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ADHD visits
By Daniel Morra, MD

I consider the evaluation of children for attention deficit / hyperactivity disorder (ADHD) to be a major part of my practice. Should you or your child's teacher have questions and would like your child evaluated for ADHD, please let me know as soon as possible. There are several steps that are necessary as part of the evaluation.

1) Obtain a behavioral rating scale form to be filled out by the parent(s) or primary caregivers. Similar forms will be sent to the child's teacher. I will "score" the forms and review the results with you at your first visit.

2) If a school teacher or principal asked for the evaluation, please try to get a letter from them requesting the evaluation.

3) Make an appointment with my office. Usually a primary evaluation for ADHD will take a minimum of 30 minutes. You will have a 30-minute slot designated for your child and I will do my best to get as much as we can out of that 30 minutes.

4) I may recommend other evaluations to help me obtain a better picture of your child's condition. Children may need to be sent to an audiologist, psychologist, neurologist, or other health care professional following a visit with me.

5) You will likely NOT receive medication from me on the first visit unless I think it would be more beneficial for your child to do so.

6) Once medication is prescribed, follow-up visits are usually scheduled weekly until we find an appropriate dosage. Regular visits should be scheduled every 3-4 months to determine whether the medication is still effective, if a higher or lower dose is needed, or if side effects preclude the use of medication altogether. Some children respond to ADHD medications (and their response can be dramatic). Some children, however, do not respond as well and may need to try more than one medication. In the same child, one medication may help, while another does nothing.

7) Counseling, behavioral therapy and/or educational training will be necessary in addition to (or instead of) the introduction to a medication. Counselors will be recommended to work on issues that affect the child with ADHD or similar behavioral disorders.

Please call my office to make an appointment if you would like to discuss this with me further.

ADHD Interventions - Environment
By Daniel R. Morra, MD

Environment

· Reduce clutter in the environment.

· Seat the child in the front of the room unless that is a high traffic area.

· Do not have the child's seat near colourful displays, windows, or commonly used equipment.

· Seat student away from high-traffic and noisy areas.

· Seat the child at an individual desk rather than a table.

· Eliminate unnecessary distractions.

· Seat the child near the teacher.

· Closed classroom architecture (4 walls and a door) helps minimise distractions.

· Decrease auditory and visual distractions during difficult or new tasks.

· Make the learning environment stimulating--add shape, colour, or texture to an activity.

· Make a study carrel available (can be made out of cardboard).

· Put brightly coloured poster board under the student's work to help him/her focus.

· Using a colour transparency over the page makes the work sharper and clearer and draws the student's attention.

· Allow student to get into a comfortable position while he/she is learning.

References:

Children with ADD: A shared responsibility. (1992). Reston, Virginia: The Council for Exceptional Children.
Classroom modifications (antecedent interventions). (1994). In M.C. Edwards and E.G. Schulz (Eds.), ADD teacher inservice program (pp. 1-5). Little Rock, AR: Arkansas Children's Hospital.
Garber,S.W., Garber, M.D., & Spizman, R.F. (1990a). If your child is hyperactive, inattentive, impulsive, and distractible . . . Helping the ADD (attention deficit disorder) hyperactive child. New York: Villard Books.
Kelly, K., & Ramundo, P. (1993). You mean I'm not lazy, stupid, or crazy?! Cincinnati, Ohio: Tyrell & Jerem Press.
Lerner, J.W., Lowenthal, B., & Lerner, S.R. (1995). Attention deficit disorders; Assessment and teaching. Pacific Grove, CA: Brooks/Cole Publishing Company.
U.S.Department of Education. (1994). Teaching strategies; Education of children with attention deficit disorder. Washington, D.C.: Author.

ADHD Interventions - Technology
By Daniel R. Morra, MD

Technology

· Set the timer to sound a warning and then a final signal when a project should be finished.

· Background noise like music may help block out other noises.

· Allow students to wear headphones.

References:

Kelly, K., & Ramundo, P. (1993). You mean I'm not lazy, stupid, or crazy?! Cincinnati, Ohio: Tyrell & Jerem Press.
U.S. Department of Education. (1994). Teaching strategies; Education of children with attention deficit disorder. Washington, D.C.: Author.

ADHD Interventions - Curriculum Modifications
By Daniel R. Morra, MD

Curriculum Modifications

· Give the child only the amount of work that can be done at a sitting.

· Give work for only one subject at a time.

· Divide long tasks into shorter ones.

· Reduce the number of practice items a student must complete.

· Provide breaks within long tasks.

· Shorten assignments and tests and reduce the amount of work involved.

· Modify tests; allow students to take tests orally.

· Reduce the difficulty of assignments.

· Make tasks interesting.

· Have a variety of tasks.

· Make sure that the tasks fit the learning abilities and style of the child.

· More short spaced practice sessions rather than longer and more in-depth ones.

· Fewer and shorter homework assignments.

· Eliminate unnecessary repetition of a task.

· Allow the child to pace the activities.

· Provide student with additional time to finish an assignment or test.

· Help with test directions by using colour, circles or underlining.

· Make sure that the child has a special place to keep books and school materials.

References:

Children with ADD: A shared responsibility. (1992). Reston, Virginia: The Council for Exceptional Children.
Classroom modifications (antecedent interventions). (1994). In M.C. Edwards and E.G. Schulz (Eds.), ADD teacher inservice program (pp. 1-5). Little Rock, AR: Arkansas Children's Hospital.
Garber, S.W., Garber, M.D., & Spizman, R.F. (1990a). If your child is hyperactive, inattentive, impulsive, distractible . . . Helping the ADD (attention deficit disorder) hyperactive child. New York: Villard Books.
Lerner, J.W., Lowenthal, B., & Lerner, S.R. (1995). Attention deficit disorders; Assessment and teaching. Pacific Grove, CA: Brooks/Cole Publishing Company.
U.S. Department of Education. (1994). Teaching strategies; Education of children with attention deficit disorder. Washington, D.C.: Author.
What's wrong with my child? (1992, April). Ladies' Home Journal, 109, 98, 100, 102, 104.

ADHD Interventions - Instructional Strategies
By Daniel R. Morra, MD

Instructional Strategies

· Teach children how to cross out answers on a multiple-choice test.

· Use a signal for silence.

· Have the student respond at the end of each task and provide reinforcement.

· Be flexible with assignments, scheduling, and grading.

· Give opportunities for choice.

· Praise the child's attempts.

· Recognise the child's strengths.

· Involve the child as a responder and thinker not as a passive learner.

· Try to keep class size and group size as small as possible.

· Provide lots of personal attention.

· Use signals like snapping your fingers or colour coded cards to control the class.

· Alternate high interest subjects with those the student finds less stimulating.

· Let the child know that he/she is loved under any circumstances.

· Schedule tasks that require attention in the morning.

· Increase the proportion of time spent on the lesson itself rather than on discipline, organisation, etc.

· Move quickly through easy tasks.

· Increase the quality rather than the quantity of time spent on a lesson.

· Use peer tutoring.

· Alternate instruction time with individual work time.

· Interact with students during seatwork time.

· Keep the classroom structured.

· Model cognitive strategies like the think aloud strategy.

· Use co-operative groupings.

· Keep lesson objectives clear.

· Encourage collaboration among students.

· Allow at least 5 seconds of thinking time before prompting for answers.

· Have students recite in unison.

· Vary your tone of voice and model enthusiasm.

· List the main ideas or concepts before the lecture.

· Give clear directions, oral and visual.

· Provide a model of what to do.

· Summarise key words given in answers.

· Repeat key concepts.

· Write key concepts on the board and state them.

· Direct questions to students who begin to drift off task.

· Move quickly.

· Cue kids with words like, "One, two, three, eyes on me."

· Dim lights to signal activity change.

· Stick to a well-planned schedule.

· Collect assignments in a routine way.

· Model efficient procedures.

· Give 2 tasks with the task that the student prefers last.

· Make tasks more interesting.

· Make sure your vocabulary is developmentally appropriate.

· Give one instruction at a time.

· Repeat and paraphrase.

· Slow the rate of presentation.

· Alert student to important parts using key words.

· Use visual aids.

· Use peer tutoring.

· Provide written lists and outlines following oral instructions.

References:

Children with ADD: A shared responsibility. (1992). Reston, Virginia: The Council for Exceptional Children.
Classroom management of children with attention problems. (1994). In M.C. Edwards and E.G. Schulz (Eds.), ADD teacher inservice program (pp.1-5). Little Rock, AR: Arkansas Children's Hospital.
Classroom modifications (antecedent interventions). (1994). In M.C. Edwards and E.G. Schulz (Eds.), ADD teacher inservice program (pp. 1-5). Little Rock, AR: Arkansas Children's Hospital.
Fiore, T.A., & Becker, E.A. (1994). Promising classroom interventions for students with attention deficit disorder; Education of children with attention deficit disorder. U.S. Department of Education.
Garber, S.W., Garber, M.D., & Spizman, R.F. (1990b). Is your child hyperactive? Redbook, 175, 32, 34, 35.
Jordan, D.R. (1992). Attention deficit disorder; ADHD and ADD Syndromes (2nd ed.). Austin, Texas: Pro-ed.
Kelly, K., & Ramundo, P. (1993). You mean I'm not lazy, stupid, or crazy?! Cincinnati, Ohio: Tyrell & Jerem Press.
Lerner, J.W., Lowenthal, B., & Lerner, S.R. (1995). Attention deficit disorders; Assessment and teaching. Pacific Grove, CA: Brooks/Cole Publishing Company.
U.S. Department of Education. (1994). Teaching strategies; Education of children with attention deficit disorder. Washington, D.C.: Author.
Weber, J., Jr. (1994, June 6). When kids just can't pay attention. Business Week, 123.

ADHD Interventions - Study Strategies
By Daniel R. Morra, MD

Study Strategies

· Have students put away extra items during work time.

· Let the child create a personal distraction sign and keep a sign log--a personal record

· Give the child an, "I Can Pay Attention" card to keep up with increasing attention.

· Make a summary chart for amount of attention shown in certain areas.

· Make an individual responsibilities list.

· Help the child mark in his/her calendar.

· Have the student underline or rewrite directions before beginning.

· Label, highlight, underline, and add colour to important parts of tasks.

· Help the child plan ahead.

· Help the child organise

· Tape a list of assignments, projects and due dates, and materials to be taken home to the desk, books, and assignment folders each day and remind the child to check the list.

· Allow the student to have a study partner.

· Help the student use assignment sheets, daily schedules, and "to do" lists.

· Teach older children how to take notes from an oral presentation and a book.

· Have student write assignments from the board into pocket notebook.

· Provide students with pocket folder (coloured ones for each subject).

· Have student repeat instructions after listening to them.

· Have the students repeat to themselves information that they have just heard.

References:

Classroom management of children with attention problems. (1994). In M.C. Edwards and E.G. Schulz (Eds.), ADD teacher inservice program (pp.1-5). Little Rock, AR: Arkansas Children's Hospital.
Classroom modifications (antecedent interventions). (1994). In M.C. Edwards and E.G. Schulz (Eds.), ADD teacher inservice program (pp. 1-5). Little Rock, AR: Arkansas Children's Hospital.
Garber, S.W., Garber, M.D., & Spizman, R.F. (1990a). If your child is hyperactive, inattentive, impulsive, distractible . . . Helping the ADD (attention deficit disorder) hyperactive child. New York: Villard Books.
Jordan, D.R. (1992). Attention deficit disorder; ADHD and ADD Syndromes (2nd ed.). Austin, Texas: Pro-ed.
Kelly, K., & Ramundo, P. (1993). You mean I'm not lazy, stupid, or crazy?! Cincinnati, Ohio: Tyrell & Jerem Press.
Lerner, J.W., Lowenthal, B., & Lerner, S.R. (1995). Attention deficit disorders; Assessment and teaching. Pacific Grove, CA: Brooks/Cole Publishing Company.
U.S. Department of Education. (1994). Teaching strategies; Education of children with attention deficit disorder. Washington, D.C.: Author.
What's wrong with my child? (1992, April). Ladies' Home Journal, 109, 98, 100, 102, 104.

Colds, coughs, and congestion
By Daniel Morra, MD

Children are constantly being exposed to different respiratory VIRUSES. Usually a child will develop congestion with a clear discharge. After several days, the discharge will become cloudy or yellow-green, and after several more days, the congestion will improve. Antibiotics should not, and in all likelihood, WILL not be given in these early stages of a respiratory infection. Fortunately, many people are becoming increasingly aware of this fact.

Less often the cause of cough and congestion is due to a BACTERIAL infection. Bacteria tend to cause fever and purulent (i.e. containing pus) drainage, and can be responsible for worsening symptoms in a child who had a viral infection. Bacteria, unlike viruses, are indeed treated with antibiotics, and your doctor will prescribe them should they be needed.

Recent studies have indicated that "a sinus infection" should not even be considered in the first seven days of a respiratory infection. For those of our patients who say they are prone to "sinus problems," most of these are just susceptible to respiratory infections. Treating symptoms inadequately (see below) will indeed lead to infection of the sinuses or another SECONDARY infection, requiring antibiotics as mentioned above.

Allergies can cause persisting symptoms as well, including nasal congestion, runny nose, itchy eyes, and cough. Unlike infections, which are episodes of ILLNESS, allergies often linger and are NOT associated with fever. Of course, children with allergies will also get infections which cause fever and worsening symptoms. Allergies do not necessarily predispose a patient to respiratory infections, but they can indeed make the symptoms worse.

HOW SHOULD YOU TREAT THE SYMPTOMS?

Certain measures will help a child with congestion and cough, such as using a humidifier or vaporizer to moisten and soothe irritated airways.

Encourage liquids at all times, especially clear liquids. These will serve to thin the copious secretions that many patients have with allergies and respiratory infections.

Saline nose drops or spray are useful, safe, and inexpensive. They are often the only treatment we advise for congested infants. They can even be made at home, using 1/8 teaspoon of salt in a 4-ounce glass of warm water. Place 2-4 drops in each nostril as often as needed followed by GENTLE use of a nasal aspirator to clear secretions.

Cough and cold medications are commonly recommended, although none are very effective, except in causing undue side effects, only two of which are rapid heart rate and drowsiness. Although many children could use some drowsiness to improve their sleeping, we do not want that to come about because of the side effect of a medication!

Non-prescription medications are often just as effective as those marketed by prescription. Individual responses of some patients may be better than others, but clinical studies usually fail to show any difference between the various brands and ingredients.

DECONGESTANTS should lessen nasal stuffiness and discharge.

ANTIHISTAMINES are usually good for allergies only, unless the nose is "running" uncontrollably with a viral infection, in which cases, the medicine may help to lessen the amount of secretions.

EXPECTORANTS keep a cough "loose" during the daytime.

COUGH SUPPRESSANTS do just what they say, and when used regularly for a few days, will usually help a child to sleep at night.

For all of these medicines, it is good to use them for a few days straight, rather than to use them "here-and-there." The goal is to maintain a level of medication in a child's bloodstream so the medicine can do its job, and this is done by giving it regularly for a few days (in addition to the other supportive measures described above). Cough medicines used sporadically (i.e. here-and-there) will often do no good at all, but may only cause unwelcome side effects.

DOSING OF COLD MEDICINES is often difficult since the dosages usually aren't on the labels for smaller children.

For all of the cold and cough medicines, the dose for children ages 2-6 is simply 1/2 to 3/4 the dose for ages 6-12. Children aged 6 months to 2 years get 1/4 to 1/2 the dose.

Example - Robitussin Cold/Cough - directions for 6-12 years old is 1 teaspoon every 6 hours. You would give 1/2 to 3/4 teaspoon to a child aged 2-6 years old. You would give 1/4 to 1/2 teaspoon to a child aged 6 mo - 2 years.

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ANTIBIOTICS, when given, should be taken for the entire number of days prescribed by the doctor. There is no "magic number" of days, 7, 10, 14, whatever, but the medicine should be taken until it is gone. You should never have extra antibiotics "just laying around the house" ready to be used at any time. The down sides of this are as follows:

1) Your child will likely get many more viral infections than bacterial, and the antibiotics will be useless in those instances.

2) You will be contributing toward what is called "antibiotic resistance." Bacteria have gotten smart over the years, and the more they see a particular antibiotic, the more they can be ready for it when they see it. Bacteria will NOT be killed by antibiotics to which they are resistant.

Resistant bacteria will, I like to say, "laugh" at antibiotics to which they are resistant, and the infection that your child has with such a bacteria can linger, causing longer and potentially more harmful infections.

3) There is another medication in your house which could cause harm to your child.

Suffice it to say, only use an antibiotic when specifically directed to do so by your physician.

***********************************
Call the office should you have any questions about the above.

Call the office for an appointment should the above measures fail after 5-7 days, or if your child appears more seriously ill at any time.

Fever
By Daniel Morra, MD

Fever is an increase in body temperature and is one of the body's defenses against outside attacks, i.e. infections. Normal temperature is not a particular number but rather a range - 97 to 100.4 degrees F (or 36 to 38 degrees C). It also varies with time of day, age, general health, and physical activity.

Mild illness pushes the temperature up slightly, but we are not concerned about the temperature in children who are mildly ill. We encourage you to measure the temperature in all infants (a rectal temperature is preferred) as well as in those children who appear ill (OK to use an oral or ear thermometer, but these temperatures are a bit less accurate).

A temperature over 100.4 is a fever for most children. That temperature is particularly worrisome in an infant who is less than 6 weeks old - that infant should be seen in the office immediately and may have to be admitted to the hospital.

DO NOT PANIC OVER A FEVER! Remember that it is a body's normal response to illness. Although fever can cause seizures in some children (i.e. febrile seizures), a fever is not harmful unless it goes over 106 degrees F - which is extraordinarily rare.

The reason to treat a fever is to make a child comfortable. Treating the fever DOES NOT LESSEN THE ILLNESS. It isn't important to lower a child's temperature except for comfort.

Important things to do in infants or children with illnesses with fever:

1) Keep the child comfortable - lightly dressed if warm, warmly dressed if they feel cold.

2) Offer fluids. Clear liquids are often better tolerated than milk, but you may offer a child anything he/she wants to drink.

3) You may bathe young children in lukewarm water for 20 minutes. DO NOT USE COLD WATER OR RUBBING ALCOHOL TO BRING A CHILD'S TEMPERATURE DOWN - this is not only ineffective, but is also potentially harmful.

4) Older children may appreciate a cool washcloth across the head.

5) We prefer to use acetaminophen (i.e. TYLENOL) to treat fever. This is a very safe and effective medication which can be given every 4 hours. The dose is about 6 mg for each pound of weight. Medicines should be given by weight in children so as not to overdose them.

This is a quick guide to Tylenol doses:

13 pounds - approx. 80 mg = 1 dropperful of INFANT Tylenol

20 pounds - 120 mg = 1 1/2 droppersful of INFANT Tylenol or 1/2 teaspoon of CHILDREN'S Tylenol

26 pounds - approx. 160 mg = 2 droppersful of INFANT Tylenol or 1 teaspoon of CHILDREN'S Tylenol

6) Ibuprofen (i.e. Motrin, Advil) can be given for fever which doesn't respond to Tylenol. Occasional use of this medicine is safe, but don't use it as your first choice. The dose of ibuprofen is 4 mg per pound of weight, and should be given every 6 to 8 hours. A 25-pound child should be given 1 teaspoon every 6-8 hours.

NEVER GIVE ASPIRIN ("BABY ASPIRIN") TO REDUCE FEVER IN A CHILD. THE USE OF ASPIRIN HAS BEEN LINKED TO AN INCREASED RISK OF REYE SYNDROME, A RARE BUT SERIOUS DISEASE AFFECTING THE BRAIN AND LIVER. USE TYLENOL AS YOUR FIRST CHOICE, IBUPROFEN AS YOUR SECOND.

Call the office if your child has a fever along with any of the following:

1) age <3 months

2) ill appearance, unusual drowsiness, or severe headache (regardless of age)

3) persistently ill appearance after the temperature has been brought down below 100.4 F

4) delirium, hallucinations

5) complete refusal to drink

6) underlying disorder or treatment affecting the immune system

7) travel outside the country during the preceding 8 weeks

REMEMBER: Many doctors (Dr. Morra included) believe that fever may actually help to shorten the course of infections by activating the immune system. If your child is not made uncomfortable by the fever, it does NOT need to be treated.

This handout was adapted from the Shore Health Group handout on fever and the section on fever from the AAP Book, GUIDE TO YOUR CHILD'S SYMPTOMS, copyright 1997.


Vomiting and/or diarrhea
By Daniel Morra, MD

YOUR CHILD IS VOMITING – WHAT CAN YOU DO?

Vomiting is the result of stomach irritation. Usually a child vomits several times, and vomiting may persist for hours before finally subsiding. Serious consequences from vomiting are unusual. If a child vomits just a couple times, wait a few minutes before offering anything by mouth. Then offer any clear liquid at room temperature, such as flat soda, Gatorade, half-strength, or, in the case of an infant, Pedialyte or a similar pediatric electrolyte solution. Start with small sips every 5-10 minutes. If that’s tolerated, gradually offer larger sips, and then simple foods like crackers or dry cereals. Infants MAY be given formula if tolerated. If the vomiting continues, do not get discouraged. The vomiting phase will pass – it will just require PATIENCE.

A liquid sold over-the-counter called Emetrol may help to control vomiting and/or break a cycle of vomiting, but in general, medications should not be used. Your child is vomiting to remove a toxin (i.e. harmful substance) or infection from their body. Stopping this will actually prolong the vomiting, and potentially make your child’s problem worse.

YOUR CHILD HAS DIARRHEA – WHAT CAN YOU DO?

The body is always putting fluid into the intestines. Diarrhea occurs when some of this fluid is not reabsorbed, resulting in frequent watery stools. Usually an infectious agent (bacteria or virus) causes this problem. Diarrhea continues until the intestine heals, which may take days or even weeks! Unfortunately, there is no medicine which cures diarrhea per se. While some medications can be helpful, the major goal is to replace fluids that are being lost and provide nutrients until the child improves on his own. Some medicines such as Pepto-Bismol or Kaopectate can be used, but are usually more harmful than good, and as with anti-vomiting medications, may actually serve to prolong your child’s infection.

It is now rare for a child to be hospitalized for dehydration, but it can be necessary when too much fluid is lost. Here’s how to prevent that!

Infants with diarrhea are initially given special fluids such as Pedialyte. For toddlers, you may use a 50:50 mixture of juice and Pedialyte to make it taste better. Pedialyte helps to prevent dehydration because it contains sugar and salt – things your child’s body needs to keep its electrolytes normal. Juice and/or water does not contain everything the body needs, and can sometimes make diarrhea worse.

The goal of intake is 2 ounces of fluid per pound of weight per day (e.g. 40 ounces for a 20 pound child in one day). You should just give 1 tsp every 2-3 minutes if your child is vomiting as well. It’s tedious but very effective if continued – just KEEP IT UP! Once the vomiting slows down or stops, you may give 4-8 ounces every hour. Foods may be given as soon as the child will tolerate them, and these should not be withheld for more than 12-24 hours. Foods that are usually well-tolerated are those in the B.R.A.T. diet, namely Bananas, Rice, Apples (or applesauce), and Toast (or crackers) Cereal and potatoes are often tolerated as well. Breast milk and formula may also be given if your child prefers. If regular formula is not tolerated, you may try a lactose-free, soy, or “diarrhea” formula for the duration of the illness.

OLDER CHILDREN WITH DIARRHEA

As mentioned above, medications are usually not helpful and may prolong diarrhea in some children. However, some medications can be helpful in older children, i.e. those over age 3.

The same ingredient (attapulgite) is now found in several brands – Donnagel and Kaopectate advise one dose after each loose stool, up to 7 times daily. Diasorb uses twice the dose, up to 3 times daily (same total amount). Imodium A-D is a treatment option in older children, but we do not prefer to use this in preschool children. New studies have found some value in using Pepto-Bismol in bacterial diarrhea (i.e. Salmonella), but this can turn the stools black, which sometimes scares patients and their parents. Pepto may also be of use in children with chronic diarrhea.

WHEN TO CALL FOR ASSISTANCE OR AN APPOINTMENT

Most children can be treated with the advice above. The exceptions are children who may have a serious underlying cause to the vomiting and diarrhea, or those children who have a more severe or complicated course.

We expect parents to call for any of the following:

1. an infant with severe vomiting of every feed, or profuse diarrhea
2. a child who is markedly listless or unduly irritable
3. severe abdominal pain – especially if localized to one area of the abdomen
4. vomiting for more than 12 hours
5. diarrhea containing blood
6. dark, coal-tar-like black stools
7. fever greater than 101 F for more than 2 days
8. no improvement in diarrhea after 3-5 days
9. signs of dehydration – see below

Signs of mild to moderate dehydration – absence of tears, dry mouth, dark and/or foul-smelling urine, irritable, tired (younger child) or weak, lightheaded (older child)

Signs of moderate to severe dehydration – drowsy, pale, limp child, with a rapid, weak pulse, rapid and deep breathing, sunken eyes, very dry mouth, no urine output for more than 6 hours.

Constipation
By Daniel Morra, MD

CONSTIPATION

One of our #1 complaints by phone and in the office concerns bowel movements (or the lack thereof). The below should help to answer most or all of your questions about constipation. It is adapted from a handout we give to patients in our office.

Definition:

1. painful passage of stools. The most reliable sign of constipation is discomfort with the passage of a bowel movement
2. inability to pass stools. These children feel a desperate urge to have a bowel movement (BM), have discomfort in the anal area, but are unable to pass a BM after straining and pushing for more than 10 minutes
3. infrequent BMs. Going 5 or more days without a BM can be considered constipation, even though this may cause no pain in some children and even be normal for a few. An exception to this is the breastfeeding infant. After 2 months of age, many breast-fed babies pass normal, large, soft BMs at infrequent intervals (up to 7 DAYS is not abnormal) without pain. These babies are NOT constipated.

COMMON MISCONCEPTIONS IN DEFININING CONSTIPATION

Large or hard BMs unaccompanied by any of the conditions above are usually normal variations in BMs. Some normal people have hard BMs daily without any pain. Children who eat large quantities of food may pass extremely large BMs. Babies less than 6 months of age commonly grunt, push, strain, draw up the legs, and become flushed in the face during passage of BMs. However, THEY DON’T CRY. These behaviors are NORMAL and should remind us that it is difficult to have a BM lying down (as babies do all the time!).

CAUSES OF CONSTIPATION

Constipation is often due to a diet that does not include enough fiber. Drinking or eating too many milk products can cause constipation. It is also caused by repeatedly waiting too long to go to the bathroom, as is common with toddlers who are too busy playing to worry about going to have a BM. If constipation begins during toilet training, usually the parent(s) is(are) applying too much pressure in the toilet training process.

EXPECTED COURSE OF CONSTIPATION

Changes in the diet usually relieve constipation. After your child is better, be sure to keep him/her on a nonconstipating diet (see below) so that it doesn’t happen again.

Sometimes the trauma to the anal canal during constipation causes an ANAL FISSURE (a small tear). This is confirmed by finding small amounts of bright red blood on the toilet tissue or the stool surface. As long as there are not LARGE amounts of blood, this is OK and will resolve when the constipation is resolved.

HOME CARE – DIET TREATMENT FOR INFANTS (LESS THAN 1 YEAR OLD)

If your baby is under 2 months of age, try 1 teaspoon (tsp) of dark Karo syrup (found in the supermarket) twice daily.

If over 2 months, give fruit juices (such as apple or prune juice – 100% juice) in small amounts twice daily.

If over 4 months, add strained foods with a high fiber content, such as CEREALS, APRICOTS, PRUNES, PEACHES, PEARS, PLUMS, BEANS, PEAS, or SPINACH twice daily.

Strained bananas are neither helpful nor constipating.

HOME CARE – DIET TREATMENT FOR OLDER CHILDREN (>1 YEAR OLD)

Make sure your child eats fruits or vegetables at least 3 times a day (once per meal). Raw unpeeled fruits and veggies are the best. Some examples are PRUNES, FIGS, DATES, RAISINS, PEACHES, PEARS, APRICOTS, BEANS, CELERY, PEAS, CAULIFLOWER, BROCCOLI, and CABBAGE.

AVOID ANY FOODS YOUR CHILD CAN’T CHEW EASILY!

Increase bran. Bran is an excellent natural stool softener because it has a high fiber content. Make sure that your child’s daily diet includes a source of bran, such as one of the newer “natural” cereals, unmilled bran, bran flakes, bran muffins, shredded wheat, graham crackers, oatmeal, high-fiber cookies, brown rice, or whole wheat bread. Popcorn is one of the best high-fiber foods for children over 4 years old.

Decrease consumption of constipating foods – milk, yogurt, ice cream, cheese, and cooked carrots.

Increase the amount of fruit juices your child drinks – however, be warned that too much fruit juice can cause diarrhea! (Exception – orange juice is not as good as some others)

SITTING ON THE TOILET AND THE PROBLEMS IT CAUSES

Encourage your child to establish a regular bowel pattern by sitting on the toilet for 10 minutes after meals, especially breakfast. It is a normal process of the body to move along the things that a child has eaten the day before and push them out after he/she eats breakfast! Some children (and ADULTS!) get backed up repeatedly if they don’t do this.

If your child is resisting toilet training by holding back, stop the toilet training for awhile and put her back in diapers or pull-ups.

STOOL SOFTENERS

If a change in diet doesn’t relieve the constipation in 5-7 days or so, you may give your child a stool softener with dinner every night for a week. Stool softeners are not habit-forming. They work 8-12 hours after they are taken. Examples of stool softeners that you can buy at your drug store without a prescription are Haley’s M-O (1 tablespoon), Metamucil or Citrucel (1 tablespoon), or plain mineral oil (1 tablespoon).

MEASURES FOR ACUTE RECTAL PAIN

If your child ever has ACUTE rectal pain needing immediate relief, one of the following should provide quick relief:

- sitting in a warm bath to relax the anal sphincter
- a glycerine suppository (available at your pharmacy – use only one!)
- gentle rectal stimulation for 10 seconds using a thermometer
- gentle rectal dilation with a lubricated finger (covered with plastic wrap).

CALL OUR OFFICE:

IMMEDIATELY for advice about an enema if your child develops severe rectal or abdominal pain.

DURING OFFICE HOURS if your child does not have a bowel movement after at least 5 days on the nonconstipating diet or if you have any questions or other concerns.

Bedwetting
By Daniel Morra, MD

BEDWETTING

This information sheet was adapted from a similar handout from our office, and is especially appropriate for a child over the age of 4 years who has NEVER had a dry bed for more than a couple months and rarely has “accidents” during the day.

Bedwetting occurs in 30% of children at age 4, 15% at age 6, 3% at age 12, and 1% at age 18. It is more common among boys, and there may be (and usually is) a family history of bedwetting.

A normal physical exam and urine test (urinalysis) in these children is usually necessary to evaluate for an underlying medical problem.

There are several causes for bedwetting. One or more of these causes may affect any child. Some children have a small bladder (average size = age + 2 ounces, an adult bladder holds 12-16 ounces). Some children do not experience the natural nightly increase in the hormone that conserves water. As a result, these children produce dilute urine in larger quantities during the night. Some children are delayed in the maturation of the process whereby the brain unconsciously inhibits bladder contractions. Bedwetting will during light as well as deep sleep, but bedwetters are typically deep sleepers.

Bedwetting treatment does not and should not include punishment or conflict over fluid restriction. It DOES require reassurance and an attitude of support from the parents and other caretakers. Older children can be encouraged to be a part of the effort by helping with sheets, although the bedwetter should be PRIMARILY responsible for helping with wet linens.

Most children with small bladders will need to get up at least once or twice nightly, and should practice this at bedtime. You may want to have nightlights or flashlights available should the child wake at night. Parental wakening of a child is not recommended since it may delay the child’s ability to wake himself at night. Bladder stretching exercises are worth trying if they are not a source of conflict. Try having a child urinate into a container with volume markings on the side. Each time he feels the urge to urinate, he should hold it until the urge is unbearable. Then, he should urinate into the container, trying to outdo his mark from the previous time. This can be used as a game for younger children, as a child can gradually learn to stretch his bladder to collect increasing amounts of urine. Of course, the urine should then be poured into the toilet and flushed!

Withholding caffeinated beverages such as tea, coffee, and cola after 6 pm is appropriate.

An enuresis alarm may encourage the learning process and aid the unconscious process of dealing with a full bladder. The alarm is sewn into the underwear of a child, and will sound when in contact with any moisture. These alarms can be disruptive to an entire family’s sleep, so implementing this should be carefully thought through. Time (on the order of WEEKS) and a “team effort” by the entire family is necessary for this method to be successful.

A safe and rapid response can be obtained with a spray called DDAVP (desmopressin). This is a synthetic form of the chemical that stimulates reabsorption of water, and thus decreases urine output. One or two sprays in each nostril at bedtime will reduce urine production at night for most children. This medication can also be given in the form a pill (0.2 mg – one pill to start, and gradually increasing to three pills as needed). The medication is useful, but most children return to bedwetting when it is stopped. If your child takes the pills, these can be weaned (3 pills, 2 pills, and so on) so he will not have to take them for the rest of his life. Although a pill provides a “magic bullet,” it is not the primary answer – behavioral methods should be used first and foremost.

Some parents have had good results with a book called DRY ALL NIGHT, which can be read by both child and parent in conjunction with other behavioral methods. The author is Alison Mack and the book was published in 1989 by Little, Brown, and Co.

Bedwetting is a frustrating problem, but it can be overcome. If the above methods are unsuccessful, usually within a few months, your child should come to the office for further evaluation.

Head injuries / concussion
By Daniel Morra, MD

Accidents that result in a head injury cause a great deal of concern. This page (adapted from a similar handout from our office) will help you care for your child after a head injury.

The first decision is whether your child should see a physician. Not every child needs an examination or skull x-ray (or CAT scan), although we examine any child at the parent’s request.

Children MUST be seen if the injury was so forceful that a skull fracture is likely, such as a very hard fall onto a hard surface, if the child lost consciousness, or if any of the worrisome signs listed later on this page should appear.

Children DO NOT NEED an examination or skull x-ray (or CAT scan) if they had a minor accident and are acting well afterwards.

The major treatment for head injury is observation for signs of increased brain pressure which would require neurosurgery.

Commonly after an injury, children will vomit or want to rest. A headache is also very common after a head injury. These ARE NOT danger signs, and your child CAN be allowed to rest or sleep after a head injury. However, after about an hour, you should wake the child to see if he/she responds to you in a normal way.

POSSIBLE DANGER SIGNS for which we should be called IMMEDIATELY:

1. progressive or steady worsening irritability
2. loss of awareness
3. lethargy (i.e. when the child is awake, he/she seems overly listless or does not respond to you appropriately)
4. onset of vomiting which begins more than 1-2 hours after the head injury
5. very unequal pupil size on examination of the eyes
6. labored breathing (not hyperventilation due to anxiety)
7. any other inappropriate behavior for your child

While your child may not be in danger if some of the above signs occur, you should be concerned and notify us IMMEDIATELY.

If the injury occurred in the morning or afternoon, daytime observation should suffice. If the injury occurred during the evening, you may need to awaken your child every 1-2 hours during the night at first, and then less often if he/she appears well.

If increased brain pressure develops, it usually does so within hours. However, rarely, it can develop up to days later, even after the most minor head injury (look for the same signs as outlined above).

Bruises, lumps, and swellings commonly occur with head injuries. These can be treated with cool compresses if your child is willing to cooperate. In most, if not all, instances, these will resolve on their own with time. Lacerations (deep or gaping wounds) may require sutures (“stitches”) and should be evaluated in the office (during hours) or in the emergency department (after hours). Acetaminophen (Tylenol) may be given for headache.

An addition from Dr. Morra – if any head injuries take place during a sporting event, either competitive or recreational, there are guidelines as to whether the person who sustained the injury should return to play. I am sure you are familiar with head injuries sustained by athletes, and these are better known as “concussions” (which applies to all head injuries, not only sports-related). Signs of a concussion include those outlined above, as well as disorientation, dizziness, and altered memory. A PLAYER SHOULD NOT RETURN TO PLAY IF ANY OF THESE SYMPTOMS (OR THOSE OUTLINED ABOVE) ARE PRESENT. You should also have your child evaluated in the office to better evaluate whether he/she can return to play.

If symptoms of a concussion are not completely resolved, and a player returns to play and sustains a second head injury, this can have potentially devastating consequences, including brain swelling, coma, and death, so please take such head injuries seriously!

Please call the office with any questions or concerns you might have.

My beliefs about chiropractic care
By Daniel Morra, MD

I believe there is a role for chiropractors in our community. When it comes to pain and musculoskeletal problems AND MEDICAL OPTIONS HAVE BEEN EXHAUSTED, I believe a chiropractor or acupuncturist could be considered. Referral to a chiropractor will ONLY be issued by me if a patient has seen an orthopedist, neurologist, and/or a physical or massage therapist first.

As relates to some chiropractors' beliefs that they can affect medical processes with spinal manipulation, I am a staunch opponent of the chiropractic field. In my medical opinion, babies cannot be cured of colic by chiropractic. Allergies and asthma cannot be cured or affected by chiropractic. Manipulation by a chiropractor cannot prevent devastating childhood illnesses, which many studies have shown necessitate the administration of vaccines such as DTaP, Hib, polio, MMR, Varivax ("chicken pox vaccine"), Prevnar (pneumococcal vaccine), Hepatitis A, and Hepatitis B. Chiropractors can be used to affect changes in the musculoskeletal system, just as an optometrist treats the eyes or a podiatrist treats feet. However, when they start extending themselves and claiming that manipulation can affect the physiology of the body (i.e. how the body systems work), I think they are extending themselves too far. This is similar to me claiming that I am an expert on infectious diseases or pediatric surgery. I don't claim to be able to do more than I know or to able to do more with medicine than can be done. Chiropractors should not do that either.

If you would like to discuss chiropractic care with me further, please call the office to make an appointment.

   
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Immunizations ("shots")
By Daniel Morra, MD

Below is a list of the immunizations that your child should receive, based on our recommendations as well as those of the American Academy of Pediatrics and the Centers for Disease Control.

See the key below for explanation of abbreviations.

2 MONTHS - DTaP #1, HepB #1/Hib #1, IPV #1, Prevnar #1

4 MONTHS - DTaP #2, HepB #2/Hib #2, IPV #2, Prevnar #2

6 MONTHS - DTaP #3, Hib #3, Prevnar #3

9 MONTHS - HepB #3

12 MONTHS - MMR #1, Varivax (Prevnar #4 may also be given here). We also recommend that children 1 year of age or older have blood work done, including a blood count (CBC) and lead level.

15 MONTHS - DTaP #4/Hib #4 (one combination shot), IPV #3 (Prevnar #4 may also be given here)

5 YEARS - "kindergarten shots" - boosters of DTaP, IPV, and MMR

11-15 YEARS - Td (tetanus) booster

> 15 YEARS - Lymerix

COLLEGE AGE - Menomune




KEY for immunizations:

DTaP - diphtheria/tetanus/pertussis (pertussis = whooping cough)

HepB - hepatitis B, series of three shots which protects against potentially devastating liver infection, sometimes given in combination (i.e. one needle) with Hib

Hib - H. influenzae, a bacteria causing primarily meningitis in young children, sometimes given in combination with DTaP or HepB

IPV - polio, which is nearly being eradicated (i.e. completely eliminated) from the world due to this vaccination

Prevnar - the newest of the vaccinations, available as of Spring 2000. Protects against pneumococcus, an organism which is primarily responsible for ear infections, sinusitis, and pneumonia, but which can also cause devastating infections, including meningitis, in children under age 2

MMR - measles, mumps, rubella (rubella = German measles)

Varivax - chickenpox

Td - tetanus booster - should be given every 10 years. Should be given within 5 years if you sustain any injury resulting in a dirty wound.

Lymerix - Lyme disease, available only for children over the age of 15

Menomune - meningitis, protects against a devastating form of bacterial meningitis. We recommend this for any of our patients who are going away to school or the military. This fatal disease is transmitted very rapidly among populations in tight quarters (i.e. college dormitories, military installations, etc.).

These vaccinations are proven safe and effective in protecting against these potentially deadly diseases. The shots themselves can cause some side effects, and we explain these when the shots are given. Of course, you should call our office if you have any questions.

IF YOU BELIEVE YOUR CHILD IS HAVING A MORE SERIOUS REACTION TO A VACCINE, YOU SHOULD CALL OUR OFFICE IMMEDIATELY.