Saturday, December 30, 2006

Paediatric Grand Rounds 1:19

Abby's PGR: the small scale lacks neither sophistication nor complexity

Whether we've taken an elegaic turn because it's approaching the end of year, or there is a general zeitgeist, the paediatric blogosphere offers many thoughtful posts. We have sex, drugs, issues of life, death, morality; ethical dilemmas that reflect religious and cultural values as well as the challenges posed by advances in medicine. Because this is PGR, we also have snot, magical thinking and the general weirdness of contact with children.

Machiavelli famously claimed that statecraft involves fortifying the banks against the rivers of misfortune. We're not all the way there, but most of us are fortunate enough to live in societies where we have fortified the banks of paediatric health against the erosive forces of disease, morbidity and mortality. We live in good housing, we have clean water, standards for air quality, good nutrition, safety standards, improvements in medical science and public health measures such as vaccination. Most of us can be confident that children will survive through to adulthood.

Reading Dr. Flea's series of posts on vaccination has been like a tour through recent social history with some remarkable social changes and a recrudescence of familiar objections to vaccinations. You've probably already read through these posts but if you have a blog, please think about putting up a link to them to improve their search engine ratings. I had a nasty shock recently when I was looking up vaccination on Google and the first few pages of results were dominated by anti-vax entries: it is important to address this imbalance in information. The significance of this was brought home with great force by an email that Dr. Flea received from a mother who thanked him for quieting her anxiety about the risks of immunisation that she had developed from her awareness of media sources and her excursions into parts of the internet.It is sobering to recall what a comparatively recent privilege it is that children survive through to adulthood. The London Bills of Mortality up to 1830 had documented a significant improvement in death-rates for the under-fives: from 1730-79 66.2 percent of the children died; from 1780-1829 there was a substantial drop to 37.8 percent. Dickens commented on this in the outraged voice of an anxious father in The Uncommercial Traveller:
I learn from the statistical tables that one child in five dies within the first year of its life; and one child in three, within the fifth. That don't look as if we could never improve in these particulars, I think!
Those who did survive childhood endured the helplessness of watching parents, siblings, and their own offspring killed by disease or the aftermath of it. Compilations of statistics can be dry and roundly abused but in the 1851 Census the covering commentary made a desolate cry against the widespread individual loss: "[U]ntimely death is a great evil. What is so bitter as the premature death of a wife, -- a child, -- a father?".

The novels of Dickens, the Bronte Sisters and Mrs Gaskell (amongst others) are full of sickly children or children who succumb to an untimely death. Despite this grim reality, there was opposition to the government introduction of new Public Health measures such as clean water and vaccination. Vaccines were intrinsically linked to civil liberties and accusations of abuse of governmental powers. In 1853 the UK Government imposed an act that made vaccination compulsory. Gibbs countered by setting up an anti-vaccination society of people opposed to the idea of "medical spies forcing their way into the family circle". In 1854 there was a leader in The Times that summed up this attitude with brutal clarity:
The British nation abhors absolute power. We prefer to take our chances with cholera and the rest than be bullied into good health.
Some of the comments on Dr. Flea's posts have been modern echoes of these viewpoints. Anthony Cox of Black Triangle wonders whether his proposal that there should be greater parental awareness of the safety systems used to monitor vaccine safety would reduce concerns about vaccination.

Social changes and collective action have led to startling improvements such that today, even with the comparatively high level of prematurity, and the survival of very ill children, the mortality rate for children is less than 1 in 100 in the UK. Even so, Dr. Sam Blackman of Blog MD still needs to hold The Most Difficult Conversation. Just how do you discuss end of life issues with a young patient and their family? I'm resisting the urge to quote swathes of this powerful writing, apart from:
The ‘C’ word tends to turn off rational thought and turn on the “white noise of emotion” machine at 110 decibels...The ‘C’ word conjures up images of very small coffins.
Dr. Clark Bartram of Unintelligent Design tells us about another difficult conversation that is grounded in dilemmas that have been created by advances in medical technology. Is it at all feasible to expect children to make informed, adult decisions about matters in their future? Is it right or proper to compel a twelve-year old to bank his sperm for future use?

Neonatal Doc has been contemplating his own difficult conversations: Honesty. As with Sam
Blackman, sometimes the emotional white noise makes it very hard for relatives to follow the details.

Kal of Trauma Queen reminds us of another reason why infant mortality rates have been improving: we know how to restore the airways of choking babies (scroll down for this heartstopping account of a call to a one month old).
Pink, wriggly babies are what we look for, pink and floppy is indicative of being well on the way to blue and floppy which is well on the way to, well, you get the idea.
Sometimes, you can be thankful for a biting, crying child. Control Room Despatcher Mark of Nee Naw is grateful for the detailed protocol that helped him to talk a parent through unblocking the airway of a choking toddler for whom neither backslaps nor the Heimlich manoeuvre had worked.

I sometimes feel annoyed with parents who seem to be so caught up in the complexities of their own lives that they ignore their responsibilities to their children and their contribution to their wellbeing. Dr. Signout gives us her account of admitting a one week-old baby whose mother did not know that she was pregnant until she give birth: The Story of Ignorance. The story shouts more than usual chaotic circumstances yet there are surprising and touching actions from the adults concerned. Nonetheless, Signout poses the stark questions:
Is it not possible to be too stupid to raise children? And if the story of ignorance is an invention, what are the odds that it is covering up something more benign?
It may be groundless optimism, but I have to hope for a better outcome than she anticipates.

On a seasonal note, Dream Mom tells us that sometimes, when the diagnosis is unknown, the prescription is Santa. Moreena of The Wait and the Wonder is prompted to seasonal speculation about the nature of unhappy families. However, she also provides a lively insight into how experienced parents distinguish between a change in mental status that might presage a deterioration in health in a severely ill child, and the run-of-the-mill weirdness of children's logic and conversations: happy like little snowflakes. Dr. Jest of Dr. Jest's Caseblog describes his own recent experience of a child's logic when a little boy tries to avoid a physical exam by clamping his hands over his eyes: Interview with the...ostritch.

Despite the holidays, Madeline, the self-styled Whitterer on Autism is only too aware that an autistic child's need for consistency demands that there should be minimal disruption to routines: read her Holiday Survival Guide.
If the parents permit the days to become holidays, either for their own benefit or that of their children, you can pretty quickly find that they regress a few months...

Seven months to acquire two new foods and a blink of an eye to lose them again.
On the topic of autism, Dad of Cameron disputes that there is sound evidence to support the autism epidemic that is much bruited in the media. He links to an interesting presentation: It's Not JUST Better Diagnosis.

After the sturm and drang of some of the above threads, I return to the usual mundanities of a common paediatric problem when I offer a guide to using nasal irrigation to shift your child's mucosal gunk. Dr. Alex reminds us of the rather charmingly-named slapped cheeks disease and discusses the persistent issue of intoe-ing.

Dr. Bryan Vartabedian of Parenting Solved gives us a surprising modern twist to the traditional problem of young children swallowing anything that they can get their hands on. We learn why small magnets pose new risks for toddlers.

On the theme of oddities, Awesome Mom describes Strange Things. We learn how odd it can be to adjust to a child who has the full working use of two arms where his elder sibling has one:
I still dress Harry like I am compensating for a gimpy left hand. I just can't break the habit.
In Fogel’s The Escape from Hunger and Premature Death, 1700-2100, he argues that until comparatively recently, most people were battling a series of infections almost all the time, and that people (particularly children) expended a substantial amount of their calorie intake on fighting infection. It is a relatively recent development that we are so secure in our access to adequate calories that we can now concern ourselves with details of our diet. We are bombarded with advice about how we should feed children. Sandy Szwarc of Junk Food Science gives us a fine discussion of the paucity of evidence behind the claims that we should reduce children's intake of salt. She tells us that a meta-analysis that was much-hyped in the media "offered no clinically meaningful evidence, only speculations". She rightly questions how the researchers can acknowledge that the "physiological need for salt intake in children has not been studied,” yet still conclude that
current salt intake in children is unnecessarily high and is very likely to predispose children to develop hypertension later.
Scalpel or Sword tells us something about the changing nature of paediatrics that it is not unusual for a trip to the ER to be more about emergency parenting assistance rather than a health emergency. Neonatal Doc relates the story of a very young mother who was Waiting and seemed in need of parenting assistance for herself, as well as her children.
I wish I knew what to do with people like her. Spending all day in a hospital waiting room with a three day old baby and a toddler? That's almost mind boggling.
Leaving aside the issue of inadequate parenting, as the historical threats to children's health diminish for most of us, what are the new frontiers in paediatric medicine? Dr. Sam Blackman wonders whether it is a modern phenomenon that when parents learn of a diagnosis they almost always ask,
“Was there something in my genes that caused this? Is it hereditary?”. ...[I]t is fascinating to ponder the reasons why people ask this question, and whether or not they would have asked it 25, 50 or 100 years ago.
Darwin's daughter Annie, died when she was 10 years old. Influenced by Lamarckism, and his own theories, Darwin tormented himself with thoughts that he had contributed to Annie's death by passing on the sickly characteristics that he'd acquired during his lifetime. Darwin also contemplated what it meant for there to be a divine influence; Annie's death caused him to ask hard questions about his faith. Ultimately, he lost his Christian faith and died a self-described Agnostic.

Abel Pharmboy of Terra Sigillata discusses the clash between medicine and religion when parents' religious or cultural beliefs lead them to reject paediatric healthcare treatment. Do parents have the right to martyr their children to their own beliefs? Abel wants input on this question from those who care for children and paediatric patients.

Parental guilt, concern and adequacy seem to be common threads in children's health throughout history but as some of the above links highlight, so is the delight of caring for children and watching them develop.

Thank you for joining us on 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 January 13, 2007 and your host is Dr. Bryan Vartabedian of Parenting Solved. Email your contributions to him at fox42 AT mac dot com

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.

The illustration reflects the idea that the scale of something is no indication of its sophistication or complexity: like much of paediatric care. Credits for the photos are as follows or courtesy of the Family Bartram. 1. abby, 2. armonk, 3. red dot, 4. Hermit Crab, 5. drops of yellow petals, 6. Caught me hiding, 7. P, 8. snake hand (20040329), 9. G, 10. Tiny frog, 11. Magical Colours, 12. Tiny Frog, 13. R

Created with fd's Flickr Toys Mosaic tool.

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Friday, December 29, 2006

ATP, Insulin, Mitochondria and the Energy Shuffle

Men in traditional Scots dress at a ceilidh: they are executing a tricky group dance with potential for injury and mayhem
I've always thought about energy production as one of those team dances such as Strip The Willow: or any group dance that is both well-controlled and frantic, but always on the verge of descending into chaos. The energy cycle is like a dance (the Energy Shuffle?) in which three of the lead participants are adenosine triphosphate (aka ATP to its friends and afficianados), insulin and mitochondria. Sometimes, this dance is not quite right, and people can feel Tired All The Time. The way that we breathe can contribute to this clumsiness in the Energy Shuffle: and it may have a role in the generalised feeling of tiredness.

The basic currency of energy in the body is ATP. ATP molecules function like battery packs that move through a cell, providing energy for all of a cell's many processes. This ubiquitous molecule is:
used to build complex molecules, contract muscles, generate electricity in nerves, and light fireflies. All fuel sources of Nature, all foodstuffs of living things, produce ATP, which in turn powers virtually every activity of the cell and organism. Imagine the metabolic confusion if this were not so: Each of the diverse foodstuffs would generate different energy currencies and each of the great variety of cellular functions would have to trade in its unique currency. (Kornberg A., 1989, p. 62. For the love of enzymes. Harvard University Press. Cambridge, MA.).
We have about 85g of ATP in our bodies and without it, we couldn't produce energy to sustain our essential life systems or processes: e.g., there would be no energy to work the heart or pump the blood. The physiology textbooks vary on the absolute figures, but I've read that at any one time, we have enough ATP in our heart muscle to fuel the next 10 heartbeats.

So, if we only have 85g of ATP, and, every day, the amount of ATP that we need to produce and use is equivalent to about half of our body weight, then we must recycle ATP very efficiently. And we must have very good alternate systems that leap into action whenever demand exceeds supply (however, the story of lactic acid will wait for another post). How does ATP work? In the same way that haemoglobin forms a bond with oxygen and then releases it on demand to tissues, ATP is a molecule with energy stored in a specific bond that is readily released and used within the cells of the body (see below); more specifically the mitochondria that are sometimes described as cellular power stations.

Mitochondria are fascinating. According to endosymbiotic theory, they have descended from free-living bacteria that now lodge in our cells (there is a review of Lane's lively interpretation of the controversies and theories about how that symbiosis may have happened). Mitochondria maintain and preserve their own genetic instructions, follow their own timetable for division and effectively speak their own language. Depending on the cell, it may have hundreds or thousands of mitochondria, which might occupy up to 25% of the cell's cytoplasm.

Mitochondria process organic materials (derived from foodstuffs and oxygen) into energy in the form of ATP: they do this by skilful manipulation of oxygen to liberate energy from our digested and processed foodstuffs. Mitochondria burn (oxidise) organic molecules as their fuel within the cells. The commonest fuel for cellular energy is glucose. However, some cells consume a lot of energy: so much so, that, like the heart, it isn't practical to have sufficient on-site storage for more than a few processes, we need constant access to more glucose. The usual analogy is that a house's appliances can obtain their energy from either a storage tank, or they can be connected to the mains gas pipeline: similarly, cells obtain their glucose from the blood supply that is a delivery mechanism resembling the mains gas supply.

Appliances turn on and off: their energy turns on and off accordingly. How do cells signal their need for energy? Insulin. The pancreas produces insulin depending on the blood glucose level. Cells in muscle and adipose tissue that need energy (i.e. glucose) issue a pressing invitation to insulin that attracts glucose in with it: the blood glucose level drops correspondingly. Blood glucose values stay within a narrow range of between 70 mg/dl to 110 mg/dl (3.9 to 6.1 mmol/litre): the levels increase temporarily after eating. We maintain very small amounts of glucose in the blood. E.g., in a healthy adult male of 75 kg with a blood volume of 5 litres, a blood glucose level of 100 mg/dl or 5.5 mmol/l would correspond to about 5 g (1/5 oz) of glucose in the blood and approximately 45 g (1 1/2 ounces) in the total body water (about 60% of the total body weight in men). 5g is roughly a level teaspoon by volume.

If blood glucose levels are too high, the liver sets out insulin greeters that trigger the increased absorption of glucose, transforming it into a storable, easy to access energy source (glycogen) and eventually fat (a longer-term form of energy storage that is not as easy to mobilise).

We have the fuels, insulin and mitochondria, but what actually happens to the ATP so that it is recycled so rapidly and efficiently? Unsurprisingly, ATP has adenosine at its heart, with a tail of 3 phosphates. Energy is released and becomes available for use when a reaction causes the bond of one of the phosphate-oxygen groups to release: energy is released and the molecule is transformed into adenosine diphosphate (ADP). Typically, the presence of appropriate molecules, enzymes and electrical chemical gradient in the local environment means that ADP is immediately recycled within the mitochondria and hooks up with another phosphate group to become ATP again. According to Trefil:
hooking and unhooking that last phosphate [on ATP] is what keeps the whole world operating. (Trefil J., 1992; 1001 Things everyone should know about science. Doubleday. New York, p. 93.)
Kornberg claims that “the terminal phosphate is added and removed 3 times each minute” for each ATP molecule (pg 65, op cit).

The phosphagen system is instrumental in the rapid "hooking" and "unhooking" that both releases energy and replenishes ATP levels quickly. Muscle cells contain creatine phosphate. The enzyme creatine kinase removes the phosphate group from creatine phosphate: the phosphate group is transferred to ADP to form ATP. The cell transforms ATP into ADP, and the phosphagen rapidly converts the ADP back into ATP. It is the combination of ATP levels and creatine phosphate levels that make up the phosphagen system. At rest, normal cell metabolism can synthesise ATP from fuels like glucose and this ATP can re-synthesise the reserve of creatine phosphate in anticipation of the next burst of exercise. The phosphagen system has the capacity to sustain high-intensity energy output in working muscle, but only for 8 to 10 seconds. If a muscle continues to work, the creatine phosphate levels decrease correspondingly: separate mechanisms are needed to continue energy production.

ATP contains sufficient energy for most cellular activities; however, at times, more energy is required. If releasing one bond releases so much energy, an obvious solution would be for ATP to release two phosphates instead of one. Amongst a variety of other reactions, this process does happen: ATP releases two phosphates to produce adenosine monophosphate (AMP) but the phosphates are released as a chain termed a pyrophosphate, rather than as two separate phosphate groups.
ATP → AMP + PPi
However, although it is relatively straightforward to transform ADP back into ATP, pyrophosphates are unstable and rapidly convert to inorganic phosphates
PPi + H2O → 2 Pi
which means that the ATP to AMP conversion is irreversible. Reconstituting ATP from AMP is an example of the precision and the complexity of the cell energy system. The enzymes and mechanisms outlined above are so exact that they can only replace a single phosphate: they cannot add two new phosphates to an AMP molecule to form ATP.

Part of the solution is the specialist enzyme adenylate kinase. Adenylate kinase transfers a single phosphate from an ATP molecule to the AMP molecule, producing two ADP molecules.
AMP + ATP → 2 ADP
The two ADP molecules then enter the normal Krebs cycle that converts ADP into ATP.
2 ADP + 2 Pi → 2 ATP
This reaction can supply ATP when the creatine stores aren’t sufficient. However, although the reaction sustains the cellular motor, there can be an accumulation of AMP that is not processed in the cell. The body can downgrade and eliminate AMP, which is then eliminated from the body but if too much is eliminated then the existing ATP stores may not be sufficient to supply maximum energy. The adenylate kinase reaction is the salvage pathway that allows better ATP recycling and consequent improved muscle recovery after exertion.

However, if there were not sufficient materials to allow salvaging, then the metabolic by-products of AMP have to be eliminated, and fresh ATP is created from scratch in a pathway called the de novo, or new, pathway. This latter process can take some time and is implicated in slow muscle recovery post-exertion. However, chronically decreased blood flow to tissues and subsequent lowered oxygen delivery (as may happen under conditions of chronic systemic hypocapnea) can also contribute to a depletion of ATP. Over-breathing can result in hypocapnea and low levels of oxygen in the tissues: these are plausible mechanisms that can produce both acute and chronic symptoms of severe pain, cramping, stiffness and soreness: a generalised feeling like this can contribute to the sensation of feeling Tired All The Time (there will be a separate discussion on the metabolic importance of lactic acid and how hydrogen ions can irritate nerve endings and stimulate pain).

I tend to assume that children who are mouth-breathers are over-breathing. When people who have been chronic over-breathers learn how to re-train their breathing, they frequently report that they feel more energy. It may be that some people are experiencing the stamina that accompanies the adequate/efficient recycling of ATP. They are performing the energy shuffle with full energy and force.

Wednesday, December 27, 2006

Paediatric Grand Rounds Wants Your Post, Please!

Mock-up cover for Standing Baby magazineYes, 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. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

I am hosting the PGR this week, and it will be a day earlier than usual to allow for the New Year holiday.

Please get your post to me by 5pm London time, Friday 29 December. Time and Date should resolve any time zone problems. My address is

breath dot spa AT googlemail dot com

BritMeds 2006 (5) Is Up!

BritMeds 2006 logo with a Union Jack backdropNHS Blog Doc, Dr. Crippen has been trawling British Blogs for posts on a medical topic for BritMeds. I'm searching for a word that is somewhere between gothic and grotesque to describe the weird and wonderful posts that have made it into the list.

The posts do have some seasonal references but are definitely light on seasonal cheer except for the astonishing reference to the amount of alcohol that we Brits consume over the holidays, 137 units of alcohol over the week. SHP offers us a less than blithe NHS Band Aid.

This will not raise your seasonal spirits but will entertain you.

Sunday, December 24, 2006

How to Clear Your Child's Nose or Help Them to Clear It

Mosaic of itchy, troublesome noses: some nose-pickingI spent Saturday morning helping to remove what felt like pints of gloop from the noses of children. The children had come along to their first workshop with more than the usual mucous as most of them had a cold. We strongly emphasise the benefits of nasal breathing in the workshops so some form of mass de-gunking was in order so that we could proceed at a reasonable pace. We handed out the plastic aprons and demonstrated the wonders of nasal irrigation.

A few years ago, Billy Connolly (or someone similar) characterised folk-singers as people who sit round in Fair-isle jumpers and open-toed sandals, hand-knitting tofu and wholewheat spaghetti. Talking about nasal irrigation makes me feel strangely akin to those folk-singers. There is just something about it that screams woo or crankiness. And yet...The excellent NPR offers a news item on the benefits of nasal irrigation. Serious people like Brad Wright, confess to positive experiences with nasal irrigation, and there has been another journal paper about the benefits of nasal irrigation and what deters people from using it.

Brad Wright is an anatomy instructor who is now studying medicine. He describes the techique of nasal irrigation as a middle-ground between medication and surgery and shares his own (positive) experience of it. Nasal irrigation is apparently safe and effective for treating many conditions affecting the nasal cavity and sinuses (especially sinusitis and rhinitis). Nasal Irrigations: Good or Bad is a readable overview of the topic (the full paper is available in pdf) that does not need to be read with a defensive hand cupped over the nose.

The National Jewish Medical and Research Center offers a detailed overview of nasal irrigation for different age-groups and gives good descriptions of the different methods. Nasal irrigation offers the following advantages, it:
  • clears mucous from the nose; it may make medication more effective
  • clears allergens and irritants from the nose reducing their impact
  • removes bacteria and viruses from the nose reducing the frequency of infection
  • decreases swelling in the nose and increases air flow
  • can soothe irritated or inflamed passages.
The basic technique is to mix up a home-recipe for the irrigation solution, or to make up a commercial mixture, and then to irrigate the sinuses. After some experimentation and reading around on the (unvalidated) pros and cons of different solutions, I recommend this basic recipe:
  • 16 fl oz of tap water (heat it in the kettle or microwave)
  • stir in and dissolve 1 teaspoon of refined seasalt (but use rock, kosher or other uniodized salt if you have seafood allergies etc.)
  • stir in and dissolve 1/4 teaspoon bicarbonate of soda.
The irrigation method will determine whether you use all or only part of this solution: if you use only part, then store the remainder in the fridge and use as required, but use in within 48 hours or discard. Warm up the water before you use it, if you have stored it. If you find this mixture irritates your nose, then use slightly less salt. If the irritation persists, then irrigate with a milder solution every other day until your tolerance increases or your symptoms decrease.

Now that you have surreptitiously made your solution, you probably need to find a handbasin or shower cubicle where you won't be disturbed. You may wish to play a radio or CD that will cover the sound effects of the next few minutes. Lean over the sink or stand in the shower cubicle.

You can use positive or negative pressure to irrigate the nose. Positive pressure means that you squirt in the fluid from a bottle/bulb syringe or special gadget (of which there are many); negative pressure means that you sniff up the solution from (say) your cupped palm.

I recommend saying 'k' while you irrigate: this helps to close up the soft palate and prevent swallowing the salt water if you accidentally introduce it into your mouth. If the water does get into your mouth, just spit it out. This is one of the few occasions when you will need to breathe through your mouth.

If you use the sniff method, then pour saltwater into your cupped palm. Sniff the liquid up one nostril at a time. Allow the fluid to drain and blow your nose lightly. This technique may not be as effective but may be used in some situations such as when out socialising and the nose is irritated by cigarette smoke and other methods are not available (you do need to travel with a small quantity of salt available).

For the other methods, you may need to experiment with your head position. Lean forward (about 45 degrees) so that you are looking at the floor of the shower or into the handbasin. Rotate your head (about 45 degrees) so that one nostril is above the other.

Squeeze the fluid up the upper nostril, aiming towards the back of the head (only aim towards the top of the back of the head if this technique doesn't work to loosen the hard mucous). After a few moments, the solution should drain from the lower nostril. Let your nose drain as much as possible before blowing your nose in the standard way (i.e., blow it while letting air escape through only one nostril at a time). Depending on the state of your sinuses, you may occasionally experience a delayed, nasal outpouring. Repeat the procedure for the other nostril.

If the mucous is difficult to shift, and you don't have any neck problems or contra-indications, lean your head back and squeeze as much solution into one nostril as you can. Keep your head tilted back for a while and allow the solution to soften the mucous. Then drain and blow the nose in the usual way.

If you accidentally introduce some of the salt solution into your middle ear (because of the close anatomy, it does happen) then tilt your head in the opposite direction to clear it.

I recommend that you should help young children to irrigate the nose while they are in the bath, or by holding them over a sink, and using one of the child-sized bulbs or bottles to introduce the fluid. You may need to aspirate the nose first if the child is very young.

If you use a nasal irrigation pot, syringe, bottle or more sophisticated gadget, it is important to clean it daily. Follow the manufacturer's directions as appropriate. A bottle or pot should be cleaned and then rinsed with ispropyl alcohol or a white, distilled vinegar mix of 1 part vinegar to 3 parts water. Unless otherwise indicated, equipment should be left to drain completely (not standing in a puddle of water) and to air-dry.

There are more sophisticated techniques/gadgets for nasal irrigation, but no studies have confirmed that one technique has substantially more benefits than the others. The most effective technique is the one that you find comfortable and that allows you to practise nasal irrigation on a regular basis or as-needed.

For those of us who are fascinated that there are journal papers on the topic of nasal irrigation, Dr. David Rabago and his colleagues at the University of Wisconsin Madison, have just published Qualitative Aspects of Nasal Irrigation Use by Patients With Chronic Sinus Disease in a Multimethod Study. The headline findings are that:
[Hypertonic Saline Nasal Irrigation (HSNI)] is an effective, safe, well-tolerated, inexpensive therapy that patients with frequent rhinosinusitis and chronic sinus symptoms can learn in the office and use at home over the long term with minimal training and follow-up...Clinical success with HSNI will likely be improved by brief patient education, HSNI demonstration, in-person coaching, and the ability to tailor HSNI use to individual needs.
The researchers noted that several trials report that HSNI is a safe and well-tolerated therapy for a variety of rhinsinusitis and sinus symptoms. They interviewed people who had recently participated in an HSNI study and had used nasal irrigation.

The interviews uncovered 4 main themes in the participants' attitudes.
  1. They felt empowered because HSNI improved self-management of symptoms.
  2. HSNI treatment contributed to a rapid and long-term improvement to quality of life.
  3. The main barriers to HSNI uptake were:
    • discomfort when using the technique
    • the length of time it takes
    • mild side-effects:
      • sudden saline drainage
      • nasal irritation or burning.
  4. They were able to overcome the barriers because of follow-up and training.
At the workshop, the children lost their usual yellow-green-brown spectrum of mucous ropes. I strongly suggested that they should repeat the procedure later in the day and about 2 hours before bed-time. One of the last times that I did this during a cold outbreak, everybody who did this had a more comfortable night, except for one child. There was a phone call to tell me that the child had a very blocked nose and had woken up coughing at 2 o'clock. No, they hadn't irrigated the nose again or even aspirated it. No, the parents had not raised the head of the bed by 4-6 inches. No, they hadn't practised any of the sleep recommendations. No, they hadn't done any of the homework exercises. No, they hadn't done any of the anti-coughing exercises.

I suggested that one of the parents should aspirate the child's nose and perform a partial irrigation by squeezing some solution up the nostrils and letting it drain. Meanwhile, I asked that the other parent should gather together some hardback books or bricks (they had some in the garden which they covered in plastic bags) and raise the head of the bed. I asked them to take the child through the anti-coughing exercise.

When I heard from them at a more civilised time of the morning, the child had returned to bed and slept through the night. I reminded the parents to help the child irrigate during the day and to perform the homework exercises. The child needed to irrigate 4 more times during the day but slept through the night. On the day after, the mucous had cleared, the child no longer had a post-nasal drip or cough and was thoroughly lively again.

It may sound cranky, but there are considerable benefits to nasal irrigation, even when somebody already has a cold. Unless you know of any contraindications, it is useful for children: it removes the mucous and prevents it from standing in the sinuses where it is prone to a bacterial infection.

If you have recurrent sinus problems etc. then talk to your medical adviser about nasal irrigation and whether or not it might benefit you. If you get the go-ahead, then gather together your ingredients and any equipment that you might need and experiment in the privacy of your own bathroom or shower cubicle (if the child is old enough, otherwise, help them). You have nothing to lose but mucosal gunk.

Edited Dec. 28: it can take a few days to normalise and adjust the mucous levels. If you find that the nostrils are a little dry after irrigation, use an earbud to apply a trace of glycerin and water mix just inside the nostrils, then rub the nostrils together to distribute the lubricant.

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

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Thursday, December 21, 2006

Working with Pirates with Asthma or Sleep-Disordered Breathing Part 4

Pirate Mosaic with traditional images and treasure
Yesterday, in Part 3, we left the boys preparing for an expedition to an island with a fabled chest of gold air that would somehow lead them to treasure guarded by a dragon to try and find enough money to fund their return home.

How the Jammy Boys Came To Be Pirates, Part 4

They set sail for Fresh Air Island (for that was the name on the map) as soon as the tide turned. They sailed for three days and nights until they reached the island. [Depending on the facilities, the children run up and down the rigging, pretend to swab decks or repeat the rowing exercises, with their mouths closed and maintaining nasal breathing.]

This time, they had a man to contact about the chest full of gold air. So they went ashore and found the man. He was a happy looking man with thick white hair and a full beard. Captain Jack got straight to the point, “I believe you can tell us all about where we can find a chest full of gold air”, he said, “Yes, I can”, said the man, “Because I am a doctor. You can find it right there”, he said, tapping Captain Jack on the chest. And then he tapped the Jammy Boys, each in turn. “What do you mean?”, said the Jammy Boys who were puzzled.

“Well”, said the doctor, “When you breathe in and out through your nose, we call that gold air. When you breathe in or out through your mouth, we call that grey air. You should keep your gold air locked inside so that you have a chest full of it”. [Check that each child has a clear nose and is nasal breathing.]

“That’s all very well”, said Alan, “But we need real gold so that we can reach Britain”. And he told their story to the doctor. The doctor frowned and then brightened. “I can help you he said, “But you must promise to follow the advice I give you as it is very important”. Captain Jack was a little down in the mouth and asked, “Is this going to lead us to real gold? The sort we can spend to send these boys back to Britain?”. “Yes, said the doctor, “And to prove it, here is an ingot from the treasure trove that I will give you a map to”. And, so saying, he drew a gold ingot out of his pocket, marked with the stamp of King Charles. The Jammy Boys looked on in astonishment. “My grandfather was a pirate”, explained the doctor, “And he was one of the men who hid treasure in a cave. But before they could retrieve it, a dragon moved into the cave. Now the dragon guards the gold day and night”.

“Why have you never tried to get the gold?”, said Captain Jack. “Well, my grandfather repented of being a pirate”, said the doctor, “And he made us promise that we would never become pirates or make use of his ill-gotten gains. But he said that if we came across someone who needed the money desperately, then we should tell them the secret passage into the cave, and how they could get past the dragon. But before I tell you these secrets, you must promise to take my advice”. The Jammy Boys were used to this by now and said, “We promise. What is your advice?”.

The doctor listed off the points, using his fingers. “You must play outdoors every day”, said the doctor. “And as you play, you must keep your mouth closed and breathe gently through your nose. Even when you are catching bubbles, chasing a ball, running or playing football. In fact, you should breathe quietly and gently through your nose at all times. The more you do this, the stronger you will get and the quieter you will be – and this is very important if you are going to be able to remove the treasure without waking the dragon. If your nose ever gets blocked, you should do this.”. [Repeat the nose clearing exercises as appropriate to the children. The children can run up and down the room with the mouth closed, if there is space. Otherwise, burst bubbles or some other activity.] "And, everyday, I would like you to hum strongly for 15 minutes." [The children hum an appropriate selection of tunes.]

The Jammy Boys promised to follow the advice they had been given and they did. The doctor gave the map to Captain Jack and they set sail for Treasure Island. The island was two weeks journey. And during that time the Jammy Boys did everything that they had promised. They ate fruit and vegetables without complaint and they drank milk and water. They read quietly before falling asleep, and kept their mouths all night long. They were careful to keep their mouths closed during the day, while they were busy doing other things, like swabbing the decks or playing. They played in the fresh air every day. All of the time, they kept their mouths closed whenever it was possible, and they breathed quietly through their noses. They grew stronger, and their colour improved. Every morning they felt as if they had had a good night’s sleep and had more energy. [The children rehearse how they settle themselves for sleep.]

The morning that they reached Treasure Island the Jammy Boys were happy but Captain Jack looked worried. “I think that I glimpsed The Shape-shifter in another cove”, he said. “Those vicious pirates might be ahead of us”. “Don’t worry”, said the Jammy Boys, “Even if they know about the treasure, they probably don’t know the secret entrance to the cave or how to defeat the dragon”.

They set off for the caves. They had to climb up a sheer cliff face, and stick their fingers and toes into tiny cracks to help them. [Depending on the facilities, simulate climbing the wall while keeping control of the breathing.] But they managed, they were so fit and healthy that it all seemed easy to them. After a few near-misses among some of their shipmates, they made it to the cave where they saw the dragon lying fast asleep with his body curled around an open chest of treasure. The chest was overflowing with treasure. They saw more gold ingots, and rubies as big as eggs, and pearl necklaces and all sorts of precious objects.

The doctor had told them that they needed to be very quiet as they walked towards the dragon. And if the dragon started to wake up, they needed to stand as still as statues. Captain Jack asked for volunteers to go with him to take the treasure. All of the Jammy Boys stepped forward and Captain Jack looked at them with pride, “Brave Lads”, he said.

Captain Jack and the Jammy Boys inched forward, breathing as silently as they could. If anyone of them developed a blocked nose, he performed an exercise until his nose cleared and he could breathe quietly again. Whenever the dragon moved, they stood as still as statues, so that the dragon couldn’t see any movement. Nearer and nearer they drew to the treasure. Captain Jack quietly closed the lid of the chest and the boys wriggled between the coils of the dragon until they loosened his grip on the chest. [During this, the children should be performing steps or wriggling; depending on their condition, they may be breath-holding or breathing quietly.] Captain Jack lifted the heavy chest and they slowly and quietly made their way back to safety.

Captain Jack pointed out a different way out of the caves. They obviously could not go back the way that they came because of the weight of the treasure. They held their breath and moved slowly and quietly around the front of the dragon until they reached the safety of the tunnel. They were walking down the tunnel when they heard some noisy breathing ahead of them. The noise of the breathing grew louder and louder so Captain Jack sent a scout ahead to report.

The scout returned quickly. “It’s Blackheart and his men”, he said, “And they’re coming this way. There’s a big crack in the wall where we can all hide if we hold our breath and are very quiet. We must go there now”. With hardly a moment to spare, they all squeezed into the crack and held their breath. [If this is OK with the children and the medical history, act this out.] The Jammy Boys shook slightly as they saw Blackheart again in the light of their flaming torches, his face pulled into a different one than they had last seen.

After all of the men had disappeared up the tunnel, they all climbed out of the crack in the wall and moved quickly up the tunnel. They could see daylight when behind them they heard the sound of a dragon roaring and men screaming. The dragon had been woken up by the noise the men made with their breathing and was lying in wait for them with his own scorching breath. He roared so intensely that the walls of the cave seemed to shake and the boys felt a pounding in their chests. “Quickly”, said Captain Jack, “We must get back to our ship before Blackheart realises that we beat them to the treasure!”.

Just as he said that, they heard Blackheart shout, “Captain Jack. I’ll have you and those boys”. The sound of running footsteps echoed through the cave. Captain Jack, the Jammy Boys, and the crew of The Homeward Bound ran as quickly down the hillside as they could. But, fit as they all were, with the advice that they had followed, the treasure was very heavy and was slowing them down. Blackheart and his men were gaining on them.

Up ahead of them on the path, they saw a column of men dressed in blue, white and red carrying swords. “It’s the Navy”, groaned Captain Jack, “I’m glad to see them but they’ll never let us keep the treasure”. “Leave it to me”, said Alan. He rushed up to the column of men and asked to speak to their officer. “We’re so glad to see you”, said Alan. “We went to find treasure so that we could claim the reward and use the money to go back home. But Blackheart and his men found out about it and they are trying to take it off us. They are right behind us”. The officer looked a little surprised, but saw a group of heavily-armed men running towards them and called his men to action.

There never was such a fight, such swash-buckling and sword play. [Depending on what is available, the children may fight and should keep control of their breathing.] There was a desperate struggle between Captain Jack and Blackheart and the fight went this way and that, with both men gaining the upper-hand. The swords flashed in the sunlight. But finally, because of all the advice they had been given, Captain Jack proved to be fitter and stronger and he managed to trip Blackheart and pin him to the ground while sailors tied him up.

When they were all safely on the naval ship, the officer asked the Jammy Boys and Captain Jack to tell their story. He nodded as he listened. “We were looking for Blackheart and his men because we spotted The Shape-Shifter in the cove. There will be a good reward for capturing Blackheart. As well as the reward for returning the treasure”, said the officer. “There will be a good share for all of you. And we will be proud to take these brave boys back to London. We are headed there. We will send a letter to your parents so that they know you are safe”.

The Jammy Boys said goodbye to Captain Jack. He now had so much treasure from his share of the reward that he said he and his men were going to give up being pirates because their heart wasn’t in it. They were going to sail about on the High Seas, having adventures and rescuing anybody who needed their help.

A month later, the Jammy Boys arrived in London. Imagine their surprise and delight when they saw all of their parents waiting on the dockside for them. They had many stories to tell about their adventures and all of the advice they had been given. But for now, it was enough to let their parents hug them.

The children have rehearsed most of the important exercises. There should be an opportunity to review the breath management exercises, such as how to speak when breathing through the nose, and how to control coughs and sneezes. Make sure that the children understand the importance of maintaining nasal breathing and other measures such as good hygiene to prevent cold and flu transmission.

Flickr detail of images: Thanks to the CC people who make this possible.
1. Fort Lauderdale pirate, 2. Lil' Pirate, 3. pirate skull, 4. Pirates' Loot

Created with fd's Flickr Toys.

Wednesday, December 20, 2006

Working with Pirates with Asthma or Sleep-Disordered Breathing Part 3

Pirates MosaicYesterday, in Part 2, we left the boys preparing for an expedition to an island to try and find enough treasure to fund their return home.

How the Jammy Boys Came To Be Pirates, Part 3

They set sail that afternoon and reached Dentists’ Despair two days later. Captain Jack, the crew members and the Jammy Boys located dental surgeries and gently climbed in. [The children practise climbing over obstacles with their mouths closed and breathing through the nose.]

But they didn’t find any gold. They found hardly any material for fillings. What could be the matter?

They searched five different surgeries. When they broke into their sixth one, they were startled to find that there was a man asleep in the dental chair. He was more surprised however and said, “Who are you?”. Looking as fierce as he could, Captain Jack said, “We are ruthless pirates. And we are here to steal all of the gold fillings”. [The children creep about stealthily in burglar mode, breathing 'properly': they rehearse the anti-coughing and anti-sneeze techniques that they learned yesterday.]

The man laughed. “Gold fillings”, he said, “There’s no need for fillings of any sort on this island”. The Jammy Boys looked at each other, what could he mean? “I’m a dentist”, explained the man. “People on this island used to need a lot of fillings because they ate lots of sweet things and drank only fizzy drinks. But then they started eating fruit and vegetables and cut right back on sweeties. Now they drink only milk, water and fruit juice. Nobody eats toffees or anything that pulls out fillings so people hardly ever come to see me any more. Didn’t you know that’s why this island is known as Dentists’ Despair? It’s because there is hardly any work here for dentists”.

“If you don’t mind me saying”, said the dentist. “You don’t look like ruthless pirates. Why are you doing this?”. Captain Jack explained about what had happened to the Jammy Boys and that he needed gold to afford to send them home. “Oh dear”, said the dentist. “I’ll tell you what. If you promise to adopt some good advice that I give you, then I will give you directions to an island where you might be able to find some gold”.

“Oh, thank you”, said the boys who may now be pirates but remembered their manners. “What is it that you would like us to do?”. “Well”, said the dentist, “Of course, I want you to brush your teeth every morning and every night. You must also promise to eat fruit and vegetables and to eat sweeties and chocolate only occasionally. Fizzy drinks are very bad for teeth and you should only have them for treats. Please drink milk, water or fruit juice”. “We promise”, said the Jammy Boys, “Now please give Captain Jack the map for the island where we can find gold so that we can go home”.

They set sail on the next tide. They kept their promise to the dentist and did what he had told them. Two days later, they reached Sleepy Island. “We’ll definitely find gold here”, said Captain Jack. “Apparently, all of the people on the island have trouble getting to sleep and so the Sandman has to come here and scatter gold dust in people’s eyes to help them sleep. We’ll wait until nighttime and then we’ll visit all the houses and very quietly gather up the gold dust from the corner of people’s eyes. We’ll soon have enough gold dust to pay for your passage home”.

They waited until nightfall and then all went ashore. They found open windows and softly climbed in. They visited many bedrooms and looked into the eyes of everybody that they saw, but they didn’t see any gold dust. [The children run about on tip-toe, very quiet, with quiet breathing.]

“I don’t understand it”, said Captain Jack, “There’s no dust in people’s eyes but they are all wearing tape on their mouths. What is going on?”. He was so cross that he bumped into a book on the bedside table and knocked it off. The loud thump woke up the couple sleeping in the bed. They looked like grandparents. They were obviously surprised to see people in their bedroom but the Jammy Boys thought that they looked very friendly.

“Who are you?”, they said. Joshua thought that it would be better if he explained, and so he told the story of Flambago and their adventures on The Homeward Bound, and how Captain Jack was trying to help them but needed gold. And they had come here because they had heard about the Sandman sprinkling gold dust in people’s eyes, “But we can’t find any”, he finished, “Which means that we still can’t afford to travel home”.

The couple looked at each other. “Well”, they said, “It’s true that we all used to have trouble falling asleep and staying asleep, but we don’t have problems any more. We sleep differently now. If we give you some advice and you promise to take it, we can give you a map to an island where there we’ve heard rumours of a chest full of gold air, and where you will find clues to another place where there is gold guarded by a dragon”.

The Jammy Boys looked at each other. “We promise”, they said, “What do you want us to do?”. “Well”, said the man, “You must promise to wind down gently before you go to bed. And read stories rather than play noisy games. And to sleep on your side and never on your back”. “Preferably, your left side”, chipped in the woman. “And you must sleep with your mouth closed using whichever technique suits you best”, said the man, “That way, you will have a good night’s sleep and will be fit to face any dragons that you meet”. [The children rehearse lying down for sleep in the proper position and with the mouth closed. If they need to clear the nose first, they use the exercises that we have used before, whether steps, nodding dog or humming.]

“We will do all of those things”, said the Jammy Boys, “Please give the map to Captain Jack so that we can start as soon as we can”.

Clutching the map, they returned to the ship.

Similar education points to yesterday. However, today, the children also practise breath management while talking and while they are more active. They practise anti-coughing and anti-sneezing exercises. They also rehearse how to recover from coughing or sneezing without provoking further coughs or sneezes. They practise quiet running. They rehearse how they ready themselves for bed. They have various sanctimonious suggestions made to them about fewer fizzy drinks and sweeties.

Flickr detail of images: 1. pirates! (DSC02409), 2. Pirate in cage, 3. Pirates and Gangsters!, 4. Pirates Pub in Bahamas

Created with fd's Flickr Toys.

Tuesday, December 19, 2006

Paediatric Grand Rounds 1:18 Pirates of the PGR

Images of pirates engaged in various activities

No cuddly Santa for us, My Hearties. This is a swashbuckling, buccaneering sort of Paediatric Grand Rounds, I have looted and pillaged various blogs and seized control of the Good Ship PGR. If there are posts that I have missed (e.g., you sent them along to Sam Blackman whose PGR I either mutinied out from under him or whose most prized asset I negotiated away from him, depending on your turn of mind), then please send them along to me and I shall do a running edit. 23:30 London time, it seems that Captain Blackman has fought back bravely, discovered the pirate within and found himself another vessel which he has named PGR 1:18: it is well worth a visit.

As a warning that danger can arise unexpectedly, and not just in navigating the course and location of the PGR, I pose the blithe question, Risk v. Danger: Does Familiarity Cause Us To Forget That Asthma Can Be Life Threatening?

Ship's doctor Flea has been exercising himself in instructing us about the benefits of vaccines for illnesses that were a scourge both on pirate and normal ships. On My Left Shoulder is an exploration of the history of the smallpox vaccine. Flea's colleague, the Insolent Orac on whom Patrick O'Brian's Stephen Maturin should have been based, is publicising a new blog that tells the story of the triumphs and tragedies of vaccines.

Curiosity-hunter, and First Mate Clark Bartram, introduces us to the Bride of the Not So Normal Newborn Nursery. Kid's Doc Meg is the ship's apothecary and magician. She has recently been irritated by parents who express regret for the waste of their co-pay rather than relief that their child is well: The Magic Wand. However, Dr. Jest reports that Family Doctors such as himself are in high seasonal demand for his ability to heal and protect through touch alone.
they bring in little Lilly and Freddy, to be "checked", so they wont be ill over Christmas. Still their faith is as touching as it is undeserved, as though my simple scutiny this week can ward off all evil. Would that it were,so. Still a lad can dream, and as you can probably tell, I rather like becoming one of Santa's helpers just for the week.
Entertainment Director Doc Around The Clock tells us about a 17 year old boy, a game of dodgeball and why SCUBA Diving After Pneumothorax May Be A Big Pno Pno. In her own addition to the entertainment schedule, the fabulously named Dr. Lourdes De Asis is now showing the Simpsons Food Allergy Cartoon. She is also screening a recruitment video for Pirates of the Care-ibbean.

Purple Kangaroo and her joey, Baby E, have an extensive range of allergies that make life difficult. Despite her young age, Baby E. is already a little maritime trooper who has learned to be co-operative, even when the preparations and process of undergoing an endoscopy exhausts her mother.

Crew Member Bryan Vartabedian may be looking after the pirates' children, but when it comes to his own, he says, Doctor, Don't Heal Thy Kids. Cancer Dad know that sometimes it is small gestures that make such a difference to the confidence that families have in the caregivers who tend to their sick children: Nightingale.

Parents worry, even when they are pirates who would prefer to be known for their ruthlessness rather than their warm hearts. It is possible that any parents of new borns, that don't have previous family experience with food allergies, are not equipped to make a proper call on their child's condition and tend to overestimate the incidence of food allergy. Are Parents Food Allergy Paranoid With New Babies?

General deck swabber and Ship's Counsellor, Kevin Leitch frequently feels that It's A Beautiful Day. He has posted a video of his daughter to show us just such a day and discusses an email from someone who is grateful to the blogging parents of children with autism for expanding understanding and improving relationships between parent and their autistic child.

Keeper of the ship's conscience, Neonatal Doc, was marooned on a raft of regret and self-questioning when he he discovered that one of his tiny charges had a small spontaneous intestinal perforation: it was very subtle but he's irritated that it was Missed. Sam Blackman joins him in the feeling of regret when he recalls that this time of year is indelibly associated for him with the loss of some remarkable patients. He discusses his own emotions and the colours, textures, emotions and biology of Crying.

We recently ran across Dr. Sarah from that fine vessel, Good Enough Mummy who has been debating for some time whether her son would have surgery to correct a squint. She lets us in on the difficulty of running tests in children and the fascinating workarounds that people find. Check out the Quick Squint Update for a medical parent's view on the matter and then head over to Dr. Sidarth Sethi for a discussion of amblyopia.

New from Mattell in time for Christmas is the gift that no parent would wish to have to give but is an interesting educational tool for children with ostomies.

Being on a pirate ship and with the vacation fast approaching, the mail has been a little irregular getting to me. If you submitted a post nomination to former Captain Sam Blackman that was lost in the mutiny/peaceful handover (tomato, tomato, potato, potato) then please send it along to me and I shall edit it in when I update the ship's logbook. [Edit in the light of recent events: standfast, hold it over and send it along to me for the next edition.]

Clark Bartram is always on the look out for new hosts for Paediatric Grand Rounds. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

I am the host of the next Paediatric Grand Rounds. Please start thinking about your posts because it's not as if there is anything happening between now and the New Year. I will do my best to be flexible but I would like the submissions in by 17:00 GMT on Saturday 29th. Time differences will be made clear at Time and Date.

My email address is breath.spa AT googlemail dot com

Images courtesy of Flickr. 1. Pirate, 2. Pirates, 3. Pirate Contemplation, 4. Yarr there be Pirates!

Working with Pirates with Asthma or Sleep-Disordered Breathing Part 2

Images of pirates engaged in various activities

Yesterday, in Part 1, we left the boys in a dark and desperate situation. As we pick up the story, the boys are still in the hold.

How the Jammy Boys Came To Be Pirates, Part 2

Alan, Joshua, Matthew and Peter huddled together. They didn’t know what Blackheart would do with them. A couple of the boys were a little panicky. Peter told them all to imagine what their parents were do it they were there. The boys remembered feeling warm and safe and imagined those feelings. [Practise self-hypnosis with the children in whatever position is comfortable for them. Check they are breathing from the diaphragm and practise exercises to encourage this if they are not.]

Despite the discomfort, using their imaginations, the boys felt so warm and safe that they drifted into sleep. It was many hours later that the door to the hold opened and men came in and picked them up. “What’s happening?” said the boys. But the men tucked them under their arms and refused to answer. The boys were brought up on to the deck, where above them, they saw a plank. They gulped. They looked at each other in horror. They had a good idea what was going to happen next.

“We thought that you were going to keep us on board to protect you from the Navy”, cried the boys. Blackheart sneered, “As long as they think you’re on board, we don’t actually need you. Besides, the men need some comedy and making you walk the plank will provide it”.

One by one, the men prodded the boys and jeered at them as they made them walk the plank. Before Alan mounted the steps to the plank, he whispered to the other boys, “Pinch your nose and hold your breath when you are walking the plank and when you fall in the sea. So the water doesn’t go up your nose or in your mouth”. [Depending on the medical history, the children breathe out, perform steps across the room, mouth closed, pinching the nose shut and holding the breath. They perform different numbers of steps, depending on their condition and age.]

Each of the boys was very brave and did what Alan had told them to do. When they landed in the water, they could float successfully because they didn’t have water in their nose or mouths. They all looked at each other. “What happens now?”, they said. Peter thought that they should group together and start swimming. Luckily, they hadn't gone far before they discovered flotsam and jetsam floating nearby and they managed to get on top of those.

They paddled with some loose wood that they found. They stayed afloat for hours and were getting colder and colder. Peter suggested that they should sing but the sea was a little choppy and the boys were worried about getting water in their mouths. Peter wondered if they would still be able to cheer themselves up if they hummed some of their favourite tunes. [The children pick some of their favourite tunes and hum them vigorously enough that the cheeks vibrate but no so vigorously that they hurt the throat. This should open up their noses even further but may also encourage the flow of mucous, so be ready with tissues.]

The boys were cold and exhausted. They were relieved when they saw a ship called The Jammy Jack. But then they started to worry, “What if these are more pirates?”, they said. “Too late” said Matthew, “They’ve seen us”. The boys had their hearts in their mouths as they waited to see what would happen next.

A boat was lowered from the ship and came towards them. There were four men rowing the boat. [Row again, as previously, with the mouth closed and breathing through the nose.] “Ahoy, there”, the men shouted, “Climb into the boat”. And with that, they lifted the boys up and placed them gently in the boat. On the way back to The Jolly Jack, they wrapped the boys in blankets and gave them sips of water to drink.

When they reached The Jammy Jack, the Captain was there to meet them. “I’m Captain Jack”, he said, “And this is my ship. You are welcome aboard. Tell us what happened to you. You must have done something terrible to be abandoned at sea like that. You were lucky we saw you”. The boys cried out in protest and told Captain Jack what had happened to them.

They told him about Flambago. And The Homeward Bound and Blackheart. “Can you help us”, they said, when they had finished.

“Well, I’d like to help you, boys”, said Captain Jack. He looked a little embarrassed. “The truth is, I’m looking for gold because I need the money for repairs to my ship. But as soon as I can, I will leave you at a main shipping port from where you can take a ship to Britain.” I can give you room and board but you will have to work as cabin boys to help out. His face brightened as he said, “I know, you can be the Jammy Boys who belong to The Jammy Jack. But for now, you need dry clothes, food and a warm bed to recover from your adventures”. The Jammy Boys liked their new name and were pleased to be in less danger than they had been for what seemed like a very long time.

The boys lay down to sleep. [Ask the children to pretend to go to bed. They need to check which nostril is clear and lie down with that nostril up top. They need to arrange support if they need it.] The Jammy Boys slept soundly, and the next day, they set to work swabbing the decks so that the timber did not dry out or warp. [The children practise vigorous swabbing while keeping the mouth closed and breathing through the nose.] They liked their name, and they liked the three-quarter length dark blue trousers and white shirts that they wore. But they missed their parents and wished they knew that they were safe with Captain Jack who was very kind to them.

One morning, they were excited when they put into a dock and Captain Jack said, “Come into town with me, my Jammy Boys, and stick close”. They were disappointed when they saw how small the town and dock where, and realised that they wouldn’t be able to board a ship for Britain from there. The town seemed very dirty and was full of dangerous-looking people. They stayed close to Captain Jack and walked with him to the Howling Goblin Inn, which was a dark and crooked building.

“We’ve come here to see what we can find out about where we can find some gold”, said Captain Jack. “We have to find a way of listening to people without them noticing us”. Peter saw a bedraggled cat walk into the dark alley and disappear through what seemed to be a crack in the wall. He pointed it out to Captain Jack, and they all went to investigate. They pulled weeds away from the wall, and saw a hole in the wall leading to a space under the floorboards. There was enough room for Peter to wriggle inside with Captain Jack. [The children wriggle on the floor with the mouth closed, and breathing through the nose.]

The inn was smoky with the fumes of dozens of pipes and cigarettes. The smoke hung like boiling storm clouds, wrapping itself around people and rolling away slowly when the door opened and brought in fresh air. “The air in here is so bad”, whispered Captain Jack, “That we need to make our breaths very, very small. Let’s do that”. [Lying on the floor, make breaths very small, make sure mouth is closed and breathing through nose. Pretend to take tiny breaths, like a mouse.]

Captain Jack said, "No matter what, no matter how bad the air, there must be no coughs or sneezes. If you feel that you are going to sneeze, try to stop it by rubbing your nose just here", and he pointed to the right spot. [The children pretend that they are going to sneeze and rub the nose to take the urge away.] "What's more," said Captain Jack, "If you feel that you are going to cough, then stop it. Clear you throat softly several times". [The children practise gentle throat-clearing. They make quiet, polite noises.] Captain Jack warned, "If the feeling that you need to cough doesn't go away, then you might find that you are taking in a deep breath. If you do, then breathe out as quickly as you can, through your nose. Follow that up with some gentle, mouse-sized breaths and that should stop it. We must be as quiet as we can or we will be in great danger." [The children practise these, and other, anti-coughing techniques, based on their medical history.]

Peter was as quiet and still as he could be. He could see and hear through the gaps in the floorboards. He didn’t see any parrots. He saw a large black bird that let out loud, shrill notes: it seemed to be a cruel cross between a falcon and a raven. He was surprised to see that it was drinking beer out of a small bowl that had been set out on the table for it.

Captain Jack ignored the bird. He was listening to what people at the table were saying. They were looking at a map and talking about an island called Dentists’ Despair. The more he listened, the more he heard mention of sweeties, chocolate, ice-cream and fizzy drinks. “Oh”, he said to Peter, “The people on this island must eat and drink lots of sweet things and need lots of fillings. Sometimes, people have gold fillings. If we go to this island, we will raid the dental surgeries and take the fillings and then we will have enough gold to be able to send you home to Britain”. When no-one was looking, Captain Jack slid his knife into a crack and was able to pull the map towards him.

Captain Jack and Peter wriggled back they way that they came. But when they got there, they heard the boys reciting poems and limericks. It seemed that some people had stopped to ask the boys what they were doing, and, caught off-guard and a little panicky, Joshua had blurted, "We're rehearsing". To prove it, the boys had then had to recite all the poems that they could remember. [The children each recite a poem or read something: they need to speak while maintaining their nose breathing.]

When the coast was clear, Captain Jack and Peter emerged. The Captain was a little surprised but congratulated the boys on their quick thinking and their performance. They returned to the ship. While Captain Jack made their plans, the Jammy Boys carried on with their chores and had to climb the rigging to make sure that the sails were ready for their trip. [The children climb the rigging if there is a nearby playground. Otherwise, they go through an obstacle course, keeping the mouth closed and maintaining nose breathing, as much as is practical.]

Similar education points to yesterday. However, today, the children also practise breath management while talking and while they are more active. They practise anti-coughing and anti-sneezing exercises. They also rehearse how to recover from coughing or sneezing without provoking further coughs or sneezes.

Images courtesy of Flickr. 1. Pirate, 2. Pirates, 3. Pirate Contemplation, 4. Yarr there be Pirates!

Monday, December 18, 2006

Working with Pirates with Asthma or Sleep-Disordered Breathing

Pirate Mosaic
We use a lot of stories when we work with children with asthma and/or sleep-disordered breathing. We vary the stories according to the children's interests (e.g., young boys tend to like pirates) and we incorporate the particular exercises that suit the children and that are compatible with their medical history.

Recently, I was asked about the sort of story and activities that we incorporate. It will depend on the room and the facilities: e.g., whether there is a dress-up chest, access to particular toys or even a near-by playground with equipment like a Crow's Nest or pirate rigging.

The following is the basis of a story that I adapt frequently. I will post it in several parts and at various points in the story, I'll indicate some of the exercises that we might do in a workshop.

How the Jammy Boys Came to Be Pirates Part 1

It was very strange how the Jammy Boys came to be pirates. They weren’t always pirates. They weren’t always the Jammy Boys. They used to be just Alan, Joshua, Matthew and Peter when they lived with their parents and were best friends together back home on Flambago Island.

But a huge storm had destroyed all of the housing, schools and businesses on the island, including the businesses where their parents worked. During the storm the wind was so strong that the boys had needed to shelter with their parents behind some stone walls. The wind had taken their breath away and they had needed to sit upright and breathe very quietly and gently while they waited for the wind to drop. [If necessary, clear the nose first with various exercises and techniques. Practise sitting up and breathing very quietly, like a mouse breathing so gently the wind can't steal the breath.]

When the storm was over, the boys could not believe the destruction and devastation that they saw all around them. None of the trees or plants were still rooted in the ground. None of the buildings were still standing and everybody would have to live in tents until the houses were rebuilt. There was no power or water. There were no schools left. [If there is equipment, children pick their way around as if through debris. They keep the mouth closed and breathe through the nose while picking up and shifting objects.]

So their parents gathered the boys together and said, “ Alan, Joshua, Matthew and Peter we love you very much. The island is dangerous and not suitable for you now. You must sail home to Britain on The Homeward Bound to be with your grandparents. You can go to school while everything on the island is rebuilt. We will bring you back as soon as everything is ready for you”. [Pretend to be rowing a boat, keep the mouth closed and breathe through the nose. The limber children can turn out a knee at 90 degrees and use that to row, changing legs as necessary. Other children can sit up and pretend to row.]

What the boys’ parents could never have guessed was that the boys’ ship would be stormed by pirates while it was travelling towards Britain. The Homeward Bound was five days out of port when the ship was boarded by pirates during the night. It had all been very dark and confusing. The boys had been fast asleep when they were snatched from their beds by men who were dressed in loose midnight blue breeches tied at the knees, and dark jackets over pale-yellow shirts. [Pretend to be asleep. Check which nostril is clear and lie down with that nostril on top. Sleep on the side, with the upper-body supported for those who need it.] They were brought up to the deck where they were surprised to see so few of the crew of the ship. They couldn’t understand it until they noticed that the doors and hatches to the crew’s quarters were jammed shut. And all of the men who had been on watch were tied up and looked as if they had been sandbagged.

The Captain was being held prisoner by a man whom they recognised. It was a man that none of them liked. He had a series of small metal rings set into the skin on his face. There were two above each eyebrow, and four set across the top of his forehead in his hairline. There were three rings around each ear, set into the hairline. And there were four rings set into the hairline at the top of his neck. Whenever they saw him, he made them feel cold inside because he smelled of damp places and darkness. He had been on board The Homeward Bound pretending to be a member of their crew. But it looked like he had been the one who had trapped all the crew below decks and had put the watchmen out of action. The Captain said, “What are you doing with the boys, Blackheart? Leave them alone. They can’t do you any harm”. Blackheart replied, “I’m taking them with me, along with your cargo of gold, silks, and spices. The Royal Navy won’t be so keen to fire on my ship if they know that these boys are on board”.

Alan, Joshua, Matthew and Peter could not understand it. They all called out, “Captain, why did you let Blackheart on the ship if he knew who he was?”. The Captain shook his head, “I’m sorry, boys. I only realised who he was when they took me prisoner and I saw his ship, The Shape-Shifter. Nobody knows what Blackheart really looks like because he can change his features at will. He can run a chain through those metal rings and change the way he looks”. The boys shivered. [The children practise gently rubbing their cheeks and round their nose and foreheads. They can pull and distort their faces, gently.]

“That’s enough talking”, snarled Blackheart. And with that, the boys were picked up and carried off The Homeward Bound and onto The Shape-Shifter. The last thing that they saw was the sails and masts of The Homeward Bound being destroyed to delay the report of the boarding. The boys were thrown into the cold, dark hold and were left there without blankets, food or water. They looked at each other in horror. [Take the children through the progressive relaxation exercise (as appropriate) and check that they can reliably breathe with the diaphragm.]

There are various educational points throughout this story. The children learn the difference between noisy, active, stormy breathing that can leave you feeling robbed of breath, and quiet breathing, which is mouse-sized. The children practise sitting on a seat with their feet on the floor and the legs untangled.

The children rehearase moving around, moving objects and being active while keeping the mouth closed and breathing through the nose. Before lying down, as if going to sleep, the children learn to put a finger under the nose to assess which nostril is more used when breathing in: they lie down with that nostril uppermost. Under some conditions, we might introduce wedges that support the children in a semi-recumbent position when asleep.

The children learn to assess themselves for squidgy sinuses. They can also gently massage their own faces. They may learn a short progressive relaxation exercise to use if they notice signs like sweaty palms or to help them when settling for sleep. They learn to assess whether they are using diaphragmatic breathing.

1. ARR!, 2. Yo ho ho, 3. Rogue Orange, 4. My New Pirate Hat

Created with fd's Flickr Toys.

Sunday, December 17, 2006

BritMeds 2006 (4) Is Up!

BritMeds 2006 logo with a Union Jack backdropNHS Blog Doc, Dr. Crippen has been trawling British Blogs for posts on a medical topic for BritMeds. I'm searching for a word that is somewhere between gothic and grotesque to describe the weird and wonderful posts that have made it into the list.

There are several fascinating and infuriating posts about the treatment received by people with chronic illnesses or those who are unfortunate enough to have medically unexplained symptoms before receiving a diagnosis.

There are humorous posts and thoughtful blogs that affirm that the NHS is going to hell in a handcart. Amidst that is the feeling that people have a tremendous affection for the NHS and all that it represents.

The BritMeds - more drama that the BBC at Sunday tea-time.

Friday, December 15, 2006

Risk v. Danger: Does Familiarity Cause Us To Forget That Asthma Can Be Life Threatening?

Mosaic of images reads A is for Avoidance

I am officially a Grinch, I'm entirely comfortable with it as long as I don't cross the line and become a misanthrope. One area in which I am in danger of misanthropic tendencies is adults who smoke in the home or car when there are asthmatic children present. I described two children that I had worked with who had made great progress until a smoker moved into their home. In the comments, HCW acknowledged my concerns, but questioned whether the
smoking boyfriend is fully aware that asthma can be life-threatening? It amazes me that I still meet people who believe that 'nobody dies of asthma any more'.
Ironically, there has been a lot of coverage this week of the news that, despite the increased prevalence of asthma, there has been a drop in the number of asthma deaths among children. This is excellent news but HCW is right: this may be a case where familiarity is breeding contempt. The numbers may be falling but asthma can kill if it is not managed appropriately.

Now, in the case that I discussed, it was difficult to ascertain just how much the mother had told the boyfriend. I did ask her to talk to him very seriously about the health consequences for the children if he continued to smoke around them. We discussed whether or not she felt confident enough to suggest that the boyfriend might attend a smoking cessation clinic.

I have a vague memory of a piece on the issue of Of Not Wanting To Know What Hurts You in the NYT. Any mistakes or mis-representations in the argument are my own and nothing to do with the author. The basic argument was that people worry more about comparatively esoteric risks (like MRSA) than familiar dangers such as asthma: we feel more outrage about MRSA than common disease such as asthma.

According to Peter Sandman (a risk communications wonk) the chance of being affected by a disease is not the major factor that influences whether we experience outrage. It is factors like control and familiarity (or the lack of both) and whether the disease provokes dread or disgust that are much stronger influences.

MRSA can kill gruesomely and quickly and it tends to occur in hospitals where you have (usually voluntarily) handed over some responsibility for your health to the medical, nursing and other staff.

On the other hand, asthma is all around us, in the home, school, workplace. It is also a chronic illness like diabetes, that has some well known management techniques and offers people some sense of being in control.

Dr. Sandman says that for Diabetes II most people understand the importance of diet and exercise. The question is not whether people can be bothered to control it but whether or not they feel that they can. Car accidents can be as horrific as some illnesses in their consequences but we travel by car so frequently that we don't experience dread about motor transport.

Prof. Howard Levethal lectures in Health Psychology. According to the NYT, he says that when we contemplate unfamiliar diseases, we cast about for measures to help us evaluate the risk. Unfortunately, we may ground our evaluation in alarmist media reports, our own experience and hearsay. For example, we may have recourse to prevalence to judge the risk. Rare events are more frightening than common events.

It seems that we use simple population polling to assess risk. If we know that lots of people have a disease but few of them have publicly distressing symptoms, and they don't need to be hospitalised and few of them die, then it must be relatively benign. If, however, a condition is rare, and the first few times that we hear about it, it publicises distressing symptoms, medical emergencies and death, then we fear that condition, no matter whether it is very unlikely that we would develop it (e.g., anthrax, bird flu and MRSA).

I feel that people fall into this familiarity lessens dread trap, even with their children, and this can influence the way that they perceive asthma. According to an Asthma UK survey, only 4% of their survey participants have asthma under control. This seems to be a classic example of Sandman's argument, that the fact that we know it can be controlled is different to the issue of whether people choose to control it (I'm overlooking, for now, the people who have unstable brittle asthma).

Asthma may be very common, it might not evoke dread or disgust but it can kill and it can make children very ill. We should celebrate the fall in the death rate attributed to asthma, but it is a serious illness that needs to be treated with respect, not be the cause for untimely regret.

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