would reduce smoking
• 22% felt confident enough to discuss a quit date with parents
• 29% would refer parents to a smoking cessation program
• 14% would prescribe or recommend nicotine replacement therapy
• 12% would arrange follow-up visits for smoking treatment
• 12% would recommend behaviour therapy.

The authors recommend that clinicians should explore parental smoking from four perspectives:

• record whether parents are smokers and taking a smoking history
• educate parents about the benefits of reducing a child's environmental exposure to tobacco
• suggest changes to reduce the child’s exposure
• make smoking cessation referrals to the parents' doctor.

A study of diabetic children with uncontrolled ketoacidosis prompted Salvador Minuchin to say that "behavioral events among family members can be measured in the bloodstream of other family members". The notion that when one family member is ill, it may be another family member that needs a psychosocial or pharmacological prescription is a poignant example of allostasis and allostatic load. I've borrowed this following explanation of allostasis from Dr. Salt's summary of a classic paper:

[stress has] many mechanisms, but among the most prominent are the manifestations of physiological stress responses as a result of living and working conditions, inter-personal conflict, as well as the sense of control of one’s environment and optimism/pessimism toward the future. "Allostatic load" refers to the cost of adaptation to a stressful environment, which elicits repeated and sometimes prolonged adaptive responses ("allostasis") that preserve homeostasis in the short run but can cause wear- and-tear on the body and brain...We have powerful ways of modulating the harmful output of the stress response systems that include belief systems and behaviors. An important quote attributed to Dr. McEwen is, "We must also remember that the biggest problems for the human race in the future are those associated with our own behavior and misbehavior and the impact of the social and physical environment on our bodies and brains."

There can be a significant improvement in children's health as a result of a successful intervention with people other than themselves. Helping children by helping adults to give up smoking is a lot like a first attempt at balancing pebbles. It takes a lot of consideration as to:

• the opposing forces (gravity, the wind)
• the suitability of the environment (are some sources of stress adequately controlled?)
• the correct support (do you know what support you can scrape together from the surrounding resources?)

A recommendation to a quit smoking clinic or a prescription for smoking cessation aids might be the successful placement of that first pebble. Over time, people become remarkably adept at balancing rocks and pebbles: they even manage to make it look like an artform.

*Dake, J.A., Price, J.H. et al (2006). Pediatricians' Practices Regarding Smoking Cessation Among Parents of Their Patients. Am Jnl of Health Behavior, 30: 503–512. (pdf)

I've updated this post from earlier this year as recent publications indicate that it is still relevant.

For more information about the images used in the illustrations, click on them to be taken to their Flickr source.

Paediatric Grand Rounds 1:11

In the wake of recent events, many businesses and institutions have updated their ethical code for their workers. Preschoolers are constantly drilled in the foundations of ethical behaviour such as sharing, kindness, truthfulness and trustworthiness. Thanks to Elizabeth Verdick and Marieka Heinlen, young children even have codified guides in the Best Behaviour series: Teeth Are Not for Biting, Hands Are Not for Hitting, Feet Are Not for Kicking, and Words Are Not for Hurting. We're also offered, How to take the Grrr out of anger and Germs are not for sharing. Future editions and additions to the series may reflect 21st century concerns and be on the topic of Vaccines are not for harming, Blogs are not for fibbing and How to take the ouch out of disagreement.

I wonder what the authors would make of some of the stories and issues in this week's PGR and if they would suggest some new ideas and titles for them. It would be good to have some proposals.

Children are not for frightening

My explanation for the above illustration is that I sometimes work with children who have graphics-capable mobile phones or MP3 players to put together a slideshow of images that they find to be calming and relaxing. I admit, up-front, that the above images were all selected by girls. If anyone one can suggest suitable images for boys that do not involve them fake gagging on cuteness nor affecting to be soothed by scenes of violence and mayhem, I would be very grateful.

Fear can be contagious. Tom Reynolds tells us that parents have a significant role in keeping children calm in difficult situations. I learned about some of the issues involved in transporting small children to hospital and just how much EMTs and First Responders appreciate it when parents can remain calm, pleasant and understanding even when alarmed by their child's condition. On a related note, Kim gives us a backhanded look at parental behaviour in the ER in the form of a letter to a young patient. My favourite quotation in this edition of PGR is:

I hope you don’t grow up to be a demanding, screaming adult patient.
Those are called “wimps”.
When you are a big boy, you might want to join the Marine Corps. They have an excellent program in self-discipline.
Lord knows you won’t learn any from your parents.

Sticking with cuts, Scalpel introduces us to Zen and the art of laceration repair. He establishes a calm environment and leads children to relax with breathing control. From some of the accounts in PGR, it seems as if parents would benefit from learning these techniques.

The Claus are a family that could have used some advice on relaxation and staying calm. If you've ever wondered how you try to ensure that a very young child remains still enough for a CT scan without sedation, then Bethiclaus can tell you that the recommended strategy of sleep-deprivation is more about the parents than the child.

Instincts are for trusting

Judy knows that when you are dealing with tiny, sick children, you can be administering miniscule doses where small errors can make a very big difference. Judy feels that she had a conference of Guardian Angels that nagged her to keep re-checking a dosage and gave her a near miss. It is a modern example of the Paracelsus maxim that "The right dose differentiates a poison from a remedy".

Sometimes parents have an unmoving conviction that something is wrong with their child, no matter how much reassurance they receive. And sometimes they're right. Mama Mia alerts us to grunting as an unusual presentation for a condition that occurs in 1 of every 2000-4000 live births and accounts for 8% of all major congenital anomalies. The condition had been playing hide and seek during previous examinations and masquerading as a cold.

Clark Bartram tells us about another potentially life-threatening condition, new-born jaundice, and technological advances that should make monitoring easier. However, in this case, he was able to manage the baby with some simple interventions and parent education.

I rely on co-operation from education workers and parents when I run breathing workshops for children. In the long-term, they are essential to implementing any changes. With the support of teachers, classroom assistants and parents, I describe behavioural interventions that helped one young boy to lose his chronic cough and reduce his absences from pre-school.

Education is for everyone

It's the start of a new academic year and parents are dealing with school refusal. AADT offers a handy overview that distinguishes when "I don't want to go to school" becomes "I can't go to school" and describes some strategies for dealing with it. School refusal sometimes manifests itself in stomach aches, aka recurrent functional abdominal pain.

Luckily, Samuel Blackman is on hand to explain functional abdominal pain. Because context is everything, Sam tells us that his response to a complaint of stomach pain may depend upon whether he is wearing his paediatric oncologist hat or that of general paediatrician. This post is my top-pick because not only does he discuss these issues, we also learn about the impact of parental stress on a child's healthcare use and experience.

Parents who are stressed, either psychologically, emotionally, financially, or physically, have the potential to view their child's symptoms through the amplifier of their own state. Physicians who understand their parents and have a good rapport with them, can help find help for parents when they are distressed. It's good for the parent, and it's good for the child.

Doctors in the UK are now so accustomed to being 'educated' by journalists and patients coming in to see them, clutching the latest newspaper article about mis-diagnoses and new treatments, that some of them are listening to current affairs programmes that will give them a jump-start on the medical news of the day. Dr. Jest had food for thought when he heard about a proposal to improve teenagers' IQ by dosing them with Omega 3. He proposes a novel method for Truant Officers to enforce compliance in the 'naughty' children who don't attend for their daily dose. But he does wonder if supplements are the best approach to addressing emotional and behavioural problems that may be diet-related.

Even special children need some ordinary discipline

Some children have such complex and dramatic health needs that commonplace dental check-ups seem of low priority. But even simple procedures require such elaborate precautions and measures that Awesome Mom had reluctantly come to the conclusion that it is time for Mean Mommy to make an appearance and enforce some basic standards.

Melissa Wiley considers a similar issue when she asks for advice on when to discipline children and how to distinguish between behavioural challenges that are related to a child's special needs or complex medical issues, and those that are grounded in their age, temperament or circumstances.

Ears are not for blocking

Sometimes, children are just too young for discipline or education to have an impact. Most parents have come across chocolate tidemarks on the wall and cookies that turn up in the DVD player, the washing drum and behind pillows. Family doctors like #1 Dinosaur are completely familiar with some of the substances that children put in their ears and the robust attitude that they have to the fate of their excavations.

Because ears are for listening, Rob Lamberts regrets it when a breakdown in trust or communication leads to patients transferring out from a physician's service but he offers reassurance for those who feel the need to make the change.

Dr. Sethi discusses times when a parent needs to be listened to carefully and with great sensitivity. He summarises a survey that reports that parents who are facing end-of-life decisions for their children find it helpful to have spiritual/religious support.

There can be little consolation for those who have lost a child or are caring for those with special needs. Moreena of the Wait and the Wonder acknowledges that goodness, justice and fairness seem very remote when you are coping with the loss of a child. But, when she was asked a difficult question, "Have there been any unexpected silver linings discovered in parenting a child with complex medical needs?" Moreena tells us what she has learned about goodness.

Children are not for abusing

So many parents work so hard to ensure the happiness and wellbeing of their children that it shouldn't be necessary to state this self-evident truth. But as Neonatal Doc knows, abuse can be clear cut and sickening. But sometimes, there is a collision between medical and legal requirements, particularly when it involves a parent's lifestyle choices, rights and responsibilities, that make it difficult to define abuse. Orac is wary of the state intervening to undermine parental rights and responsibilities, but he knows that bad medicine makes bad law. The Abraham Cherrix case and the proposed changes in legislation to strengthen patients' rights are an intersection of legal and medical issues that can not be resolved by the current draft legislation. When does deference to parental rights become tantamount to colluding in medical neglect?

On a similar theme, Flea is angry about a fellow paediatrician's casual attitude to alternative autism treatment. When does the use of unvalidated, potentially dangerous therapies constitute abuse through medical neglect or actual harm?

Dr. Kavokin presents a crash between personal freedoms and the needs of a child. He offers us a case study and a quiz about foetal alcohol effects and babies posted at RDoctor Medical Portal.

Tiesha maintains a sombre sidebar rollcall of children who have died in restraints. She emphasises the importance of nursing assessment during and after restraints in child and adolescent psychiatric facilities. Tiesha shares some thoughts on why restraints may be necessary but how they should be managed.

Dr. Deborah Serani shares the memory of a friend and reminds us of the sad fact of suicide among young people and that it is a largely preventable public health problem. On World Suicide Prevention Day, she asks us to look through a summary of the warning signs and to make note of some essential resources.

Sex and drugs are not for taking lightly

An addition to the best behaviour series for older children. Sometimes, children's experimentation means that they abuse themselves. Many years ago I was walking home with my brother and mother when we noticed two young boys ahead of us. One of them was staggering jelly-legged around the pavement and being kept from falling by his companion. I was concerned that the boy was ill but my world-weary teacher brother said that the boy had been glue-sniffing - a judgment that was confirmed by the smell when we caught up with them and took them home to their parents.

Inhalant abuse is commonplace, but I was surprised when Tundra PA reported that huffing is widespread in Alaska: 20% of 8th graders have tried it and, in some villages, almost all of the young people have experimented with inhalants. Intoxication may be so common that it does not attract particular stigma but an interesting interplay of cultural attitudes means that, despite the scale of the problem, inhalant abuse is under-recognised.

Tara Smith blogs frequently on the epidemiology of STDs so is pleased to offer us some good news about sex and teenagers.

Manners are for minding

For some people, it has been a difficult 2 weeks since our last edition, so I'd like to thank all of the contributors who have so generously shared their posts with me. I look forward to seeing you in future editions of Paediatric Grand Rounds.

You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

The next Paediatric Grand Rounds is scheduled for September 24 and your host is Dr. Sethi of Pediatrics Info.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

Non-Pharma Remedies 1:2, the cough

Looking through the submissions for tomorrow's PGR, there are several stories that emphasise the important of working with the family to support the wellbeing of children. Surgeon in my dreams offers a fine tribute that details a paediatric physician's impact on a very young mother.

My kids’ pediatrician was always so encouraging. So sweet to me. He always brought up issues I worried about and was too embarrassed or ashamed to bring up myself, such as her constant crying (colic?) And how to deal with that without losing my mind.

...our doc never failed to tell me i was doing a great job with her...looking back as i grew up over the years...i saw that he didn't have to treat all his moms this way, but he knew i was young and he took the extra time with me.

he didn't know it at the time, but he was the only encouragement i ever had.

This anecdote is a reminder that it is best for children when the parents have strong social support, but that paediatricians, family doctors, specialists and healthcare workers can make a difference to children's health and development, sometimes in the simplest ways, by encouraging or reassuring nervous parents. It might be an obvious non-pharma intervention of the sort that Clark Bartram wants bloggers to write about, but it is, nonetheless, powerful and long-lasting.

Respiratory disease is the most commonly reported long-term illness in children - in the UK, breathing difficulties account for 34% of weekly GP consultations and 15% of hospital admissions of children. Persistent coughing can alarm parents; they are concerned that it indicates a current or imminent chest infection.

Persistent cough is a common reason for children to be excluded from pre-school groups and school. Exclusion is understandable when children are potentially infectious. However, coughs lead to unnecessary absenteeism when the child is not infectious or when clinical assessment shows no obvious cause for the cough. Recent research into the inflammation caused by chronic coughing indicates that our mothers may have been right when they told us, "Don't scratch, you'll only make it worse" and, "Don't cough, you'll only make it worse".

Changing some of the details and characteristics, I met a 3.5-year old boy with a chronic cough when I worked with a pre-school group at the start of this year. Sunil was excluded for up to 10 days a month because of his cough. Sunil alternated between tiredness and over-activity when he did attend. Sunil was pale despite his olive colouring, and the dark circles under his eyes were mute testament that his nightime coughing badly interfered with his quality of sleep. The pre-school teachers and assistants remarked that Sunil's absences reduced his opportunities to socialise with the other children.

Sunil's GP reported that Sunil had had extensive investigations for his cough, but that there were no findings that were sufficiently significant that she would advise asthma medications or the repeated use of antibiotics. She had prescribed various cough syrups and anti-histamine medications in the hope that this would improve Sunil's sleep but they had been of limited effectiveness. The parents were very concerned about the cough and their sleep was disturbed by Sunil. The GP was considering a trial period of bronchodilator medication.

We arrived at 9:00 a.m. on the day that we went into the pre-school. Sunil had been dropped-off at 8:30 a.m. and the teacher and assistants were considering whether they should phone his parents and ask them to collect him. We asked for a period to assess Sunil before contacting his parents. Sunil coughed frequently, in clusters of 3-4 at a time. His cough was non-productive but strong enough to shake his upper-body. He spoke softly and his voice sounded a little harsh. However, we felt that we could work with him to reduce his cough symptoms to the point where he would stop irritating his throat and airways. After some discussion, the teacher said that she would reconsider at lunchtime before the arrival of any of the afternoon children (Sunil would be there all day).

After the usual alarming experience of standing in a room while a ring of children sang a discordant welcome song in our honour, we ran through our usual introduction and exercises for young children. However, this time, we also asked the children if any of them coughed. For each one of the children who coughed, we asked them questions about the cough. E.g., where does the cough start? What colour is the cough? What shape is the cough? Is it hot or cold, prickly or smooth? Plus various questions about texture and other aspects of the cough experience.

And so, with a subtlety that speaks volumes as to why 'trained interrogator' was never a viable career option for me, I made notes about Sunil's cough and attached myself to him as his personal monitor. We ran through the activities for the whole group of children: we told stories that were barely-disguised propaganda for healthy breathing techniques. We made balloon animals to fit in with the characters in the stories. We played games and made soda volcanoes. We encouraged all of the children to close their mouths and breathe through their noses.

I praised Sunil at regular intervals for keeping his mouth closed when he wasn't talking. Using his words, I told him that his airway was open and calm. Sunil's cough frequency had already reduced by 10:30. When he coughed, I asked him to imagine that he was swallowing a creamy kulfi (a favourite food that he had mentioned) that cooled and soothed his throat. After a coughing episode, I reminded him to close his mouth and asked him to take small mouse-sized breaths in through his nose. We had practised different sizes of breath when we were playing with different sizes of bubble wands. Mouse-sized breaths were used when we were playing with the smallest wands and needed tiny amounts of air or we would break the bubble.

During the break-time (and, one of the excellent things about the pre-school schedule is that you are never more than 90 minutes away from a break) I took Sunil to one side and talked to him about his cough and asked him to change parts of it. I asked him to change it from prickly like a hedgehog and dark grey, to a light pink candyfloss (cotton candy?). We made various other changes to the cough and drew them. We discussed other ways in which the cough could gently leave the body and then rejoined the main group.

Between break and lunchtime, Sunil only coughed twice. Unfortunately, when the assistants were serving lunch, one of them realised that Sunil had been quiet and said, "Sunil, you've stopped coughing". Possibly prompted by the suggestion, Sunil started coughing again. I left him alone during lunch, except to remind him to close his mouth after coughing and to breathe like a mouse.

After lunch had settled we went into the playground and played a variety of games. The children had to burst bubbles with any part of the body except the hands and they had to do it with their mouths closed. We practised doing star-jumps while breathing through the nose. As a side issue, at several points, I felt that my husband and I were in danger of being overwhelmed by ankle-biters trying to grab the bubble guns. I am very grateful to the pre-school staff who kept a watchful eye on their exuberant charges.

After the activities, the children settled down for their quiet time on their floor mats. We encouraged all of the children to lie on their sides and to keep their mouths closed. If the children dozed off and their mouths opened, we showed the classroom assistants how to bend the index finger and use it to gently suggest that the lower jaw should move forward. Even while the children lay quiet or asleep, we praised them for keeping their mouths closed and their breathing quiet.

After the quiet time, we played more games and sang songs that were designed to indoctrinate the children. We finished the day with a story meditation in which the children practised more quiet breathing. We reviewed healthy breathing techniques with the staff and reinforced ways in which they could support them in the children.

We had prepared follow-up notes for the parents and handed them out when they arrived to pick up the children. We intercepted Sunil's mother and explained what we had done. We asked her not to comment on Sunil's absence of cough and to continue to praise him for keeping his mouth closed and his breathing quiet. We asked her to read Sunil some bedtime stories that were designed to reinforce good breathing habits and to implement our suggestions in the general notes and some personalised ones that we arranged to email her. We asked her to phone us if there were any problems and arranged to make some follow-up contact with her.

In follow-up phone calls, we learned that Sunil had mostly stopped coughing and had not had any more absences from playgroup. From time to time, when visiting family members, somebody would mention that Sunil wasn't coughing and then he would start again for a little while but his parents were confident that they knew what to do to help him get it under control. They reported that Sunil had stopped coughing at night and that both he and his parents had a much improved quality of sleep.

We can work with children in sessions but the long-term implementation of what we teach depends upon the co-operation of their family and other significant adults (in this case, the teacher and assistants). We are dependent upon others to help children to develop new habits and to weaken any vicious circles such as chronic cough inflaming and irritating the airways and triggering more coughing. Success depends on input from so many people that we are always very grateful to those who work with us.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

Clinical Trials for Asthma Relief with Breathing Techniques

A compilation of the trials and studies that have evaluated the Buteyko Method for asthma relief.

Glasgow

Summary: 384 (18-69 years old) people completed a blind, randomised, waiting-list protocol, cross-over trial over 24 months. The Buteyko group recorded a 98% reduction in reliever use. The control group did not change their reliever use. The Buteyko group had a 92% reduction in the use of inhaled corticosteroids: the control group had no change. The Buteyko group had a 96% reduction in the use of oral steroids: the control group had no change. This trial is the subject of McGowan's PhD thesis that was submitted in May 2006.

Health Education: Does the Buteyko Institute Method make a difference? McGowan, J, Thorax Vol 58, suppl III, page 28, December 2003.

Nottingham

Summary: 69 (18-69 years old) people completed a blind, randomised trial over 6 months. The Buteyko group recorded a 100% reduction in reliever use: there was no change in either the Pink City Lung Exerciser (PCLE) group or the group that used a dummy PCLE device. The Buteyko group had a significant change in symptoms scores: neither of the other groups reported reduced symptoms. No difference was seen between the groups in FEV1, exacerbations, or ability to reduce inhaled corticosteroids.

Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial, Cooper, S; et al, Thorax 2003;58:674-679.

Australia

Summary: 39 people (12-70 years old) completed blind, randomised trial over 12 weeks. The Buteyko group recorded a 96% reduction in reliever use: the control group reported a 6% reduction. The Buteyko group had a 49% reduction in the use of inhaled corticosteroids: the control group had no change.

The researchers also measured changes in the amount of air the participants breathed in and out of the lungs in a minute (the minute volume). The Buteyko group had a minute volume reduction of 4.9 litres/minute: the control group had a reduction of 0.9 litres/minute.

Buteyko breathing techniques in asthma: a blinded randomised trial Bowler, SD; Green, A; Mitchell, C.A, 1998, Medical Journal of Australia, 169, 575-578.

New Zealand

Summary: 38 people (18-70 years old) completed a blind, randomised trial over 12 weeks. The Buteyko group recorded a 85% reduction in reliever use: the control group reported a 37% reduction. The Buteyko group had a 50% reduction in the use of inhaled corticosteroids: the control group had no change.

Buteyko Breathing Technique for asthma: an effective intervention McHugh, P; Aitcheson, F; Duncan, B; Houghton, F Journal of the New Zealand Medical Association, 12-December-2003, Vol 116 No 1187.

There have been conference presentations on evaluations of the Buteyko Method. In the UK, a doctors' group reported savings on drugs costs after an evaluation of the Buteyko Method. Earlier this year, there was a letter in the New Zealand Medical Journal that reported a case series of Buteyko with a very small group of children.

Bruton and Lewith reviewed the Buteyko Method for asthma relief.

Buteyko's theory relating to carbon dioxide levels and airway calibre is an attractive one, and has some basis in evidence from experimental studies. However, it is not known whether altering breathing patterns can raise carbon dioxide levels significantly, and there is currently insufficient evidence to confirm that this is the mechanism behind any effect that BBT may exert.

They conclude that further research is necessary to establish the effectiveness of the Buteyko Method and to validate the mechanism of action.

The Buteyko breathing technique for asthma: a review. Bruton, A. & Lewith, G.T. (2005). Complement Ther Med, 13 (1), 41-6.

Bruton and Holgate review breathing re-training for asthma relief. They investigate the role of hypocapnea and whether it is plausible that bronchoconstriction may be corrected by hypercapnea.

This article reviews the available evidence supporting the hypothesis and concludes that although attractive, there is currently insufficient evidence to attribute the benefits of breathing retraining to this mechanism.

Hypocapnia and asthma: a mechanism for breathing retraining. Bruton, A. and Holgate, S.T. (2005). Chest, 127 (5), 1808-11.

Holloway and Ram reviewed breathing techniques for the relief of asthma as part of a Cochrane Systematic Review. They concluded:

At present...no reliable conclusions can be drawn concerning the use of breathing exercises for asthma in clinical practice. However trends for improvement, notably in quality of life measurements, are encouraging and further studies including full descriptions of treatment methods and outcome measurements are required.

Breathing exercises for asthma. Cochrane Database Syst Rev., 2004;(1):CD001277. Holloway, E. & Ram, F.S..

Non-Pharma Remedies 1:1

A short time ago, irritated by the claim that doctors are little more than glorified pharmacists, Clark Bartram came up with a radical notion about the good news, bad news flow in blogs about medical matters.

Every Saturday on my own blog I will write about non-pharmaceutical interventions that have improved the lives of pediatric patients. I ask that every medical blogger would do the same with a focus within their own realm of expertise. But why limit it to just the docs? I am also calling for blogging patients and family members of patients to write about how a member of the medical community has helped them or their loved one without pulling out a prescription pad. For every post in the blogosphere about drug company conspiracies and doctors who keep people ill only to make more money, I want to see two discussing the benefit that society has reaped from non-drug contributions from docs, nurses, therapists, or any other practitioner of modern medicine.

CB has kicked this off with an interesting entry about newborn jaundice and his recommendation for increased breast-feeding and the right sort of light.

I made my first attempt at this earlier today but it was turning into a novel. Changing names and various other details, my shorter story is as follows. A 14-year old boy, John, attended one of my worshops because he snored so loudly that his family was torn between smothering him or banishing him to sleep in the garden shed. Of course, when I say shed, it was more one of those very fancy home offices, but you have the flavour of just how desperate these people were.

Despite the long hours of noisy sleep, John was as tired as the rest of his family. He stumbled through the morning and even fell asleep at school. John's GP had assessed him for narcolepsy and similar disorders but decided that he had sleep-disordered breathing. John was referred to an ENT specialist but faced a long wait for an assessment. John's family felt that their collective stiff upper-lip had deserted them and they were exhausted. Which is why they turned up, dark-eyed and dragging with tiredness, to the Breath Spa workshop series.

We'd spoken to John's GP and discussed our techniques with him. Fortunately, the GP had met GPs who teach similar methods in their practices so was happy for us to work with John. On first meeting John, and then discussing his history, it was very obvious that he had a chronically blocked nose and was an habitual mouth-breather. He didn't have any known allergies and was a frequent user of decongestants although his GP had raised the possibility that he might be caught in a rebound trap with them. John's favourite decongestant contained an ingredient that shrinks the spongy, swollen nasal membranes by constricting the fine blood vessels within them. With prolonged use, some people find that their membranes are permanently swollen, and it requires more and more decongestant use to relieve them.

We taught John the "nodding dog exercise" to clear his nose and he embraced it as rapturously as most teenage boys do. He was sullenly surprised when his nose cleared but irritated when we said that he would need to keep repeating the exercise if his nose re-blocked.

We emphasised the importance of keeping the nose clear so that he could breathe in and out through his nose. It took him a while to get the hang of nose-breathing but once he had it under control we went through some more active exercises. If his desperate parents hadn't been present we wouldn't have had much co-operation from him but John persevered and did well. We advised him to keep his mouth shut and to breathe through his nose and to do his exercises regularly until the next workshop.

John told us that he regularly woke with a headache, dry mouth and some morning reflux. We advised him to:

• do his exercises before he went to bed
• keep his mouth closed when asleep
• sleep on his side rather than his back
• raise the head of his bed.

John's mother phoned the next morning to say that John had had a peaceful night but had woken up with a very dry nose that was irritating him. We suggested that they should wash out one of the many decongestant sprays and fill it with a buffered saline solution. John was to use the saltwater spray whenever he felt the need to spray something into his nose.

We saw John two days later for another workshop. He complained that his mother woke him up when he was asleep because he was so quiet that she thought something was wrong. He was fed up because the whole family monitored his breathing and took every available opportunity to tell him to "Shut your mouth" if his lips parted for a second.

Being hard-hearted, we listened to the positives, skipped over the negatives and moved on to more advanced exercises and breath management techniques. We ask people to read aloud to practise talking while maintaining nose-breathing. John reacted to this as well as most adolescent boys do when called upon to read in an English lesson. I've never run a survey on this but it is my impression that most boys would sooner sit in a tub of fish-guts than read aloud. It was probably only a hard stare and the implication of a half-nelson from his father that stopped John from walking out. For John's part, if looks could kill, my shrivelled remains could have been carried from the room in a bread-basket.

Whether there was bribery or some other form of coercion involved, I don't know, but, despite his complaints, John continued to make good progress. His parents reported that he no longer tied the bedclothes in knots when asleep. His family enjoyed uninterrupted sleep once his mother got over the urge to go and check on why he was so quiet. John woke up with energy in the morning and no longer dozed off during the day. He was generally more active and his general health improved which seems to be parent code for he didn't catch the usual colds or bugs.

After 8 weeks of practising his exercises most of the new breathing techniques had become his habits. We advised him that he could stop the extra exercises and just maintain the new breathing habits and sleep practices but should start the exercises again if he developed a cold or started snoring again.

John was fortunate enough to be able to deal with his snoring and heavy decongestant use with a salt-water spray, nose-breathing, and a few changes to his sleep arrangements along with a lot of support and encouragement from his family. We shall draw a veil over the form that this support etc. took at times. However, this was one of those occasions when a small, sustainable behavioural intervention helped an entire household of people.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

Paediatric Grand Rounds Wants Your Post, Please

As the host of the next Paediatric Grand Rounds I invite you to send in your submissions for the next issue. I'm looking for posts on anything that concerns paediatric health. At the risk of sounding cliched, it takes a village, so I welcome contributions from family doctors, paediatricians, nurses, counsellors, scientists, teachers, parents, etc, etc.

Please send the posts to

breath.spaATSIGNgooglemail.com

I'm in the UK, so please send your contributions by Saturday, September 09, 17:00 London time. If it helps, you can look up the time differences at Time and Date.

I look forward to your submissions and building on the excellent work of the previous hosts.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

Why is Food Allergy Like Gossip?

Knowledge about food allergies is like gossip, by and large, there is a lot of speculation but very little fact. There are confusions about what is an intolerance and what is an allergy. There is a lot of mis-understanding about what constitutes a clinically valid allergy test.

So, it is good to see the BMJ offer a discussion piece on, Are the dangers of childhood food allergy exaggerated? The frame for the discussion is:

The numbers of deaths from food allergy are small and not all are preventable. Allan Colver believes that the increasing prescription of emergency prophylaxis to children fuels anxiety rather than saving lives, but Jonathan Hourihane argues that there are no data to show that prescription of autoinjectors increases anxiety and their provision, as part of an integrated care plan, is justified.

I found this discussion useful. I would write more (of course) but my left arm is playing up and I need to ice it.

However, I do need to make one request. An invaluable correspondent has told me that one theory as to why young children rarely die from severe reactions to foodstuffs etc. that might kill older people is because they have huge reserves of adrenalin. I can't find any references to this and have no feeling for the accuracy of this. Thoughts, opinions, leads?

For more information about the image used in the illustration, click on it or visit the detail on Flickr.