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Virtually every child, no matter how easy his temperament, will go through a phase of temper tantrums. This is a manifestation of the struggle for autonomy that is an important developmental phase for the toddler. Temper tantrums are seen generally between 6 months and 6 years of age, and have their peak around 18-36 months (the ‘Terrible Twos’). Usually they decrease over time, unless reinforced by parents, in which case they will become a child’s learned response to frustration or to not getting his own way.

Cause

There is no discernible cause for temper tantrums. They are seen as an inevitable consequence of a youngster’s struggle to assert autonomy and independence from his parents. The immediate precipitating cause for a tantrum is almost always frustration, either to the parent saying ‘no’ to a request so that the child is not allowed to have his way, or else the frustration that comes from the child not being able to perform some developmental task. Usually the tantrum is manipulative and directed towards the parents.

Clinical features

All parents will be only too aware of the characteristics of a temper tantrum. While the precipitating factors, intensity, duration and action during a tantrum will vary from child to child, there are certain features which are universal. In response to frustration — usually the parent saying ‘no’ — the child may scream, throw himself on the floor, vigorously flail arms and legs, often kicking toys, furniture, the floor, or the parents. Sometimes toys and other objects are thrown across the room. The episode is usually terminated by the parent, who distracts the child or gives in to the original demand, or else picks the child up.

Left to his own devices, however, the child usually loses interest in the tantrum as soon as he is deprived of an audience. Parents will observe that the child stops the tantrum momentarily at regular intervals to make sure that the parent is still in the room. In other words, the parent is clearly the target of the demonstration, and this provides the most important clue for management of temper tantrums.

Toddlers seem expert at picking the times when parents are the most vulnerable to the effects of a full-blown temper tantrum, such as when they are out shopping (‘the supermarket syndrome’), or else visiting friends. This of course makes it even more likely that the tantrum will have the desired effect, and in turn will strengthen the child’s resolve to turn it on again the next time — ’same time, same place’.

Sometimes the child seems to lose control during a tantrum, so he becomes really worked up and genuinely distressed. What started off as a manipulative ploy then becomes a rather frightening event for the child.

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Our levels of acceptance fluctuates during the working-through process. When we have a setback we get caught up in our old ways of thinking and feeling. Some people may again start to doubt they have the disorder, and begin to worry that the diagnosis may be incorrect.

Non-acceptance means we are only making the situation worse for ourselves. We all have periods of doubt about the diagnosis. If this does happen it is important to go back and talk with our doctor.

Compounding this doubt are the anxiety symptoms and how they change. Once we get on top of one symptom, another one takes its place. Any new symptom needs to be checked by our doctor, and sometimes we may feel like a hypochondriac. However, it is more important for us to know what the new symptoms are, instead of continually worrying. If we are told the new symptom is another anxiety symptom, we need to accept the diagnosis and not get caught in the vicious circle again.

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A general guideline is to allow an infant about five or six months old to establish her own sleep habits. By then, most children have the neurological maturity to sleep more soundly. When your child is between fur and six months old, begin to encourage the sleep association you value.

The following is a discussion of the sleep associations that most commonly cause problems.

Feeding. The child who is nursed or fed to sleep learns to need the calming that comes from eating, sucking, and being held. If she rouses during the night, she will call for more of the same. She may also wake seeming “rested” with a burp after 20 minutes, but she will not be establishing dependable routines.

As she loses that newborn drowsiness, begin to keep her awake during feedings (easier said than done for some babies) or purposely rouse her while laying her down so that she knows she is falling asleep in her own bed, not in your arms.

Sucking. Pacifiers help some children settle themselves to sleep. Be aware that their use after ‘about three or four months means that this habit will eventually need to be unlearned.

Rocking. Rocking is a pleasant, calming experience for both child and parent, but it can be a strong sleep association. One alternative is to rock a child to soothe and lull him, but not put him into a full sleep. Or rock until it ceases to be soothing—perhaps at four or five months with the sociable child, or later, as mobility increases, when she squirms to get down to play.

Children love to “nest”—that is, move around in bed until it feels just right. If we confine them by rocking, walking, or whatever, we deny them this winding down pleasure. If you are a “pillow fluffer” yourself, you will understand.

Loveys. Many children become attached to special blankets, stuffed anim or toys. “Loveys” make it easier to sleep without parents. To avoid the pai of a lost or forgotten lovey, make more than one available (buy matchi blankets) or make it so general that a replacement might not be noticed.

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They will not develop if you change your position often, keep dry, put some sort of padding over these danger points and get someone to massage them briskly, often. All of that is easier said than done. It is not much fun to change your position often if you are in pain and especially if there is only one position that is really comfortable for you. It is hard to change position often if you are partly paralysed or so weak that you can’t do it without help. It is hard to keep dry if you are incontinent. It can be fiddly to try to arrange padding over your danger points. You might feel reluctant to ask busy nurses, friends, or relatives to spend time helping you to change position and rubbing any sore areas to help restore a brisk circulation. However, it is worth taking all of this seriously. Things are likely to be even more difficult for you if you do develop a pressure sore, because then you won’t be able to sit or lie in the position that produced your sore at all!

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Some people have an inherited tendency to high fat levels in the blood and diet alone may not be sufficient to lower the levels. There are drugs which can reduce the amount of fat retained and these may be necessary.

Coronary artery disease may develop in people in the early thirties but heart attacks become more common in the late forties and early fifties.

Women seem relatively immune from heart attack until after the menopause, when the incidence rises dramatically and may exceed that for men.

Gradual narrowing of the coronary arteries may lead to the condition of angina.

When the heart has to work harder with more exertion, the heart muscle requires more blood to supply its own needs. With narrowing of the arteries, not enough blood may be able to get through.

The diagnosis of angina is usually easy to make as the story is so typical, although examination may not reveal any abnormalities and even the electrocardiograph may be normal.

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Diagnosis is established by repeated examinations which reveal that the uterus is not increasing in size, and the pregnancy test carried out on the urine becomes negative.

The treatment is D and C.

It is worth remembering that miscarriage is an all-or-nothing business.

Should the threatened miscarriage settle down and the pregnancy proceed to term, then the baby is normal.

Some women fear that when the threat to pregnancy has been averted, an abnormal baby may be preserved. Therefore, they worry considerably and unnecessarily for the remainder of the pregnancy.

Even when a woman is unhappy with the pregnancy, miscarriage may still produce an emotional reaction. Depression is common and of course is due to a normal grief reaction.

We grieve for something lost.

At this time husbands need to be particularly understanding.

And often associated with the depression is a sense of guilt.

A woman may worry that either she did something she should have avoided, or neglected some precaution she should have taken.

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Sweat glands are a specialized group of cells lying in the dermis which produces sweat. These glands are found over the whole skin surface, with considerable regional variation in density of distribution. They are most numerous on the palms, soles, forehead and armpits. The duct of the sweat gland opens on to the skin surface independently of hair and sebaceous gland openings. On the forehead or armpits there are frequently 200-300 sweat glands per square centimetre, and under extreme climatic provocation an individual may produce two litres of sweat an hour. In this way sweat glands are able to flood the skin surface with water, which has a cooling effect, and hence they are very important as part of a heat exchange mechanism. The closely associated blood vessels dilate or constrict to either dissipate or conserve body heat. This is therefore a very effective thermoregulatory system, one which maintains a constant internal environment, enabling man to escape the rigid climatic limitations imposed upon cold-blooded animals.

Hair follicles are finger-shaped folds of epidermis dipping into the dermis, which are responsible for hair formation. Hair then is a derivative of epidermis, arising from deep within the dermis, and composed of the protein keratin. The most superficial part of the follicle forms a duct, in which the hair stands free. Since the sebaceous duct also opens into the follicular duct, the hair shaft emerges through the same pore which secretes the sebum, ensuring its direct lubrication. In the deepest part of the follicle the follicular wall and the hair are fused. This section constitutes its root, the lowest part of which is known as the bulb.

Hair is an extremely complex structure which broadly speaking consists of a central cortex surrounded by several protective layers. Hair contains neither nerves nor blood vessels and is therefore a ‘dead’ structure. There are many different types of hair, which in one form or another cover the entire surface of the skin, with the exception of the palms and soles. In most areas the hair is short and fine, like that found on a child or on the cheeks of a woman, and is known as vellus hair. The longer, broader, and usually coloured hair, such as that on the scalp, is known as terminal hair. There is no clear distinction between these types. In fact, the same follicle may produce either type under different conditions. For example, vellus may change to terminal hair on the chin of an adolescent, or terminal may change to vellus on the scalp of a balding man. The protein-synthesizing capacity of this tissue is enormous. When one considers that scalp hair grows at the rate of 0-35 millimetre daily, and that the average number of scalp hairs is about 100000, this means that about 30 metres of hair is produced every day.

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Some snack foods with a very low G.I. factor (such as peanuts with a G.I. factor of 14) have a very high fat content and are not recommended for people with a weight problem. As an occasional snack they are fine (especially as their fat is monounsaturated), but not every day. Peanuts are also very moreish and it is hard to stop at just one handful!

Mary, 65 years old, was found to have diabetes two years ago. She was overweight and was told that she had to lose several kilos. Although she had been trying to do this before she developed diabetes, she had been unsuccessful. Now she felt that the extra burden of diabetes would make life impossible for her and that she could not do any more than she was already doing with her diet. Because her blood sugar levels were too high she was presented diabetic tablets.

When we looked at what Mary ate, we could see that indeed she really was trying hard and was not overeating. However, almost all of her carbohydrate foods had a high G.I. factor. For example, she was having Weet-Bix or cornflakes for breakfast morning coffee biscuits for mid-meal snacks, lots of rice with her lunch and evening meals and watermelon was a favourite fruit All these foods have a high G.I. factor. By changing to All-Bran™ or untoasted muesli for breakfast, having oatmeal biscuits or an apple, pear or orange for snacks and by adjusting the type and amount of rice the was eating, Mary was able to eat more, lose weight and improve her blood sugar levels. Eventually she stopped her diabetes tablets too.

Sometimes, despite your best efforts with diet, tablets will still be needed to obtain good blood sugar control. This is eventually the case for most people with type 2 diabetes.

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The advantage of weight is that it is a simple, accurate and reliable measurement. For individuals, significant changes in weight over the long term usually reflect significant changes in body composition.

Over the years, several attempts have been made to establish a series of ‘ideal weight’ measures as a goal for people to aim for. One of the first of these, the ‘Broce Index’, was estimated in kilograms by taking 100 away from height (in cm). In other words, a person 180cm tall might be expected to have an ‘ideal weight’ of 180-100=80kg. Ideal weights for height have also been developed over the years (beginning in the late 19th century in the US) based on actuarial, or death statistics. More recently, ideal measures of body mass index, skinfolds and fat distribution have been used (see below). However, scientists have yet to agree on a measure of ‘ideal’, and now generally accept that a variety of the measures discussed below have to be combined.

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‘Jimmy suddenly ran this very high fever,’ Jane said on the phone. ‘I’m awfully worried. He is hot and clammy and looks pale and listless. What’s more, he wants to pass his urine every few minutes. When he does, he squeals as if it’s hurting him. Jimmy hardly ever complains… He is always a happy little chap,’ Jane went on. ‘I think he must have some sort of infection in his bladder…’

Soon afterwards I visited young Jimmy. Certainly, he rarely complained and was usually a bright happy lad. But today he was pale and obviously unwell. He had been off his food for about 24 hours, and his temperature had suddenly shot up, leaving him feeling very miserable. He was sweating profusely, and just before I arrived he had been vomiting slightly—also unusual for Jimmy. Passing his urine was definitely painful, and this immediately suggested an infection in the bladder or kidney region. When I gently prodded below his navel, in the so-called supra-pubic region, he winced. ‘Hurts,’ was all he would say, then he quietly shed a few tears. Similarly, pressure in the lower part of his back, just over his kidneys, was also quite uncomfortable.

‘We shall have a specime of urine checked out,’ I said to Jane. ‘This will tell us exactly the nature of the germ causing the trouble. It will also indicate the best treatment to give. Antibiotics are usually very satisfactory, but a sensitivity test will give us the exact result and indicate the most suitable treatment.’

Treatment

To begin with, doctors often prescribe one, of the ‘broad spectrum’ antibiotics, even before the results of investigation are received. This may start the patient quickly on the path to recovery. Many excellent varieties are now available and the urinary system is very receptive to them.

Also, keeping the patient in bed for a few days, until he feels and looks better and his temperature has come back to normal, is a good idea.

Plenty of fluids are advisable, for this flushes out the dead germs and general toxins, not only from the system but from the urinary tract in particular. It also replaces the fluids lost from perspiring and sweating.

Powders and granules given in fluid to ‘alkalinize’ the urine are often used, and this is claimed to help. Paracetamol will often reduce fevers and make the patient feel more comfortable and it reduces aches and pains which commonly accompany urinary infections. However, if there is vomiting, the more that is introduced into the stomach the worse the patient feels, so the less the better. Sucking chipped ice or cold drinks are often acceptable, and frequently retained.

Most infections in children affect the bladder region, but they are usually brought under control rapidly. Sometimes, especially if there are recurrences, it may indicate that the kidneys and upper parts of the urinary system (the ureters) may also be infected. It may be necessary to have further and more complete investigations carried out after the child has settled down and the acute bouts are brought under control.

Tests on thousands of children, especially those of school age, shows that many individuals carry around small numbers of germs in their bladders, even though symptoms are not present. Sometimes these can suddenly get out of control and an acute attack supervene. Some doctors believe that all urinary infections, however mild, should be treated.

It is a very important system, and disorders here can lead to more serious ones in later life. It is worth keeping a close check for symptoms and reporting any abnormality promptly to the doctor, for treatment or further investigation.

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