MANAGING YOUR CHILD’S HEALTH: RECOGNISING SERIOUS ILLNESS IN BABIES AND VERY YOUNG CHILDREN

Parents will often be worried that their baby is not well. The most common cause of a baby being ‘off colour’ is a cold or simple viral infection. These are very common in childhood, and in most cases no specific treatment is necessary. Your child may be a little irritable and clingy. A slight fever may be present on and off, and he may be snuffly. It is often difficult for parents to see their child not wanting to eat or drink very much but in the majority of cases all these symptoms will pass after a few days. Young children have viral infections frequently during the winter months, especially when they begin to attend daycare or kindergarten where they are in regular contact with other children.

While most simple viral infections are mild and a full recovery is assured with no treatment, a baby or young child can sometimes have a more serious illness. Sometimes, especially during the early stages of an illness, it is difficult even for doctors to pick up the signs of something more serious. Yet it is important to realise that the earlier the signs of a serious illness are detected, the sooner treatment can be started. This is particularly important for babies and very young children. Younger children can go downhill quite quickly, and early detection of serious illness is vital.

How do parents know when an illness is minor and when it might be more serious? Recent research has pointed to signs which might indicate that the baby or young child should be seen immediately by a doctor. You should watch out for:

• drowsiness

• decreased activity/lethargy

• breathing difficulty

• poor circulation

• poor feeding

• poor urine output.

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YOUR CHILD’S HEALTH CARE/MEDICAL PROCEDURES AND TESTS: SWEAT TEST AND THROAT SWAB

SWEAT TEST

This is a test which is used to confirm the diagnosis of a genetically inherited disorder called cystic fibrosis (see p. 200). The concentration of salts in the sweat is measured. In children with cystic fibrosis, the level is much higher than normal.

THROAT SWAB

If your child has a sore throat, your doctor may suggest doing a throat swab. This is a brushing of the back of the throat with a sterile long cotton bud, which is then placed in a special container and sent to the laboratory. The sample is checked under a microscope and some is brushed onto a special culture medium and incubated for 48 hours, in an attempt to grow the germ causing the infection. Many throat infections are due to viruses but certain germs, such as Streptococcus, can also be the cause. It is definitely advisable to do a throat swab if your child has pus on his tonsils. The procedure also helps to determine which antibiotic will be effective against the specific germ found.

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YOUR MARITAL HEALTH/SEX AND PROBLEMS OF DAILY LIVING: PERSONAL PLAY AND MARITAL PLEASURE: SPOUSEHOOD AND “SPERSONHOOD” – SOME SUGGESTIONS FOR IMPROVING RECREATIONAL TIME TOGETHER

Here are some suggestions for improving recreational time together.

1. Select an entirely new activity that neither one of you has ever done before, even in childhood. There are hundreds of possibilities.

2. Decide what type of recreation suits your “unit.” If one of you is very athletic and the other more artistic, the activity will have to stress other skills, leaving these for individual enjoyment.

3. Start the activity together and develop it together. If one or the other partner tends to “get ahead” in most things, make sure you leam together. This one activity is only for the two of you. You can still have your golf, tennis, running, or whatever other activity you may enjoy as an individual.

One wife reported, “We came up with something. It’s sailing. We both can’t swim, have never been on a boat, and don’t like the water. We couldn’t come up with anything, so we picked the one thing most unlike both of us. It’s working out slowly. He tried to be the captain and make me crew, but I think we worked that out after he fell off the boat while trying to tell me to be careful. There he was, mouth full of water, his captain’s hat floating beside him, and trying to tell me how to save him.”

4 Remember that individual activities are still important. One husband stated, “We have spouse activities that include tennis and walking. Then we have what we call ’sperson’ activities, individual things we do with other people. She golfs, I golf, but we’re at drastically different levels of ability there. I will never be the golfer she is, so we each enjoy it to our own level with other people more at our level.”

The marriage that plays together and plays separately is most likely to find super marital sex, for the joy and energizing aspects of fulfilling play can enter into the sexual relationship. As you consider this possibility, remember that a mutual involvement in a “mini-career” could also be a form of play. Noel Coward said, “Work is much more fun than fun.”

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CHECKING EXTENT OF CANCER BEFORE ATTEMPTING POTENTIALLY CURATIVE SURGERY – REMOVING CANCER

Say you do have a cancer which is in a part of the body that can be safely removed. How can you be as sure as possible, before the operation, that complete removal of the cancer is feasible? Firstly, you should understand that if only the visible cancer growth is removed, without a margin of apparently normal tissue, it is most unlikely that you will be cured. This is because of the ability of cancer cells to grow into the surrounding tissues. They do this in small columns or clumps which are much too tiny to be seen other than through a microscope. Before the operation, then, it is important to know just where the borders of your primary cancer growth appear to be. Your surgeon will then know whether or not it will be possible to remove an adequate margin of the apparently normal tissues surrounding it. Your doctor should check the apparent extent of your primary cancer growth by taking a careful history of your symptoms, examining you clinically and arranging, with your agreement, whatever tests—X-rays, scans, blood tests and so on—are necessary to provide a complete picture.

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HUNTINGTON’S CHOREA

An uncommon hereditary disorder, which can have disastrous effects not only on the sufferer but also on the whole family, is known as Huntington’s chorea.

It is caused by a dominant gene, so the children of a sufferer have a one in two chance of inheriting the disease. Unfortunately, it may not appear until a person is in his forties, so the sufferer has usually married and reproduced before being aware that he has it. It affects men and women equally.

Once the disease declares itself, the sufferer shows involuntary muscular movements, incoordination and mental degeneration.

Although it occurs in most countries of the world, it has its greatest incidence in closed communities where there is a degree of inbreeding.

Tasmania has one of the highest prevalences of Huntington’s disease in the world and this has been traced to the arrival in the last century of an affected Somerset woman who had nine affected children.

Unfortunately, there is no treatment.

Considerable research is under way to improve the outlook for sufferers. Proper genetic counselling for those who have a family history of this disorder can help a couple to decide about having a family.

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TOXAEMIA OF PREGNANCY – HYPOTENSIVE DRUGS

A doctor will insist that the mother lies down during the day. If she is still working then he will insist on her giving up her job.

If the blood pressure continues to rise bed rest at home or admission to hospital may be necessary.

Hypotensive drugs that lower the blood pressure may also be necessary. Once pre-eclampsia has developed it does not go away, until the baby is delivered.

It can be controlled and its effects minimised until the baby is spontaneously delivered or the pregnancy is terminated by induction of labor before the due date.

If untreated pre-eclampsia may go on to the condition of eclampsia, where the blood pressure is out of control. The mother develops fits and the baby usually dies. Eclampsia is rare only because pre-eclampsia is so well managed.

An instrument called an echograph can measure the size of the baby and see its progress. This uses ultrasonic waves in the same way as sonar is used to track submarines. The placenta produces a hormone, oestriol, and this is excreted in the mother’s urine.

Measurement of the levels of oestriol give a good indication of placental function and how well nourished is the baby.

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PSYCHE AND THE SKIN

Itchiness. A severe or even mild itch, whether localized or generalized, is, in the absence of any prior external or internal disease, most likely to be psychogenic. Often this itch may occur in an area highly endowed with nerve endings, such as around the genitals or the anal area. Various possible psychological reasons and explanations have been given for this particular symptom. These include displaced sexual gratification; a need for self-inflicted injury to satisfy masochistic impulses; the relief of tension by the neuromuscular exercise of scratching, and the expression of shame, guilt, or exhibitionistic traits.

Eczema. There are three forms of eczema, all occurring in adults, which are thought to have a strong emotional basis. These are: the so-called discoid eczema, which occurs in coin-shaped spots, mainly on the limbs, and which is extremely itchy; dyshidrotic eczema, which occurs about the fingers and toes, as small, itchy bubbles under the skin; and lichen simplex, which is a well-localized thickened area of skin which is extremely itchy. Lichen simplex may occur on any area of the body, but always in an easily accessible place. Sufferers of these forms of eczema obviously require treatment to the skin and, in addition, an understanding doctor to help them sort out, or at least talk over, the underlying problems or anxieties.

Trichotillomania. This is not such a rare condition, but it is one which frequently goes unrecognized in its minor form. Principally, it occurs in children who seek neurotic satisfaction through pulling out their own hair. Usually they select the hair of the scalp, and less often the eyebrows. The principal element in the psychodynamic of children is the turning on oneself of unexpressed rage at rejecting parents. This is the transformation of a sadistic instinct into a masochistic one. Hair pulling may be missed if it is not considered in relation to patients thought to have ringworm, alopecia areata, etc.

Adults who inflict this condition on themselves are often deeply disturbed individuals, usually with sexual conflicts which, basically, resolve around the notion that sex is dirty, filthy, and repugnant; they contrive to ’shed’ these feelings by pulling out their hair and making themselves less likely objects of sexual attention.

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THE LOW G.I. FOOD GLOSSARY

This glossary describes of some of the key foods that can form part of a low G.I. diet.

BurgenTM Soy Lin, Soy and Unseed loaf (G.I. of 19) • A mixed grain bread from Tip Top Bakeries. Sydney. Available in supermarkets. It has the lowest G.I. of all mixed grain breads. Other varieties of Burgen™ bread also have a low G.I.

Cherries (G.I. of 22) • The G.I. for cherries is based on European cherries. Australian cherries which are 6.1 per cent glucose and 4.2 per cent fructose may have a higher G.L value.

Custard (G.I. of 43) • Made with milk, so provides calcium, protein and B vitamins plus a little sugar, vanilla flavouring and a starch thickener.

Doongara rice (G.I. of 59) • An Australian grown rice with a high amylose content and low G.I. Available in supermarkets and in bulk quantities from wholesalers and some Asian food stores. Fruit loaf (G.I. of 47) • Available in wholemeal and white varieties, but choose the heavy types. The G.I. of fruit loaf is probably lowered by part substitution of flour (high G.I.) with fruit (lower G.I.).

Grapefruit (G.I. of 25) • The low G.I. factor of grapefruit may be due to their high acid content which slows absorption from the stomach.

Grapes (G.I. of 46) • An equal mix of fructose and glucose and a high acid content are characteristics of fruits with a low G.I. Grapes are a good example.

Icecream (G.I. of 61) • Most dairy products have very low G.I. factors. When we eat dairy foods a protein curd forms in the stomach and slows down its emptying. This has the effect of slowing down absorption and lowering the G.I. factor.

Kiwifruit (G.I. of 52) • Kiwifruit contain equal proportions of glucose and fructose and high acidity giving a reasonably low G.I. They are also a wonderful source of vitamin C with one kiwifruit meeting the total recommended daily intake.

Legumes (G.I. range: 14 to 56) • Abo known as pulses. These include dried peas, beans and lentils, mostly have a G.L factor of 50 or less.

Canned varieties have a slightly higher G.I. than their home-cooked counterpart due to the higher temperature during processing. Soya beans (G.I. of 18) have one of the lowest G.I. values, possibly due to their higher protein and fat content. The viscous fibre in legumes reduces physical availability of starch to digestive enzymes.

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SCIENTIFIC THINKING ABOUT WEIGHT CONTROL

Fat balance: The physiological model

The next development examined the separate nutrient balance equations, i.e. fat, alcohol, carbohydrate and protein equations. In human physiology it became clear that fat imbalance was the main cause of energy imbalance. Hence the formula to describe this became the following:

Rate of change of fat stores = rate of fat intake — rate of fat oxidation.

This developed from important physiological studies in the 1980s which found that in humans, fat stores come largely from dietary fat, and that under most conditions, fat balance equals energy balance. It is only under unusual conditions that humans convert significant amounts of non-fat calories into fat for storage. This model then suggests fat imbalance as the primary cause of an imbalance between energy intake and utilisation. Hence, the approach is a major step forward because it moves away from regarding obesity as a pathological state in a ‘normal’ environment. Because the problem of obesity is so widespread in modem societies, it suggests that the opposite is almost certainly true, i.e. that the spectrum of body sizes from lean to obese represents the normal variations of physiology and, within a ‘pathological’ environment (which favours obesity), many more are at the obese end of the spectrum. However, there are still problems with this approach. The fat balance equation above describes the changes in fat stores that occur within a given individual over time. It is less clear how differences in body fat between individuals arise. Why is it that some people remain relatively lean when they seem to have the same sort of lifestyle as others who are overfat? It also fails to explain the differences in obesity prevalence between populations. To explain this requires an expanded approach.

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SURGICAL TREATMENT OF ENDOMETRIOSIS: HYSTERECTOMY

A hysterectomy for endometriosis is surgery which involves the removal of the uterus and as many remaining endometrial implants and adhesions as possible. It may also involve the removal of one or both ovaries and fallopian tubes.

A hysterectomy is often said to be the only cure for endometriosis apart from the natural menopause. However, it does not always cure endometriosis, especially if the ovaries are not removed.

A hysterectomy in which the uterus and cervix are removed is known as a total abdominal hysterectomy (often abbreviated to a TAH). Sometimes all or part of an ovary and/or fallopian tube will be removed at the same time if they are diseased but at least part of one ovary is always left.

Following a total abdominal hysterectomy a woman will no longer menstruate but she will continue to ovulate until the time of her natural menopause.

A hysterectomy which involves the removal of the uterus and cervix as well as both fallopian tubes and ovaries is known as a total abdominal hysterectomy and bilateral salpingectomy and oophorectomy (often abbreviated to a TAH and BSO). It is also sometimes known as a radical hysterectomy.

Following a radical hysterectomy a woman will no longer menstruate or ovulate and she will undergo the menopause almost immediately.

To simplify matters and avoid confusion we will refer to a total abdominal hysterectomy as a total hysterectomy; and a total abdominal hysterectomy and bilateral salpingectomy and oophorectomy as a radical hysterectomy. We will use the term hysterectomy if we are referring collectively to both types.

Who is suitable for a hysterectomy

Hysterectomy is usually only used as a last resort to treat women whose endometriosis is so chronic and their symptoms so severe that their quality of life is intolerable. The most common reasons that women with endometriosis have a hysterectomy are the persistence of intractable and incapacitating pain or severe and persistent heavy bleeding. It should not be used, except in a few rare life threatening situations, until a range of other hormonal and surgical treatments have been tried without success.

Things to think about before a hysterectomy

The decision whether or not to have a hysterectomy involves two or three separate decisions. Firstly, you need to decide whether or not to have a hysterectomy. Secondly, you need to decide whether or not to have your ovaries removed. Thirdly, if your ovaries are removed, you need to decide whether or not to have hormone replacement therapy.

Hysterectomy or not

When a woman is faced with the decision of whether or not to have a hysterectomy she has almost invariably had a harrowing and traumatic fight with unrelenting endometriosis for many years. Her symptoms are usually so severe and persistent that they have taken over her life completely and there is no other way out. The decision to have a hysterectomy simply becomes a quality of life issue.

Nevertheless, most women have to hit rock bottom and cross that ‘invisible barrier’ of knowing emotionally that they have reached the end of their tether before they can make the decision to have a hysterectomy.

The decision to have a hysterectomy should be yours and yours alone. Do not allow anyone else — your gynaecologist, your partner, your mother or your best friend — to make the decision for you. You have to live with the decision, not them.

The decision must also be made at your pace. Do not let yourself be pressured into making a hasty decision just because your gynaecologist or someone else wants an answer by a certain date. Only you will know when you have finally reached the end of your tether so take as much time as you need. If you have to ask yourself whether or not you are ready for a hysterectomy then you aren’t.

Even though you must make the final decision it will usually be beneficial if you discuss your options with your gynaecologist, partner, family and friends, as well as other women who have been through the same operation. It is often worthwhile talking to a counsellor to help explore and resolve the issues.

Before you make a final decision get as much information as you need about the operation and its likely consequences. Do not hesitate to ask your gynaecologist any questions that you may have. If you have any doubts about the need for the operation get a second, or even a third, opinion.

Women who make the decision themselves and at their own pace usually recover more quickly and have less physical and emotional problems following their surgery.

Deciding to have a hysterectomy is a major and irreversible decision that will affect all aspects of your life. In making the decision you need to consider both the physical and emotional aspects.

You need to think about the degree to which your quality of life is compromised by your endometriosis and weigh that up against the likely advantages and disadvantages that the surgery will bring.

A hysterectomy will probably mean much less pain and disability. It will also mean that you cannot have children in the future so you will have to decide whether retaining your possible ability to have children is more important to you than relief from your symptoms and getting on with life. Your sexual response will probably change too — for better or worse — but you will not know how until after you have had the surgery.

You need to think about what effect not having all of your reproductive organs will have on your self-image. You may also need to consider the reactions of others after you have had a hysterectomy and what effect that will have on your relationships with them.

Ovaries removed or retained

The decision whether or not to have your ovaries removed is an extremely complex and difficult one because at the present time there are no clear answers regarding the pros and cons of removing or retaining the ovaries.

Some gynaecologists routinely remove the ovaries in women with endometriosis, others base their decision on the extent and severity of the woman’s disease and her age, while still others routinely retain them except under special circumstances.

It is extremely important that you find out what your gynaecologist intends to do and that you make your decision perfectly clear as to whether you want your ovaries removed or retained.

If you retain your ovaries you will not undergo a premature menopause but there will be a greater likelihood that your endometriosis will persist or recur. Unfortunately, it is not known how often endometriosis persists or recurs following a total hysterectomy: the few statistics in the medical journals range from around 10% to 85%.

Many gynaecologists believe that the ovaries should be retained in the majority of cases as they believe that the risk of recurrence is low and the risks of a premature menopause are considerable.

If your ovaries are removed you will undergo a premature menopause and have less likelihood of having a recurrence of endometriosis because it does not recur if you do not produce oestrogen. It is estimated that as few as 3% to 5% of women will have a recurrence if their ovaries are removed. The unusual cases where endometriosis recurs following a radical hysterectomy are usually due to the fact that a piece of an ovary was left behind because the gynaecologist either could not see it or could not remove it safely.

Surgical menopause — menopause due to the surgical removal of the ovaries — is usually more severe than the natural menopause because it occurs instantaneously in a younger woman whose hormone levels are higher. The drop in the hormone levels is both dramatic and sudden and many women will experience significant symptoms as a result.

Most women will experience the early symptoms of the menopause soon after their surgery — often within 24 to 48 hours. The most common early symptoms are hot flushes and night sweats. Some women will also experience tiredness and lethargy and sometimes depression, particularly if their hot flushes and night sweats stop them sleeping.

After a couple of months most women will start to experience some of the other effects of menopause. These include a dry vagina, which may cause painful intercourse, a change in sexual response, decreased libido and decreased breast size.

The main long-term effects associated with surgical menopause are a substantially increased likelihood of developing heart disease and osteoporosis later in life.

Hormone replacement therapy or not

The decision whether or not to have hormone replacement therapy if your ovaries are removed is difficult and complex because there is considerable controversy about the role of hormone replacement therapy following a radical hysterectomy for endometriosis.

Hormone replacement therapy is the administration of synthetic hormones to replace those which were previously produced by the ovaries in order to prevent or minimise the effects of menopause. It usually involves the use of both synthetic oestrogen and progesterone but sometimes only synthetic oestrogen is used.

The two main forms of administration are tablets and implants and there are a variety of strengths which can be used depending on the severity of your menopausal symptoms.

The most common side effects of hormone replacement therapy are nausea and sore breasts, although in the long-term it is possibly associated with a slightly increased risk of developing breast cancer. Hormone replacement therapy will prevent or reduce the effects of surgical menopause but it may also slightly increase the likelihood that you will have a persistence or recurrence of your endometriosis.

Hormone replacement therapy will prevent or reduce most of the symptoms of menopause, including hot flushes, night sweats and a dry vagina. More importantly it will significantly reduce the likelihood that you will develop heart disease or osteoporosis later in life.

There is a risk that the oestrogen component of hormone replacement therapy will lead to a persistence or recurrence of the implants remaining in your body. Many gynaecologists believe that because the concentrations of hormones used are much lower than those produced by the ovary the risk of recurrence is small — probably only about 3% to 5%.

Nevertheless, some gynaecologists recommend waiting a minimum of three to six months after a radical hysterectomy before starting hormone replacement therapy. This delay should allow any remaining endometrial implants to degenerate and waste away, reducing the chances that it will cause a persistence or recurrence of your endometriosis.

Some gynaecologists suggest that using only a synthetic progesterone such as Provera, rather than both oestrogen and progesterone, as an interim measure for the first few months after surgery will reduce the likelihood of recurrence while still providing some relief from the early symptoms of surgical menopause.

If you are unlucky enough to have/ a recurrence of your symptoms of endometriosis while on hormone replacement therapy it may be possible to treat the recurrence by stopping or adjusting the dosage. It may also be possible to treat it by having a course of one of the standard hormonal treatments such as Provera or Danazol.

If you do not take hormone replacement therapy you will have a reduced likelihood of having a persistence or recurrence of your endometriosis but you will probably experience the effects of surgical menopause and you will have an increased likelihood of developing heart disease and osteoporosis later in life.

A few women continue to produce enough oestrogen in their bodies to prevent or minimise the effects of surgical menopause. Many women will experience marked symptoms and, although they are often disruptive and unpleasant, some women find that they are easier to cope with than their endometriosis symptoms.

Some women have found that they have been able to prevent or minimise the symptoms of surgical menopause by having a good diet, particularly one high in foods which contain natural oestrogens such as grains, as well as vitamin and mineral supplements, regular vigorous exercise and regular sexual activity.

Risks and complications of hysterectomy

The risks and complications of a hysterectomy are the same as those outlined for a laparotomy.

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