Illness 911

How Can Chemotherapy Treat Cancer

2009-03-17T01:32:00.000-07:00

Because chemotherapy is a systemic treatment (affecting the en¬tire body), it can be used to treat either a localized tumor or the entire body, if the tumor has been metastasized. A single drug is used in some instances, but most chemotherapy regimens include a combination of three or four drugs that kill cancer cells in different ways. These drug combinations are administered according to a clearly specified schedule, or protocol. Because many different treatments are available, your doctor will discuss with you the regimen that is appropriate for your cancer. You won’t necessarily need detailed knowledge about the drugs used in chemotherapy to make an appropriate treatment decision.

During your treatment, your oncologist will monitor your progress using the same methods that were used during the diagnostic and staging studies.

Drug Classifications
How different anticancer drugs kill cancer cells or prevent them from dividing depends on their classification. Drugs in the same class kill the cancer cells by the same mechanism of action: that is, they all attack the same target within the cell. Most drug regimens are composed of drugs from different classes; the different drugs work in different phases of cell division or on different targets. For example, some drugs are incorporated into DNA and prevent cell division, others will cross-link the strands of DNA making it impossible for the cell to duplicate the DNA, others will inhibit key enzymes involved in the cell cycle or DNA synthesis, and still others may prevent the cell from undergoing mitosis by inhibiting the mitotic spindle needed to separate the chromosomes. Newer drugs work by inhibiting cell signaling pathways or by blocking the action of growth factors. There are other drugs that are designed to enhance the efficacy of the more standard chemotherapy agents (modifiers or sensitizers) and still others that can reduce the toxicity of treatment (protectors). Combination chemotherapy regimens are designed so that drugs will work in concert so that it is difficult for the cancer cell to become resistant to therapy.

Some of the common chemotherapy regimens used to treat different types of cancer. Regimens are sometimes given acronyms using the first letter of the chemical or trade name of each drug. For example, note that two of the four regimens available for Hodgkin's disease are MOPP and ABVD. Doctors use these abbreviations to communicate more easily. Because the names of some different drugs begin with the same first letter, the abbreviations don t always indicate which drugs are in a particular regimen.

Risk of Late Complications Relative Risk

2009-03-17T00:35:00.001-07:00

In any group of people, there is a risk that some of them will develop cancer during their lifetime. This risk is called the expected number of cancers. When the number of cured cancer patients who develop secondary cancers later in life is calculated, the result is the observed number of cancers.

To calculate the relative risk, the number of observed cases is divided by the number of expected cases:

Observed cases Relative risk =- Observed cases / Expected cases

Statistical methods are then applied to see whether more former patients than expected developed secondary cancers some years after their first cancer was cured. For example, let's say a group of 1,000 adults were cured of Hodgkin's disease when they were young adults. Fifteen years later, we find that 36 of these former patients have developed leukemia, but we expected only 4 people in 1,000 who have never had Hodgkin's disease to develop this leukemia. Therefore, to determine the relative risk that former Hodgkin's patients will develop leukemia later in life, we would divide 36 by 4, which is 9. In other words, there are 9 times more cases of leukemia than we would have expected.

Although the relative risk of 9 seems high, only 36 (about 3.5%) of the 1,000 patients developed this complication, whereas 964 did not, and 4 of the 1,000 patients would have developed leukemia whether they had had Hodgkin's disease or not. There¬fore, only 32 (about 3%) of 1,000 patients developed leukemia because of their earlier Hodgkin's disease or its treatment.

Epilepsy and your feelings

2009-03-11T01:40:00.001-07:00

To suffer from epilepsy is to be different from one's fellows as the result of a persistent, intangible and recalcitrant disorder which even in the most enlightened society carries with it a stigma of the unusual. The subject nearly always feels different from his contem¬poraries, and the more intelligent and enlightened he is, and the more understanding and enlightened his contemporaries, the bigger the problem he has to face, for it is greater trauma to have to be consciously treated as normal than to be naturally accepted as different.

This hurtful dilemma, ranging from sententious and embarrassing over-understanding, to miserable restriction and loneliness, pervades his life at home, at school, at work and sometimes into marriage. Dr D. Williams, writing in the 1950s

“At school I felt different even though my friends didn't treat me as such. I couldn't drink, go to clubs or parties, or even go to places like Alton Towers because of the heights of the rides. I can't even watch TV in the dark! I felt very self-conscious and it's only recently F have been able to tell people about my epilepsy without feeling embarrassed. I was convinced that no one would want a relationship with an 'epileptic' but I've been lucky so far. My parents have been really protective so that sometimes I feel like I have no life. However, my friends are brilliant. When I get upset, they help me realize that I'm just a bit different, but not enough for it to affect them or me.” Julie

These eloquent descriptions of the psychological burden of epilepsy point out that not only is 'feeling different' a major part of epilepsy - it is something which cannot always be addressed by the outside world. Since the 1950s, when the epileptologist Dr D. Williams was writing, much hard work has been done by the epilepsy movement to establish that people with epilepsy are much the same as people anywhere. Yet, for many with epilepsy, 'feeling different' can persist even when friends are accepting, employers understanding, and lovers truly appreciative of the person who happens to have seizures.

Epilepsy, unlike many other medical disorders, is a psychosocial condition as well as a medical disorder. Its invisibility most of the time, the unpredictability of seizures, and the overwhelming loss of control involved have since time immemorial been seen as a threat to social and personal order. 'To be naturally accepted as different' is an ideal which has to fight against a long cultural history of epilepsy, and how the nature of epilepsy is perceived by others.

While epilepsy is a chronic health disorder, it is unlike many other chronic conditions in that most people with epilepsy are 'normal' most of the time - except when they have a seizure, suddenly revealing themselves as 'different', something which can happen even with those whose epilepsy has been controlled for a long time. 'Epilepsy is not a continuously rough sea, but a recurrent tidal wave,' said Dr William Lennox, one of the American fathers of the modem epilepsy movement - the 'recurrent tidal wave' being the sudden unpredictable quality of the symptom of epilepsy, compared with the constant 'rough sea' of many other chronic health disorders.

Is driving a very important issue for people with epilepsy

2009-03-11T00:37:00.000-07:00

Most countries don't let people with epilepsy drive unless they have been seizure-free (from all seizure types, including auras, myoclonic jerks and absence seizures) for a set time which may vary widely, usually from three to eighteen months; the interval recently adopted by EU countries including the UK is one year. In the UK, you can also drive if you have only had seizures in your sleep for the past three years. If you are applying for a licence, you must inform the DVLA (Driver and Vehicle Licensing Agency) about your epilepsy. If you already hold a licence but have a seizure, then the law states that you must also inform the DVLA, and stop driving. You then lose your licence until once again you have been seizure-free for a year.

As with other aspects of epilepsy including work, traditionally it has been usual to treat all people with epilepsy the same and to ban driving right across the board. More recently, though, it has become clear that j the risks are not high for people who have controlled epilepsy. But, there is a grey area for people whose seizures are not perfectly controlled - is it safe to drive? If so, when? How do you decide?

Driving is a very important issue for people with epilepsy. It is often seen as a key area representing personal freedom, adulthood and independence. It is also an area with very practical implications in terms of being employable and just in sheer mobility, for example, if you depend on driving for a job, or live in a rural area where, as is common in the UK, public transport is woefully inadequate.

Research at Johns Hopkins University, Baltimore, and the University of Maryland, USA, has come up with certain specific risk factors which may help assess the chances of having a car accident due to seizures. The researchers hope that this approach may be more effective in reducing accident deaths than current driving policies which, the study also found, a significant number of people with epilepsy simply ignore, either by not reporting their seizures as required by law, or just by driving in spite of having continuing seizures. Only 36 per cent of the group with previous crashes and 40 per cent of the control group reported their seizures to authorities. And, more than half of the patients in the crash group and third of the non-crash group drove despite having seizure-free intervals shorter than their states legally required.

Driving against medical advice is often a defiant reaction which seeks to deny the epilepsy. The problem is, as with some jobs, it involves others. An Australian study showed that charges of murder and manslaughter were felt to be appropriate for people who drove despite having continued seizures.
The Johns Hopkins scientists found four characteristics which could help predict accidents:

• The length of time people go without a seizure before they return to driving - the single feature most linked with crashes. Generally, the shorter the interval, the greater the likelihood of an accident. People who did not drive for a year or longer had a 93 per cent reduced risk.
• People who experience an aura also had reduced odds of crashing.
• So did people with fewer non-epilepsy-related accidents in general before they were diagnosed.
• Reducing the number of anti-epileptic drugs, or changing them, lowered the accident risk, probably because of less sedation.

How Can Music, Art, and Horticultural therapy help people with epilepsy

2009-03-10T23:53:00.001-07:00

‘I fall sick when I hear the sound of the street vendor's flute in the evening sun, although I do not know the reason,' said the Chinese poet Kung Tsu Chen, writing in 1847. He is describing a rare form of reflex epilepsy, musicogenic epilepsy, which affects an estimated 1 in 10 million. Seizures may occur on hearing the music, or even while thinking or dreaming of music, and may take several seconds or even minutes to develop. They appear to be most common in the right temporal lobe, which houses the right auditory cortex, an area implicated in the processing of melody.

There may be another side to the coin. Some recent research suggests that music can reduce seizures as well as inducing them. One study, reported in Clinical Electroencephalography, found that some music seemed to reduce seizures. The researchers studied 29 people with frequent seizures, either awake or in coma, and found that 23 of them had a significant drop in seizures, with an average reduction in seizure rate from 62 per cent to 21 per cent. The effect was confined to Mozart's music - pop music made no difference. Moreover, the music was effective in patients who were in a comatose state, so presumably not consciously aware of the music.

The so-called 'Mozart effect' has figured in a number of other studies looking at how music affects the brain, especially as boosting mathematical and other intellectual abilities. While it is too early to speculate about using music as a treatment for epilepsy, it may well be that including more music in your daily life could be beneficial. It could also boost confidence to learn an instrument or join a choir, not least for the fact of being with other people. Singing can help loosen the ribs, chest muscles, and the anterior, middle and posterior scalene muscles where the neck joins the shoulders, so helping release tension and stress, and making breathing deeper and more regular. A Swedish study of nearly 13,000 people found that those who join in musical activities such as choirs tend to live longer - definitely worth a try!

Because it doesn't use words, art can be an especially soothing and therapeutic way of releasing feelings, something which many people with or without epilepsy find difficult. It may be especially helpful in dealing with stress, or if you feel you're 'stuck' generally in life, as it often allows unconscious messages to emerge.

Art therapy is now increasingly used for relationship difficulties, or to boost self-esteem - both of which can be key for people with epilepsy just as for other people. It may also help those who have learning difficulties in addition to epilepsy, who often have even more than the normal trouble expressing their emotions effectively, and some of whom, in their frustration, may resort to less mature ways of showing their feelings such as banging or shouting.

Some therapists offer a mix of art therapy and counseling to help people analyse their drawings and paintings. Therapists may, for example, look at why you have drawn yourself as a tiny figure in the comer and your partner as a huge giant covering the rest of the page! Colour has special significance too, which is usually fairly obvious even though people may not really be aware of it at the time of painting: red may represent passion or anger, blue coldness, black, sadness or endings.

Needless to say you don't need any artistic skill though you may be surprised, under tuition, at the artistic competency which does emerge. Contrary perhaps to common assumptions, art can be taught.

Horticultural therapy is based on the so-called biophilia effect - the love of living things. Like art therapy, it doesn't depend on using words, which again can be useful for those who find it hard to express or intellectualize their feelings. However, it may differ from other art forms which are made but not nurtured in the same way - dealing with a growing, live object over a long period.

For people with epilepsy, horticultural therapy may have special significance in terms of taking responsibility. It may also help some people think more effectively about time management, as raising plants demands planning over a period of time, sowing at certain times, and waiting for results.

Just being outside may be as helpful as anything. Research by biologists has found that natural daylight is vital for the normal functioning of the brain, the smooth running of the central nervous system, and the sleep-wake cycle.

Photosensitive epilepsy

2009-03-10T23:30:00.001-07:00

Watching television and video or using computers can affect a small minority of people with epilepsy. This can be detected on an EEC It is usually adolescent girls who have seizures precipitated by flashing lights. This problem can be life long but drugs such as sodium valproate are good at stopping the sensitivity to flashing lights. The following recommendations may be helpful.

• Make sure your posture is comfortable, and restrict your viewing if need be.
• View the TV in a well-lit room.
• Sit at least 2.5 metres away and at an angle from the television.
• Use a high-frequency TV (lOOMhz). "W
• Make sure your TV is working properly as faulty screens can cause problems.
• Some photosensitive reactions can be minimized by covering one eye.
• Special TV sunglasses are also available via epilepsy support organizations.
• Use an American video screen for computers.

Points about protein

2009-03-10T22:57:00.000-07:00

Many nutritionists say we eat too much protein - others, not enough! The effect of protein may vary from person to person. Some people find that including more protein in their diet helps control low blood sugar, boost energy, and even lose weight. Protein may also help you get rid of excess water, important especially for women who tend to suffer bloating and water retention before a period, which can affect seizure control. Good sources of protein include meat, fish, eggs, cheese, pulses such as peas and beans, and nuts.

A possible link between seizures and amino acids, chemicals which make up proteins, has been established by researchers at the University of California. The scientists found that diets deficient in amino acids can make seizures more likely in rats. While the study highlights the importance of ensuring that people everywhere eat an adequate level of high-quality protein, it does not suggest supplementing your diet with amino acids as a treatment for epilepsy in most cases. However, some individuals have tried this with reported success. Taurine, an amino acid which helps inhibit neuronal activity, has been tried in sometimes mega-doses by some people with epilepsy, who have found it does help control their seizures, though if you are going to experiment it is probably wiser to start with small doses and build up, and also to check with your doctor first. DMG (Di-methyl glycine) is another amino acid which helps oxygen move round the system and is said to stimulate the immune system.

Paul suffered from repeated absence seizures, and the occasional tonic-clonic seizure. Paul saw a nutritionist and was recommended supplements of about 90 mg of DMG twice a day, which he bought in a health food shop. He took it for about a year, and then found he didn't seem to need it any more as he no longer suffered from seizures. In his case, DMG did seem to be a miracle cure, but it is well recognized that many people can 'grow out' of their absence seizures.

Epilepsy Diet

2009-03-09T11:36:00.001-07:00

Since the ancient Greeks, epilepsy has always been treated with special diets, usually combined with other lifestyle measures such as regular hours and enough exercise. A healthy diet lowers stress, and builds up resistance to illness, another time when people are more vulnerable to seizures. Eating properly is also important because occasionally lack of food can set off a seizure. Finally, some people feel that their epilepsy is linked to nutrient shortages and/or allergic reactions to some foods and other substances, although when investigated medically such claims often cannot be substantiated.

Many of these factors will be tackled by eating a diet which follows basic well-known healthy eating rules - planning meals around complex carbohydrates such as rice and pasta, avoiding processed and refined foods, cutting right down on fat and sugar, and having plenty of fresh fruit and vegetables. Make sure you eat a variety of foods from the four key food groups - milk and dairy products; bread and cereals; fruit and vegetables; and protein such as meat, fish and poultry - in other words, a healthy diet.

Everyday healthy living - looking after yourself when you have epilepsy

2009-03-09T11:25:00.001-07:00

Looking after yourself in daily life can often be key in seizure control. While lifestyle changes may not cure epilepsy, they may sometimes be the factor which helps reduce seizure frequency or severity. Because epilepsy is so individual, what people find useful varies. This chapter looks at several different lifestyle measures which different people have found effective, including stress management, diet and nutrition, social drinking, breathing and meditation, and hobbies which can have therapeutic value, such as music and gardening.

A study of 23 people who had rejected drug therapy looked at other non-drug treatments, one of the main ones being 'life hygiene' or avoidance of seizure triggers such as lack of sleep or too much alcohol. Eight of the 23 were completely seizure-free after four years. The study concluded that treatments can be useful for people with milder forms of epilepsy, though most doctors would probably add, in conjunction with your usual drug regime. If you feel that improving your lifestyle improves your epilepsy and you want to reduce medication, do discuss it with your doctor first.

Apart from seizure control, there has been growing emphasis on quality of life for people with epilepsy. The original anticonvulsants, such as bromide, controlled seizures but effectively made people into zombies. Since then, the emphasis in epilepsy treatment has tradition¬ally been on seizure control. More recent anti-epileptic drugs appear to have much less in the way of side effects. There has also been growing recognition of the fact that enjoying life to the full is as important as controlling seizures, and sometimes more so. By raising your energy level and improving your general health, changes in lifestyle may boost your zest in life - in itself well worth aiming for.

Complications and epilepsy

2009-03-09T11:04:00.000-07:00

Women with epilepsy have a slightly increased risk of complications, such as severe morning sickness, bleeding, toxaemia (raised blood pressure and protein in the urine) and early birth, along with an increased risk of haemorrhage during labour.

Induction (when birth is started artificially) happens more frequently with women with epilepsy - in one study it was over four times more common. There is also an increased risk of assisted delivery, with caesareans, forceps and vacuum extraction being used more than twice as often. Some recent research suggests that breech presentations are more common in women with epilepsy. The majority of babies turn head down (cephalic or vertex) but, in women with epilepsy, anti-epileptic drugs may possibly slow down the baby's natural turning process perhaps by slowing down limb movements.

Frightening as this may all sound, these complications are not usually serious. Some authorities also believe that, with recent advances in care, the complication rate is becoming closer to that of women without epilepsy, though the higher rate of sometimes severe pre-eclampsia still seems to be the case.

The warning signs of pregnancy, including those of pre-eclampsia, include:
• severe headache
• severe abdominal pain
• breaking of the waters
• mistiness, difficulty and blurring of vision
• vaginal bleeding.
If you experience any of these, consult your doctor or hospital immediately.

Prodromata and predicting seizures

2009-03-08T07:41:00.001-07:00

Two or three days before I have a seizure I get a headache which comes and goes. I see flickering light which obstructs my vision and leaves my eyes bloodshot and tired feeling. My family steer clear of me because, although I'm not really aware of it, I suffer mood swings during the run-up to a seizure and am not easy to live with. Anthea

The run-up to a seizure is known medically as the prodrome or prodromata, and some people with epilepsy are more aware of it than others. Unfortunately, it is usually unpleasant, involving feelings such as depression, irritability and heaviness; less commonly, it may involve feelings of elation or exultation. This prodrome is different from an aura in that it lasts longer, coming on typically several hours or even days before a seizure, while an aura is really the beginning of the seizure itself. The prodrome is thought to be caused by subtle abnormal changes in the electrical activity of the brain which finally build up to a seizure, though another possibility is that it is the moods of irritability and depression which finally provoke the seizure. Given all this, is it possible for seizures to be predicted? Several research centres are exploring this. For example, researchers at the University of Bonn analysed EEGs and found that an average 11 minutes before a seizure begins there is a characteristic 'loss of complexity' in brainwaves. The German research team scanned the electrical landscape of the brain before and after seizures using a mathematical property from chaos theory known as 'correlation dimension', a number which acts as a measure of how complex the brain's neural activity is. Researchers in America, headed by the US Department of Energy (DOE), also analysed EEG data and found they could detect a seizure 8 to 15 minutes before it occurred.

Research like this may help scientists develop more sensitive methods to detect and possibly prevent oncoming seizures. This could involve mind control techniques where people could try and prevent a seizure using methods such as distraction (see Chapter 4 for more on this). Using fMRI (functional magnetic resonance imaging) and other methods, the neuropsychology workgroup at Bonn is testing whether there are characteristic EEG changes preceding a seizure, and whether these could possibly be used to develop a therapy to ward off seizures. Or, it could involve sophisticated technology, such as an implantable monitor, capable of providing a warning or automatically delivering drugs or electrical stimulation to the brain if a seizure is pending. In practice, however, useful though they would be, such devices remain experimental for the time being.

Epilepsy - Links with other conditions

2009-03-08T06:35:00.000-07:00

Because epilepsy is sometimes related to underlying brain damage or disorder, it may sometimes accompany other problems also caused by brain malfunction, such as learning disability. About 25 per cent of people with a learning disability have epilepsy, and, in those with a severe learning disability, the number of those with epilepsy rises to 50 per cent. Generally, epilepsy is far more common, and frequently more difficult to control, in people who have other conditions which affect the brain, such as cerebral palsy and cerebrovascular disease (stroke) -though these conditions co-exist, and do not actually cause each other. But anyone can develop epilepsy, whatever their level of intelligence.

Epilepsy is sometimes linked to other conditions, too. For example, there is a higher incidence of epilepsy in children with autism, especially around adolescence, and some researchers believe that autism is due to an abnormality in the brain itself, or a disturbance in the body chemistry which affects the brain. Recently, researchers have focused on the brain structure of people with autism. Using modern brain-scanning techniques, researchers have found that there may be a structural difference in the cerebellum, though findings are not specific enough for scans to diagnose autism. However, neurological damage is now believed to be the cause of autism, just as with epilepsy.

Another link is with migraine - in fact, neurologist Oliver Sacks describes migraine as 'epilepsy in slow motion', as there are some similarities in brainwave patterns. A number of older studies have found that migraine sufferers had a higher prevalence of epilepsy, though these studies have been criticized as flawed. Like epilepsy, migraine may start with an aura or warning such as visual disturbance, although in migraine consciousness is hardly ever lost, as it often is in an epileptic seizure. There has also been speculation that there may be a common genetic component for epilepsy and migraine. However, a recent American study of nearly 2,000 people found that the risk of epilepsy in relatives was not associated with a history of migraine, with the exception of the sons of female migraineurs, people do not share a genetic susceptibility to both migraine and epilepsy, so leaving unclear the links between migraine and epilepsy. All this said, it is by no means uncommon for people with epilepsy to experience migraine and/or severe headaches, either as part of a seizure or alone.

Children Nightmares

2009-02-23T09:53:00.001-08:00

The majority of childcare experts claim that nightmares before the age of three years are very rare. In his book Solve your Child's Sleep Problems, Dr Richard Ferber appears to disagree with these claims. He says that 'dreams, and even nightmares, unquestionably do occur during the second year of life'. Ferber believes that nightmares are mainly a symptom of day-time emotional struggles. He says that 'although most nightmares do reflect emotional conflicts, in most cases neither the nightmares nor the conflicts are "abnormal". Rather the normal emotional struggles associated with growing up are at times significant enough to lead to occasional nightmares.'

Having been woken in the middle of the night many times over the years, to the screams of the elder siblings of my babies, I would have to agree with Ferber's view. Nearly ail of these children were between 18 months and three years, and those able to talk would, once calmed down, be able to describe the nightmare.

Although all the experts are in agreement that a child who has had a nightmare should immediately be comforted and reassured, opinion is divided on whether they can be controlled or not. Dr John Pearce, author of The New Baby and Toddler Sleep Programme believes that because nightmares occur in the lightest stages of sleep, they can often be controlled. He explains that because a child's imagination is more adaptable than an adult's, it is more open to suggestions. He advises that parents work out a plan on how to deal with the monster, ie making the monster fall into a hole, drown or get trapped in a cage.

I personally find that this approach works much better than trying to convince the child there isn't a monster. All too often I have heard a young child getting more and more upset as their parents insist on trying to convince them that the monster isn't real. This happens because a child under three years of age who wakes up frightened by a nightmare is not yet able to grasp the difference between dreaming and reality.

I have also observed that those elder siblings of my babies who have suffered from nightmares, nearly all had inconsistent bedtime routines or had previously suffered with sleeping problems. It is interesting that very few of the babies I have helped care for that were put into a routine from the very early days have ever suffered from nightmares,which leads me to believe that a consistent routine is as essential for older children as for babies.

Parenting Tips - Fear of the dark

2009-02-23T09:49:00.000-08:00

During the third year even the most happy and confident child can develop a fear of the dark. A child who suddenly starts becoming fretful and frightened at bedtime and talking of monsters being in the room should be taken seriously. At this age he is still unable to comprehend the difference between what is real and what isn't, therefore telling him not to be silly and that monsters do not exist will be of no help. Dr Miriam Stoppard says, if your child is afraid of monsters or ghosts say that you are a parent who can do magical things to them. Say that you are able to blow them away and give a big blow.' I have found this sort of approach far more effective that trying to convince the child the monster doesn't exist. Giving your child a special magic toy that sits near the door to keep the monsters out can also be a successful way of eliminating a child's fears.

Some parents tell me that leaving a small plug-in light on until the child goes to sleep can also be reassuring. If a child starts to wake up frightened in the night or have nightmares it would be advisable to leave it on all night. This in my mind is better than leaving the door open. Problems can often arise when a second baby comes along if the elder child is used to having the door open, as they are more inclined to get up in the night if they hear their mother attending to the baby.

Toddler - Dawdling and Tidiness

2009-02-22T21:51:00.000-08:00

Dawdling is very common between the ages of two and three. It also coincides with the age when many toddlers start nursery. All too often I have witnessed the scene of fraught parents struggling to get their toddler fed, washed and dressed in time for school. The more the parents coax and cajole him to hurry up, the more he will dawdle. To avoid this habit turning mornings into a war zone it is important to set strict rules for the morning routine. Ideally, the pattern should be established long before the toddler starts nursery.

The first thing that must happen when your toddler awakes is that he gets washed and dressed. He should then immediately be given breakfast. Once breakfast is over he should be encouraged to get everything ready that he needs to take to school. As an incentive, tell him that once he has done all these things he will be allowed 15 minutes to play, read a book or watch a video.
It is essential that you are consistent and firm so that he learns what is expected of him in the morning. This is all part of teaching a toddler to take responsibility for himself. The star chart is also a great way to help enforce this behaviour in the morning.

Tidiness
Getting your toddler into the habit of tidying up from an early age will help avoid much conflict at a later stage. Toddlers can be encouraged to keep their toys and clothes tidy as soon as they are able to walk. They should also learn that they have to tidy one set of toys away before getting another set out. This is easier to implement if toys are stored in different categories, in boxes with secure lids. This storage system also helps the toddler to define size, shape and colour. The cars belong in the long red box, the jigsaws belong in the tall green box and the crayons belong in the small round yellow box. While a large toy chest may be attractive to look at, I feel they are best avoided as they do little to encourage tidiness.

Baby Care Tips - Thumb sucking

2009-02-22T21:18:00.000-08:00

All babies are born with a basic instinct to suck and nearly all babies will suck their thumb at some stage. Many start while in the womb, but it is not until a baby reaches almost three months that he will have sufficient hand-to-mouth coordination to keep his thumb in his mouth for any length of time. Once the baby has developed the necessary co-ordination for thumb sucking, how often he will do it and for how long varies considerably from baby to baby. The majority of young babies who suck their thumb do so either when tired, when using it as a comforter prior to sleep, or when hungry. Thumb sucking or hand chewing usually peaks between the ages of six and nine months with the need to suck gradually decreasing by the age of one year. While some babies continue to suck their thumb at bed¬time, a baby who is continually sucking his thumb throughout the day is likely to develop a long-term habit that will be difficult to break.

If your baby is approaching a year old and is constantly suck¬ing his thumb during the day, the cause is probably boredom. The, best way to deal with this is to encourage more physical activity such as Tumble Tots or a swimming class. When at home, encourage more crawling or pushing of his baby walker and remember to rotate his toys so that he doesn't get bored. Distraction is much better than disapproval. Making a fuss about thumb sucking or constantly pulling his thumb out of his mouth rarely works and usually makes the baby or toddler more anxious^ which increases his need to suck even more.

With older children excessive sucking may become a real problem as it can cause deformities of the teeth and jaw, resulting in extensive dental treatment. Again, disapproval of the habit rarely works; it is much better to work out the cause. Boredom, tiredness and insecurity are usually the main reasons. I often find that suggesting to an older child that he is tired and perhaps should go and have a rest in his room where he can suck his thumb in private immediately encourages him to find something better to do.

Regression

2009-02-22T21:13:00.000-08:00

All toddlers and children will continue to have the occasional accident once they are potty trained. The important thing is to stay calm and consistent, and not be tempted to put him back into nappies if you have a bad couple of days. Occasionally, a toddler or child who has been dry for many months may regress completely. This often happens around the time when a new brother or sister arrives, when he starts playgroup or there is a similar emotional upheaval. If your child suddenly regresses and appears to be more withdrawn or is more demanding and displaying unusual aggressive behaviour, the regression is probably psychological. If his behaviour is normal it may be worth a visit to the doctor to rule out the possibility of a urine infection.

Whatever has caused the regression I would not advise going back to nappies. Although it may mean many wet pants for a short spell, being patient, consistent and encouraging will eventually get your child back on track. It is also worthwhile doing a progress chart for a couple of days again, to establish how often the accidents are happening. A pattern usually emerges of how often he has an accident, and this will enable you to remind him to use the potty at these regular inter¬vals. If he is reluctant to use the potty, take him with you when you need to go to the loo yourself. Making a game of using the loo at the same time will often encourage him to go on the potty, while you are using the loo. Obviously this plan is more likely to be successful if done at roughly the times you think he may need to pee.

The stubborn child

2009-02-22T21:12:00.001-08:00

Occasionally, I have a child who refuses to go on the potty, but if § he is under 2V2 years I would not force the issue. However, with a child nearer three years of age who refuses to sit on the potty I would probably resort to bribery. I know the majority of experts frown upon this advice, but sometimes, especially with a very stubborn child, it is the only way.

While a child over three years may not show all the signs nec¬essary for potty training, he is usually capable of being trained. I would skip the preparation stage and go straight into potty train¬ing and use a star chart. I would explain that every time he does a pee in the potty he would get a star - and for every star he would get a treat. The treat can be a raisin or a very small sweet like a smartie. Believe me it does work, provided of course the child receives no other treats throughout the day. Within two days I find the child is regularly asking for the potty, then the star, followed by the treat. Once I see a regular pattern emerge I would explain to the child that I had run out of the treats.

I would suggest that the next three pees in the potty would deserve a trip to the shop for a special ice-cream. By using delay¬ing tactics of a bigger treat for more pees in the potty, I would eventually arrive at a stage where the child uses the potty through¬out the day, and ends up with only one treat in the evening.

Signs that will indicate if your toddler is ready to potty train

2009-02-22T20:47:00.001-08:00

Once your toddler reaches 18 months there are signs to watch out for that indicate he may be ready for potty training. However, I should point out that the success of potty-training quickly will not only depend on your toddler being ready, but also on you being ready. All too often I hear horror stories of how potty training was a nightmare and took ages, the conclusion being that the child wasn't ready. In reality it was very often the parents who weren't ready. Even if your toddler is showing most of the signs listed below it would be inadvisable to begin training unless you have the time to devote yourself to the task 100 per cent. It is not some¬thing to undertake if you are about to move house, have just had a baby, or your toddler is just getting over an illness.

To train your toddler quickly and successfully, it is very impor¬tant that not only are you in a relaxed state of mind, but also that any older or younger siblings are happy and in a good enough routine to allow 100 per cent concentration and the extra time needed if you want to achieve this.

Provided you are feeling in a positive frame of mind, the time is right for the rest of the family and your toddler is showing all of the signs listed below, you should manage to train him success¬fully within one week.

These are the important signs that will indicate if your toddler is ready to potty train.

• He is over 18 months of age and his nappy is frequently dry when you get him up from his lunch-time nap. A dry nappy a couple of hours after his last nappy change would also be an indication that he is getting some bladder control.
• He shows signs of awareness when doing a poo; ie he goes very quiet and squeezes his legs together, or points to his nappy and says 'poo' or 'pee pee' when he has done one.
• He can understand and follow simple instructions; ie 'go and fetch your red ball' or 'put your toy in the box'.
• He is eager to participate in taking off his own clothes; ie shoes, socks and shorts, and understands what pulling his shorts up and down mean.
• He has the ability to sit still and occupy himself or concentrate for 5-10 minutes with a toy or a book.

Potty training

2009-02-22T20:42:00.001-08:00

'At what age should I start to potty train?' and 'How long will it take?3 are questions I am frequently asked by parents. While all children are different, in my experience of working with hundreds of mothers and children, the majority are ready to be trained somewhere between the ages of 18 and 24 months. Before 18 months, very few children's muscles are developed enough for the bladder control necessary for potty training. While we have all heard the stories from our mothers, aunties and grandmas, how in their day the baby was potty trained by the age of one year, the reality is that it was really the mother who was trained and not the baby. By sitting the baby on the potty at frequent times during the day she would, more often than not, catch the urine or the bowel movement. While this obviously saved her the laborious task of washing and sterilising the terry nappies used in those days, the baby could not be called potty trained in the true sense.

A toddler who is truly potty trained will recognise when he needs to pass urine or have a bowel movement and be capable of going to his potty, pulling down his own pants, and using the potty before pulling his pants up again.

Toddlerhood case study - Andrea (aged 20 months)

2009-02-22T20:39:00.000-08:00

Andrea was 20 months when her parents transferred her into a bed, so they could give her cot to her brother David, aged five months. It was a total disaster, which resulted in Andrea waking and crying and wandering out of her room several times a night. When her mother tried shutting the door Andrea became absolutely hysterical. After a week of virtually no sleep, they transferred David to a travel cot and put Andrea back in her cot. She continued to cry hysterically until she was sick. Sometimes she would do this twice in succession. Eventually in desperation her parents decided to move the cot back to David's room and put Andrea back in her bed, with the door shut. She never stayed in bed. She would spend hours crying hysterically, and pounding her fists on the door. Andrea sounded so petrified, that her mother quickly gave up on the idea and ended up taking Andrea into her own bed. She would not go to bed until her parents did and con¬tinued to wake up crying and would wander out of the room several times a night. Andrea's lack of sleep started to affect her behaviour at nursery. She was tired and groggy and did not join in with the other children.

Her mother also became tired and so low spirited that she started to let David's routine slip. As a means of settling him back to sleep once he had been woken by Andrea's constant crying, she resorted to giving David a bottle. The whole situation was a nightmare, that was repeated night after night.

After several weeks of sleep deprivation, the parents rang me to see if I could help get both the children's sleeping and feeding sorted out. I agreed to help on the condition that they went out and bought another cot. I firmly believed that Andrea was far too young to sleep in a bed.
On the first night that Andrea was to go back in her cot I advised the parents to stick to the same bedtime - of around mid¬night. She immediately started trembling and crying when she was put in to it. Following my advice, her mother sat on a chair right next to the cot, cuddling and reassuring Andrea, and saying 'Mummy's here, lie down and go to sleep'. It was an hour before Andrea calmed down and showed signs of sleepiness. Her mother spent a further 15 minutes sitting beside the cot before saying 'night-night'. She gave Andrea one last cuddle before leaving the room. Andrea immediately started crying. This went on for 15 minutes and then she was violently sick. Following my advice, Andrea was changed and comforted, without being lifted out of the cot. Her mother then sat right next to the cot again, and con¬tinued the settling pattern as before. Andrea was now very tired, but fighting sleep. Eventually, after 40 minutes, she lay down and closed her eyes for short spells. Her mother, gradually started to edge her chair further and further away from the cot, but when she got near to the door Andrea stood up and started crying again. By this time, her mother was so exhausted that she decided that she would to have to leave Andrea to cry. She gave her one last cuddle and told her to 'Lie down and go to sleep'. Andrea cried for one hour before falling asleep.

Over the next three nights Andrea's bedtime was gradually brought forward, and the amount of time her mother spent settling her was reduced. She was never lifted out of the cot, no matter how hard she screamed. Her mother would stroke her forehead and keep repeating the same phrase: 'Lie down and go to sleep9. The number of times Andrea awoke and the amount 6f| time she cried lessened each night. By the fourth night Andrea's bedtime had been brought forward to 8.30pm and she slept solidly for 11 hours.

During those five days we also solved the problem of Andrea's refusal to eat. She was still drinking milk from a bottle, at an aver¬age of two and a half pints a day - approximately 1,500 mil This is an excessive amount of milk and is the reason why Andrea con¬stantly refused to eat her meals. Some days she would only eat a slice or two of bread or a yoghurt. During those five days we elim¬inated all the bottles of milk from Andrea's diet. She would drink juice from a cup, but refused to drink milk from a cup. However, this immediately brought about a huge increase in Andrea's appetite and she would take milk on her cereal, in sauces or pud¬dings. I advised her mother to include lots of calcium rich foods in Andrea's diet, to ensure she received her necessary daily intake of bottle, as it reduces their appetite for other foods. A child over one year of age needs a minimum of 350ml (11 Vioz) of milk a day inclusive of milk used in food.

Toddler Sleeping Problem Case Study - Sarah

2009-02-20T01:57:00.000-08:00

Sarah had never slept well as a baby, and did not sleep properly through the night until she was sleep trained at 18 months. After 18 months of waking up two and three times a night, her mother was delighted to settle for Sarah going to bed around 9pm, and waking at 6-7am. She also took a nap of two hours in the middle of the day, which helped her mother cope with her difficult behaviour between 630pm and 9pm after which she would fall asleep exhausted in the cot drinking her bottle of formula. This pattern continued until her brother was born five months later.

Simon weighed over 10lb at birth, and by four weeks had out¬grown the small Moses basket he had been sleeping in. Because Sarah had occasionally slept in a bed at her grandmother's house, the obvious decision was to put Sarah in the big bed and give Simon the cot.

The first night Sarah was so excited about going into her big bed- that it took her mother slightly longer to settle her to sleep. Sarah would keep getting in and out ofjthe bed, demanding yet another story to be read. She eventually fell asleep in her mother's arms at around 9.40pm, only to wake screaming at around midnight. Sarah's mother had to spend another hour lying on the bed with her before she fell asleep. She awoke twice more in the night and each time it took nearly an hour to settle her. The following evening Sarah took even longer to settle, falling asleep at 10.15pm, and like the previous night woke up three times. During the following week a pattern quickly emerged of Sarah not set¬tling to sleep until nearly 11pm, and waking two or three times in the night.

She would only fall asleep if her mother read or sang to her which could take anything up to 2 hours.

When her mother rang me for help it was clear that putting Sarah in the big bed was a major contribution to Sarah's sleeping problems. I suggested that she should put Sarah back in her cot. Fortunately, a friend had a spare cot that could be borrowed for Simon, and Sarah was transferred back to her old cot. The number of night wakings was immediately reduced, and when she did wake, her mother managed to settle her back to sleep quickly. However, settling Sarah at bedtime continued to be a problem. Her mother would start settling her at 9pm, but it was usually between 10pm and 11pm before she would fall asleep. I believe that the reason for this was that, like a baby who associates falling asleep with being fed or rocked, Sarah associated falling asleep with being read or sung to.

When Sarah was transferred to the bed and resisted sleep, the already late bedtime meant she got very overtired and fought sleep even more. Therefore, the time her mother spent reading and singing began to get longer and longer. I advised her mother gradually to bring Sarah's bedtime forward by 30 minutes every three nights until it was 7.30pm, and that she should spend no more than 20 minutes singing and reading to Sarah. Because Sarah had been used to a late bedtime for such a long time, I sug¬gested that her mother should play a tape of gentle nursery rhymes for 40 minutes after leaving the room. She should tell Sarah that she was going to have a bath and would come back for one final 'night-night' when the tape was finished. If Sarah shouted out she was to say that she was in the bath and would come soon. By the time the tape was finished Sarah was always fast asleep. Within two weeks the length of time the tape was played was reduced to 20 minutes, and Sarah was sleeping from 7.30pm—7am.

Each morning Sarah's mother would tell her that she had gone in after the bath and given her a big night-night kiss.

Food fights - Baby

2009-02-20T01:40:00.000-08:00

During the first year, a baby will grow rapidly and most babies will have increased their height by 50 per cent and tripled their birth weight by the time they reach their first birthday. In the second year^ growth slows down and there is often a very notice¬able decrease in the toddler's appetite. Elizabeth Morse says in her book My Child Won't Eat, 'If a child grew at the same rate as in the first year, he would be 29 metres long and weigh 200 tonnes by the age of ten'. Unfortunately, many parents are not aware that the decrease in their toddler's appetite is normal. They become anxious that he is not eating enough and often resort to spoonfeeding him in the vain hope that it will get his old appetite back. Unfortunately, the pressure to get the toddler to eat more usually has the opposite effect and results in what many childcare experts term 'food fights'. Meal times soon become a battle¬ground, with the toddler screaming as his parents insist on him having just one more spoonful. If you wish to avoid these feeding problems with your toddler^ or if he is already experiencing them, it is essential that you have a clear understanding of what he needs to eat for a healthy and well-balanced diet. This will help avoid food fights and fussy eating and will also encourage long-term healthy eating habits.

Nappy rash

2009-02-19T10:41:00.001-08:00

Nappy rash can be extremely painful for a baby and while some babies are more prone to it than others, with vigilance I believe it can be avoided. Frequent nappy changing, especially in hot weather, and proper cleansing of the nappy areas are the keys to avoiding nappy rash.
• Change your baby's nappy every couple of hours regardless of whether he has had a bowel movement.
• Cleanse your baby's bottom using plain, cool, boiled water or a little baby oil and cotton wool. Avoid using baby wipes on very young babies, especially if the bottom area looks red.
• If you use a barrier cream apply only a thin layer. Too much will reduce the absorbency of disposable nappies.
• Never use baby powder. Not only does it clog the skin but even the tiniest amount can prove fatal if it reaches a baby's lungs.
• Remove your baby's nappy and expose his bottom to fresh air at least twice a day.
• If your baby's bottom does become affected, cleaning it will be less painful if unperfumed baby oil and cotton wool are used instead of water or baby wipes.

Bowel movements - Baby Care

2009-02-19T10:27:00.000-08:00

For many babies a bowel movement is accompanied by much grunting, groaning and straining, and often some crying. Con¬cerned parents worry that this is a sign of pain and constipation. In my experience, this behaviour is fairly common in young babies and constipation is rarely the cause, especially with babies under four months. Dr Spock believed the reason for fussing and fretting is that the stools of very young babies are so soft they do not put enough pressure on the anus, making elimination more difficult. There is possibly some truth in this theory, as I usually find when solids are introduced and bowel movements become firmer crying disappears. A baby suffering from genuine constipation will have irregular bowel movements in the form of small hard pellets. If your baby is crying for excessive lengths of time before and after a bowel movement, seek advice from your doctor or health visitor.