Rx For Parenting Today

Watching for Visual Problems with Juvenile Rheumatoid Arthritis

I was at a party over the weekend that included teenagers and noticed one girl wearing a removable hand splint. It drew my attention and I asked the teen if she had hurt her hand, 'No" she said "I have arthritis." She was a slender, pretty teen and I didn't see any of the prominent facial features that sometimes occur with this disorder. I knew it well having directed an arthritis clinic for five years and had had a wonderful pediatric rheumatologist, who taught me a great deal.  When I asked what rheumatologist she was seeing, the girl remarked that because they were Kaiser patients, the rheumatologist would not see her until she was 18. She was 14, so obviously another rheumatologist was needed, but she said her parents hadn't taken her to anyone else. She was taking the drug, Aleve, that helped a little with the pain.  

When I asked if she had had what is called a "slit-lamp" examination by a pediatric opthalmologist, she said she had just seen an eye doctor to have glasses fitted. This alarmed me because a patient I will never forget in the arthritis clinic I directed was blind. She had not been followed by a pediatric opthalmologist and developed uveitits, which untreated led to blindness. I gave the teen my card and said I would be glad to speak with her parents.  On the back I wrote that a slit-lamp examination of the girl's eyes by a pedaitric eye doctor was very much needed.

I have not heard from the parents and worry that I may not. Thus, parents of children with JRA need to be sure that a yearly slit-lamp examination of the eyes is done by a pediatric eye doctor and a pediatric rheumatologist follows the child.  

Parenting a Child with Hydrocephalus

I was talking to a young father yesterday who proudly showed me pictures of his one-year-old baby. He told me the baby had been diagnosed with hydrocephalus at birth and had had a shunt placed in his head at two-weeks of age. The baby had had frequent ear infections, the father said, and had  had tubes placed in his ear drums. I then asked the father if they had a good pediatrician and the father said he thought so. Then I asked if the doctor had discussed the problems which could result with hydrocephalus. "No", the man said. "I don't know anything about that." I was appalled!

Having cared for over one hundred children with hydrocephalus in a spina bifida clinic, I know the problems and complications well. The primary concern is shunt failure and the other major concern is meningitis. If, for example, the baby seemed ill and the doctor or his nurse said to go to the ER or to come to the office in the morning, the baby could be dead. I explained to the father that he and his wife must be aggressive about demanding that the doctor see the baby at any hour if there were problems. ER doctors generally have little pediatric training and so might not understand how quickly a baby with hydrocephalus can die.

I cannot imagine any physician not going over the complications of hydrocephalus. Medicine should not just be about ordering tests and prescribing medicine, it should be about looking at prevention and the whole picture.

 

The Importance of a Chest X-ray When there is a Questions About a Diagnosis

One of the most important things I learned as a pediatric resident at Los Angeles Children's Hospital was to order a chest X-ray, if I was puzzled about a diagnosis. I wish more doctors knew this, because I constantly wonder why it often takes patients so long to get a diagnosis when they have shortness of breath, chest pain, coughing, flu-like symptoms or a child with a fever who is not feeling well.

I remember being at a friend's house in another city when she told me about a neighbor's child who had been ill for five days with quite an elevated fever. The child's doctor didn't seem to be worried about the elevated temperature and told the mother he was sure the child would be fine. I said if I was the parent, I would insist on a urinalysis, blood count, and chest X-ray. Fortunately, the mother listened to me and took the little girl back to the doctor. He didn't want to bother with the tests, but the mother insisted and it turned out that the child had quite a severe pneumonia. She responded well to antibiotics and the parents were very grateful for my help. (I hope they changed pediatricians!)

I had a favorite set of twins when I was in practice and was concerned to hear one of the twins was ill, when I returned from a two week vacation. Walking into the examining room, I saw the little girl grunting and said to the mother, "Maggie has pneumonia." The mother replied that the doctor who had been taking my practice while I was gone said he didn't hear anything abnormal  in the chest. I insisted that Maggie have an immediate chest  X-ray and yes, she did have a lobar pneumonia. Pneumonia can be very silent when you listen with a stethoscope. 

I saw another child who had had a croupy cough for several weeks and had been seen by three doctors. Each one had ordered an antibiotic that didn't help the bad cough. I ordered a chest X-ray and asked to have the neck included. The little boy had a safety pin stuck in his windpipe or trachea that had to be removed surgically.

A good friend in his fifties was a long-time smoker and refused to get a chest-X-ray even though I was sure he was in trouble. He didn't see doctors very often, but finally after I kept urging him to see a doctor and insist on a chest-X-ray, he did. The man had quite extensive cancer of the lung and didn't live for just a few months after that. If he had had an earlier chest-X-ray, or even a yearly chest-X-ray, I am sure he would have had many more years to live. It was a tragic loss of life.

When Boys Sleep with Their Mothers

I am told that in some cultures little boys sleep with their mothers until they start school. I have found that, unfortunately, some mothers, after a divorce or death of a partner allow their sons to sleep with them. This creates all kinds of problems. If, for example, there are girls in the family what are they feeling? Also, separating a son from his mother as the years pass can be difficult. I had one mother whose entire life was her son and her church. Yes, he slept with her for many years. Then when he broke away from her and also found a girl friend, the mother was devastated. She came to my office in tears and wanted me to talk with her son. I convinced the woman that her son needed his independence and she should try and find some other ways to find warmth and companionship. The son also came to me and told me how difficult his mother was being. I advised some counseling but am afraid that never happened. The mother set herself up for problems early on and I was sad for her. 

I had a good friend who said after a divorce that she nearly froze to death without her husband's warmth, but she did not use her son to provide the warmth. Instead, she found other ways to fill that need, all healthy. Often after a divorce, mothers don't use their sons for warmth, but have a constant stream of men spending the night. This is very difficult for children, particularly if they are close to their father. I think parents need to put their children first and do what is best for them, not what is best for the parents. The damage that we can do as parents is often difficult to repair. Parenting needs to be unselfish; it is not a time to put a parent's needs above those of the children.  

Why Children Need a Yearly Urinalysis and TB Skin Test

When I talk with friends' teenage children, I often ask about the medical care they are receiving or not receiving from their pediatricians.  One teenage girl told me that her doctor had never looked at her below her waist. My grandson said the doctor had never checked to see if he had a hernia or other problems. Neither of them had had TB skin tests or yearly urinalysis or even any! Now that TB is on the rise and people are traveling and arriving from all over the world, the need for yearly TB skin tests is even more important. The only time a TB skin test should not be given is if a child has had BCG, as is given in some countries. 

When I did yearly physical examinations, I always checked a urine specimen and gave a TB skin test  and I was often surprised at what I found. If there is a family history of diabetes, a yearly urine specimen is particularly important. Of course, if the doctor does not take a family history, he or she will not know about diabetes in the family. I have found cases of nephritis, bladder and kidney infections and detected two cases of tuberculosis in children that had not been known. Good, basic medical care can still reveal a great deal, but if a complete physical examination is not done, including vision and hearing tests and a check on immunizations, a child is not getting good medical care. It is  always surprising what can be found if a doctor is thorough and spends the time needed to both take a good history and do a complete physical examination. 

Danger of Little Children Spraying Their Eyes with Household Products

Parenting seems to get harder and harder these days as so many products are on the market that can harm children. An excellent article in the 9/13/16 New York Times by Catherine Saint Louis discusses the risk little children have of causing a burn to their eyes by various household spray bottles. Many families these days seem to refer hand cleaning solutions in bottles rather than using bar soap. If a little child is curious and grabs the bottle, he or she can easily spray a solution right into their eyes and cause a serious burn.

The article states that the greatest number of eye injuries from spray bottles is in one and two-year-olds. Also, she notes that "From 2012 to 2013 at least 17,000 children younger than six ingested or squirted the liquid contents (from laundry detergent packets) into their eyes." The treatment when an eye injury occurs is to wash the eyes for at least 20 minutes with clear water. Then a trip to the ER should be made. 

Every spray bottle of a cleaning substance should be put up high and if little children are in the house, bar soap would seem to be a better choice. All products, such as oven cleaners, drain uncloggers and any ammonia products should also be put up high or under lock and key. I have always advised parents of little children to periodically make a  household inspection to look for any products that could harm children and put them up high. Garages are particularly dangerous places for children to be without supervision. You can never be too careful with little children because they move quickly and especially  when parents are tired or entertaining, kids can get into all kinds of trouble.

The Hard Task of Parenting Teenagers Today

Parenting teens today can be difficult, but it can also be fun if the kids have grown up knowing their parents love them and are in charge. When teens don't have boundaries or don't respect their parents, lots of trouble can lie ahead. I have had many teenage patients say they wished their parents would set limits. That way they know how to act and they feel loved and safe. One author made the statement that " The time to disarm a teenage time bomb is when they are two." I certainly agree with that. I enjoyed my children's friends and I think they enjoyed coming to our house. One teen told me later that our house saved her because her mother was so unloving and so strict. At our house, she said she felt loved and wanted. Teens have to confront so many problems these days that I could write a book just about their difficulties. Self-esteem, bullying, anorexia, bulimia, suicide, drugs, and questions about engaging in sexual activities all come up for teens. Drinking and drugs are also something teens have to face.  One study showed that 50% of parents had no idea that their children were sexually active. Teen pregnancies still are happening and as more Planned Parenthood Clinics are closed by the Republicans, teenage girls are put at great risk. I had no problem writing prescriptions for sexually active teens. I did not ask their parents' permission because knowing the parents, I was sure they would not have allowed it and the girls could easily have become pregnant. I knew their home situations were so difficult that having a boy friend was probably how they made it from day to day. 

I wish doctors who give Botox for cosmetic reasons to teens would re-think what they are doing. Is making more money that important? Doing surgery on an underage girl because she doesn't like the size of her breasts, her chin, or nose seems wrong to me. Do these girls have  such poor self-esteem that they have to resort to Botox and surgery? 

Social media and the ability to send photos to others has created a great problem. In one study 20% of girls admitted sending nude photos of themselves to boys. What are these girls thinking and where are their parents?  I think one answer is to have daily conversations with your teens, particularly around the dinner table and at night before they go to bed. I found telling each child goodnight in their own bedroom was a good time to really talk. 

 

Tips on Parenting Twins

Parenting twins can be a lot of fun, but it can also be extremely difficult. Having a good support system of family, friends, or parents who have raised twins can be very helpful. I remember one day in my office I had three sets of identical twins to see. It was a fun day, but everyone in the office was tired at the end of the day. At least, we could go home, whereas the parents had long years ahead of them. We had one family in our small town who had twins, then  triplets, and then a single child and they became exhausted. A grandmother moved in and stayed a few years. The parents sadly were later divorced. 

Some of the things I always tried to get across to the parents of twins was right from the beginning to treat each child as a distinct personality. Yes, twins are cute when they are dressed alike, but a friend who is an identical twin told me how much she resented it when her mother tried to dress her exactly like her twin. When the children start school if they can be put in separate classrooms, they will become more of their own person. Many twins want to stay together and sometimes this is to the exclusion of making friends with other children. Twins often have a language or communication system of their own and many twins say they know exactly what their twin is thinking. Twins separated at birth because of family problems often discover they have similar interests if they reconnect as adults.

Because many twins are premature babies. one or both may have special problems. If one twin is healthy and the other has something like cerebral palsy, this can make the healthy twin feel guilty. Many go into the healthcare professions. 

Parents of twins right from the beginning need to plan a weekly time for themselves. It is too easy to get caught up in caring for the twins and forgetting that you are a person who needs time for yourself and your marriage. Twins clubs can offer support and are a way for parents to make friends of parents who also have twins.