Thursday, May 23, 2013

My 15-year old hates me...

Adapted from Education.com...

My 15 y/o son insists that I left him alone throughout his childhood.  For the last couple of years he tells me he hates. He acts out in school, doesn't do school work and he smokes pot. The last 5 months were better as far as him hugging me and telling me he loves me, until today.  He got in trouble in school.  He said I told him he was a mistake.  I did not say that to him. He always twists what is said. I said he disappointed me and that he means the world to me.  He hates me again and is insisting I left him alone as a child and that is where I messed up as a mother.  He will not listen to me.  How do I change what he believes.


Expert

Dr.Monika
May 23, 2013

What the Expert Says:

Your son's acting out and using drugs are cries for help.  Sounds like there is something going on with him on the emotional level.  Has he been depressed?  Moody?  Doe she get outbursts of anger?  Any of these, or even the sole fact that he uses drugs, need attention of an adolescent therapist as soon as possible.  Your son's regular health care provider will be able to refer you to one in the community.

Best regards.

Friday, May 17, 2013

How to Deal With a Child Jealous of a Dog

Q: 

My 4-year-old son is mean to our dog, Mac. He says "that's not my dog, it's your dog." He gets mad when Mac follows me around the house.I try explaining that I raised Mac, and he's just being protective. I've tried getting him to interact with Mac by having him do tricks and giving him a treat...but my son ends up teasing Mac with the treat and not wanting to give it to him...What should i do?


A:

Have you ever watched the show "The Dog Whisperer" with Cesar Millan?  You might want to watch it with you son so that he can learn that dogs are pack animals.  They like to have a family and they like to have a leader.  If they do not have a leader they act out by constantly barking or misbehaving in various ways.  Tell your son that everybody in the family, including him, should learn to be a pack leader so that the dog can respect them.  When there is a dog in the family, the dog belongs to everybody, and everybody needs to learn how to be "calm assertive" with the dog, to give him guidance (discipline), exercise, and affection.

Monday, February 25, 2013

Conjunctivitis: The Pink Eye


Anna Tielsch-Goddard CPNP-PC

The most common causes of pink or red discoloration in the conjunctiva (the clear membrane which covers the sclera, the white part of the eyes) are bacterial, viral, or allergic conjunctivitis. This condition is also known as "pink eye."
If your child has pink or red eyes, complains of itchiness, and has any sort of crust or drainage around the eyes, you should make an appointment with your child’s primary care provider (PCP) for diagnosis and treatment. Your PCP, a pediatrician, nurse practitioner, or physician assistant, will be able to determine whether or not the pink eye is most likely caused by a bacteria, virus, or allergies.
Pink eye usually causes sleepy crust or "a glue" in the eyes, upon awakening. If your practitioner determines that the pink eye is caused by bacteria, he or she will prescribe a topical antibiotic, usually in the form of eye drops, which will reduce your child’s symptoms, shorten the duration of the illness, and reduce the risk of contagiousness.
If your child has cold symptoms, such as a cough, runny nose, or nasal congestion, the cause of the pink eye is most likely viral. If your PCP thinks that the pink eye is caused by a virus, he or she will recommend cold compresses, artificial tears, and other symptomatic treatment.
Another type of conjunctivitis, allergic pink eye, is usually affiliated with allergies, eczema, and asthma. This type of pink eye causes itchy eyes and watery discharge. Treatment involves avoiding exposure to allergens and using artificial tears or prescription eye drops to alleviate the red eyes.
Other causes of red eyes include subconjunctival hemorrhages and blepharitis.
Subconjunctival hemorrhages are caused by broken blood vessels in the eye that cause redness in the conjunctiva. They are caused by minor trauma such as vomiting or prolonged coughing, are painless, and usually resolve on their own in 2-3 weeks.
Blepharitis, a more severe inflammation of the eyelid, may also make the eyes appear red and will usually be accompanied by a swollen eyelid or crusting in the eyelid margin. Treatment, including warm compresses and a topical antibiotic, is necessary to help with healing. In severe cases a referral to an ophthalmologist is necessary.
In all cases of pink eye, you must teach your family to practice strict hand washing and avoid sharing any personal items that might spread infection. Any time your child touches or rubs the eyes, he or she should wash hands right away or use an anti-septic hand sanitizer. Avoid sharing wash-clothes and other cleansing objects.
Contact lenses should not be worn until the infection clears up. If your child wore the lenses during the course of the pink eye, discarded them and obtain a new lens case. Cross contamination usually subsides after 24 hours of antibiotic therapy.
If you child’s red eyes do not get better in a couple of days after seeing your primary care practitioner, you should make another appointment for a re-evaluation in case there is a re-infection or another cause for the red eyes.

References:
Cronau, H., Kankanala, R., & Mauger, T. (2010). Diagnosis and management of red eye in primary care. American Academy of Family Physicians, 81(2), 137-144.
  1. Hovding, G. (2008). Acute bacterial conjunctivitis. Acute Ophthalmologica,86(1): 5-17.
  1. Leibowitz, H. (2000). The red eye. The New England Journal of Medicine, 343 (5): 341-345.
  1. Sethurama, U., & Keepak, K. (2009). The red eye: evaluation and management.Clinical Pediatrics, 48 (6): 588-600.
ANNA TIELSCH-GODDARD CPNP-PC
Anna Tielsch-Goddard CPNP-PC is a Pediatric Nurse Practitioner for Children’s Medical Center Dallas at Legacy. She practices on the Perioperative Surgery teams in both presurgical assessment and pediatric-surgery.

Thursday, February 21, 2013

Winter Safety


Dr. Hillary



Winter is here, so is the snow, ice and frigid temperatures, and while winter activities may seem mundane, they can be dangerous. Winter wonderland offers plenty opportunities for various outdoor activities than can be fun, but may present all of us with safety challenges. 

Accidents are the most obvious safety issue of winter outdoor activities. However, let’s not forget frostbite, hypothermia, and heart attack. I always tell my patients that prevention is the best medicine. In agreement with this principle, I have outlined important safety measures below that you should take this winter to keep yourself and your family safe.

Before You Head Outside
- Dress in light layers, paying special attention to your nose, ears, hands, and feet.
- Wear a hat, as the most heat escapes our bodies through the head!
- Wear gloves and thick/warm socks.
- Cover lips/cheeks with a thin layer of Vaseline or Eucerin to prevent excessive skip drying and chapping.
- Check out these safety tips for sledding: Winter Sledding Safety Tips
- Check out these safety tips on ice safety: Danger Thin Ice

Getting Ready To Shovel
- Snow shoveling increases heart rate and blood pressure, so if you have a heart condition or are out of shape, do not shovel unless your health care provider says that you can.

- If you are over 40 years old, or physically inactive, check with your health care provider before trying to shovel your driveway.

- Snow shoveling is aerobic activity, so warm up before you grab the shovel.

- Pace yourself! Take frequent breaks and drink fluid to prevent dehydration.

- If you experience chest pain, shortness of breath, or other symptoms of heart attack, stop shoveling and immediately seek emergency care!

- Pushing snow in front of you is easier on your back than lifting and throwing it.

- If you have to lift, use proper body mechanics: squat, bend knees, and lift with your back straight. Scoop some snow, and walk to where you want to dispose of it. Throwing snow with a shovel, especially if you twist your body, puts too much stress on your back.

- Before you operate a snow blower, read the instructions. The most important thing to remember: Never stick you fingers in the snow blower to remove impacted snow! Use a stick instead.

When On The Road 
Have these emergency items in the car with you at all times in winter:
- Cell phone
- Flashlight
- Jumper cables
- Snow scraper/brush
- Small shovel
- Blankets
- Flare
- Sand or cat litter for traction

For long car trips, pack water, energy bars, food, extra blankets, and necessary medications.

When you stay outside on cold winter days, come inside every half hour to warm up. Every couple of hours drink a cup of hot cocoa or broth. Do not drink caffeine. Warming up will prevent hypothermia.

What is hypothermia?

Hypothermia is a term to describe low body temperature that results from extended exposure to cold temperatures. Each year over 700 people die from hypothermia, so it’s important to be aware of it and know how to prevent it. About half of deaths due to hypothermia occur among people younger than 65 years of age. However, anybody is at risk in wintertime, so take steps to prevent it!

How to prevent hypothermia?
- Dress in light layers.
- Wear gloves, hat, thick/warm socks, and water proof shoes.
- Go indoors every half hour to warm up.
- Every couple of hours, have hot cocoa or broth.
- If you are cold, stay indoors, and do not venture out again until you warm up adequately.

What is frostbite?
Frostbite results from exposure to freezing temperatures. It most often affects the nose, ears, cheeks, chin, fingers, and toes. Frostbite causes a loss of feeling and color in the affected area, and it may settle in as little as 20 minutes! Frostbite can lead to permanent damage of the affected area, and if severe, may lead to amputation. 

Signs and symptoms of frostbite: numbness, waxy white or grayish-yellow skin. If you see these signs, seek medical care right away. If you cannot see a health care provider immediately and have no signs of hypothermia, get into a warm room right away, do not walk on frostbitten toes as it may increase damage, immerse the affected area in warm water, do not rub it, do not use a heating pad. If hypothermia settles in, seek immediate medical attention!

Weight Loss


Dr. Hillary 

The beginning of a new year means (for many) a fresh start, new opportunities, and a chance to make things better or “right." We vow to eat less, exercise more, spend more time with loved ones, spend less money, etc. 

Since weight loss is a popular New Year’s resolution, I would like to encourage those who want to lose weight to start making permanent changes in their lifestyles. Since it took time to put on extra pounds, it will take time to lose the excess weight. Don't fall for weight loss programs that claim immediate results. There are no shortcuts to weight loss. Weight loss is a lifetime project that requires commitment and perseverance.

Weight loss and gain are directly related to the energy we supply our bodies by eating food and the energy burnt in daily activities. For weight maintenance, there needs to be balance between energy supply and demand. When there is more supply, the energy surplus turns into fat cells. It is only when there is more demand for energy that weight loss can begin.

The only goal of weight loss should be losing excess body fat. Losing water or muscle is not healthy and it does not improve appearance or performance! The two most important habits that anybody trying to lose weight should adopt are: developing healthy eating and getting enough physical activity. 

Developing Healthy Eating

Three square meals a day and nutritious snacks in-between are necessary for performance in our daily activities and overall health. Be mindful of your portion sizes and select foods high in fiber and low in fat and sugar. Here are some ideas to consider:

 Replace soda and juice with water.
 Broil, steam, or bake foods instead of frying.
 Eat whole-grain cereals, breads, etc.
 Replace full-fat dairy with low-fat equivalents.
 Decrease fast food intake to once a month.
 Remove temptation--Do not keep high-fat and high-sugar foods at home.
 Always eat breakfast.
 Select healthy snacks.

Healthy Snacks

Pop corn (no butter)
Graham crackers
Fruits (fresh or dry)
Raw vegetables with cream cheese or peanut butter
Low-fat frozen yogurt

Get Enough Physical Activity
Physical activity helps with weight control by using energy in our bodies that otherwise would be stored as fat. Everything that we eat provides our bodies with energy. On the other hand, everything that we do utilizes that energy. The more things we do, the more energy our bodies burn and the math is simple: our body fat starts to melt away!

Many of us come up with multiple excuses not to exercise simply because most of us don't enjoy it! Personally, I prefer to engage in physical activity with a purpose other than exercising. I like to garden, thus every spare moment in the spring, summer, and fall I spend outside planting and weeding. I even decided not to hire a yard clean-up crew this past fall so that my husband and I could get some exercise raking. In the winter we shovel our driveway, make a snowman, have a snowball fight, or go for walks in the woods to watch birds and deer. Here are some ideas to boost your physical activity in a “user-friendly” way:

 Decrease sedentary behaviors. By doing this, you’ll increase your chances of being more active. So, limit TV/Computer/Video game time to 1-2 hours per day.
 Walk your dog daily. If you don’t have a dog, borrow one from the neighbor.
 Play tag with your kids.
 Park your car as far from a store’s entrance as possible.
 Take the stairs instead of an elevator.
 Get a jump rope and jump with it twice a day for 5 minutes.
 Check out a yoga or other exercise tape or CD from your local library and exercise with it a couple of times a week.
 Team up with your family members or friends and go on 30-minute walks around the neighborhood 2-3 times a week.
 Get up to change the TV channels instead of using the remote.
 Have a dance party with your kids.
 Don’t forget that gardening is an excellent way to burn calories!

Benefits of Regular Physical Activity

To get the most benefits, you should exercise at least 20-30 minutes every day. Aerobic activity such as brisk walking, jogging, bicycling, dancing, and swimming should be a part of your exercise routine. Here are some tips to make sure you have an enjoyable and effective experience:

 Choose activities that you enjoy.
 Build up an exercise routine gradually.
 Exercise at a comfortable pace.
 Wear comfortable shoes and clothes.
 Exercise in a safe environment.
 Hydrate your body before, during, and after exercise.
 Challenge yourself!

Examples of Aerobic Activity

Brisk walking
Jogging
Bicycling
Dancing
Swimming

Tips for Effective & Enjoyable Physical Activity
 Choose activities that you enjoy
 Build up exercise routine gradually
 Exercise at comfortable pace
 Wear comfortable shoes and clothes
 Exercise in a safe environment
 Hydrate your body before, during, and after exercise
 Challenge yourself!

Tuesday, February 19, 2013

Influenza Survival Guide


Dr. Hillary
Influenza is the most common disease in the U.S. that can be prevented by vaccination. Yet, 5-20% of the population (about 15-60 million people) come down with this potentially life threatening respiratory illness. Annually, there are approximately 36,00 deaths related to influenza.


Serious complication due to the flu can occur at any age. However, children, people over 65 years of age, and those with chronic medical conditions are at the highest risk. The symptoms of the flu include: fever, headache, fatigue, dry cough, sore throat, runny and stuffy nose, and body aches. These symptoms usually occur suddenly, and those affected report feeling as if they were “hit by a truck.” Although symptoms of a regular cold are similar, they develop gradually over a few days and are not as intense as the symptoms of the flu. For comparison of cold and flu symptoms, see Table 1.

{sidebar id=17} The influenza virus multiplies in the lungs and it spreads from one person to another via droplets from coughing and sneezing. That’s why it is very important to cover your mouth (preferably with your sleeve, not the hand) when coughing or sneezing. Washing your hands is also crucial to prevent the spread of the virus.

What to do when the virus strikes? 
Two of the most important things that you can do for yourself or your family members when they get the flu is to rest and drink plenty of clear fluids. Warm tea with honey and lemon for older children and adults, as well as chicken soup (homemade is the best, but canned counts too) will help to thin out secretions. Scientists confirmed what moms and grandmas knew all along: chicken soup helps in upper respiratory illnesses by loosening up mucus. Therefore, a daily dose of chicken soup daily during the illness will help you feel better and may speed up the recovery. If you are a vegetarian, vegetable broth or warm tea with honey will do.

Flu Treatment
Rest
Warm clear fluids (no milk as it thickens mucus and worsens symptoms)
Chicken soup (loosens up mucus)
Expectorant (i.e. Robitussin, Mucinex)*
Fever reducing agents (i.e. Tylenol, Motrin, or Advil)*
Saline nasal drops (relieve congestion)
Antiviral medications prescribed by your health care provider
Possibly antibiotics

*Contact your health care provider to get safe dosing instructions for children.

Do not be afraid of the fever. Fever simply means that the body is trying to fight off the infection. Since it stimulates the immune system, reducing the fever may not be necessarily beneficial. I use general rules of thumb when counseling patients about the fever treatment:

 If the fever is less than 102 and the patient is comfortable, I suggest fluids and cool compresses to the neck, armpits, and the groin area. The skin in those areas is thinner than anywhere else and blood vessels are closer to the surface. Cool compresses will help to cool the blood, thus reducing the fever. But do not let the feverish person shiver as shivering, which is caused by contracting muscles, increases the body’s temperature.

 If the fever gets to 102 or above, or for any fever that causes discomfort, I suggest acetaminophen (i.e. Tylenol), or ibuprofen (i.e. Motrin, or Advil) in addition to fluids, rest, and compresses.

 Viral illnesses, such as the influenza, may produce fever lasting for 3-4 days. At any time the fever persists beyond 3 days, or it cannot be controlled with fever reducing medicines like Tylenol or Motrin, you should seek evaluation of your health care provider.

Most people recover from the influenza in about 1-2 weeks. However, a significant number of people infected with the flu will develop complications, such as an ear or sinus infection, pneumonia, or encephalitis. In addition, the flu may exacerbate chronic illnesses, such as asthma, heart diseases, or COPD. Furthermore, a significant fatigue that accompanies the influenza may persist for 3-4 weeks.

One of the most effective ways to prevent getting sick with the flu is through vaccination. Young children 6 months of age or older, adults over 65 years of age, people with chronic illnesses, especially those affecting the respiratory and cardiac system, should get vaccinated against the influenza annually.

Why do I need to get the flu shot every year?
The influenza virus is very adaptable and is constantly changing. Different strains of the virus may exchange their genes or simply mutate leading to the birth of new influenza strains. The influenza vaccine available to us every fall is a result of scientific predications as to which influenza strain will predominate in the up-coming season. Since no prediction is ever exact, the available vaccine may not necessarily be 100% effective if the prediction for the season turns out inaccurate. In addition, since the virus has the ability to change rapidly from season to season, the flu vaccine that will be available to us this year probably would not be effective in the next flu season. Thus we should get vaccinated against the influenza every fall.

Monday, February 18, 2013

Preparing Your Child for Tonsillectomy


Anna Tielsch-Goddard CPNP-PC

A tonsillectomy and adenoidectomy, often referred to as a "T&A," is one of the most common pediatric surgeries. 
The tonsils and adenoids are gland tissues that are found in the throat. These glands are part of the body’s immune system and help fight infection. Sometimes, the tonsils and adenoids can become infected and cause problems, such as bacterial infections known as tonsillitis or strep throat, or they can become so enlarged that they cause airway obstruction.
The tonsils are located in the back of the throat, and the adenoids are higher in the throat behind the nose and the roof of the mouth. The tonsils can be seen by shining light into the mouth and looking at the back of the throat. The adenoids are not visible through the mouth or nose and special pictures, such as an X-ray or CT scan, must be used to look at them.
If your child has any of the following, he or she may need to be evaluated by an ENT physician (an Ears Nose and Throat specialist) to assess whether your child may need to get his or her tonsils and/or adenoids removed:
  • mouth breathing
  • noisy breathing throughout the day
  • recurrent ear infections
  • snoring every night
  • restless sleeping
  • breath pausing while sleeping
  • frequent throat infections, and/or abscesses (pockets of pus) on the tonsils
Just having large tonsils alone does NOT necessarily mean that your child must have their tonsils removed. Each child should be evaluated individually.
Prior to surgery
Your child’s physician may want to order a blood or urine test prior to surgery. Most hospitals will call you to let you know when they want your child to stop eating and drinking, usually on the night before surgery. Do not let your child eat or drink anything after these times or most likely the surgery will be canceled the next day. This precaution is to reduce the possibility of complications from anesthesia, such as aspiration pneumonia, which can be caused from having liquids in the belly while being put to sleep. You should talk to your child about his or her hospital visit. Have your child pick out a familiar toy or blanket to bring along to the hospital.
Surgery
Your child will be asleep under general anesthesia for their T&A, and he or she will not be able to feel anything during the procedure and will not be in pain. The pediatric ENT surgeon will remove the tonsils, and the throat will be able to heal naturally without any stitches. The tonsils are removed through the mouth and there is no cuts or incisions into the skin. Most children are able to go home several hours after their surgery as long as they are breathing without difficulty, are able to swallow and have something to drink.
In some cases, your child will need to stay overnight in the hospital for observation. Your medical provider should let you know before the day of the procedure if this might be the case. Children that need to stay overnight after a T&A are usually younger then 2-3 years old, have prior sleep apnea symptoms, or have chronic diseases, such as seizures, and need to be closely monitored after having surgery.
After your child’s T&A 
It is important to be with your child or have a caregiver come to the hospital for the next few days after a T&A. An upset stomach for a few hours after surgery and feeling sleepy after the anesthesia are normal. Your ENT specialist will prescribe pain medication to give your child after the surgery. It is important to follow these guidelines and give your child the pain medication after the tonsillectomy.
Good fluid intake and no "horse play" after surgery are very important. Any surgery comes with risks and possible complications, even though these complications are very rare. Watch your child for any type of throat bleeding after the surgery. If there is throat swelling, throat bleeding, or your child is having difficulty breathing, this is an emergency, and you must bring them to the ER or call 911 for immediate treatment.
Most children are absent from school between 5-10 days after a tonsillectomy. They should not participate in gym or any type of strenuous physical activity for 14 days (or 2 weeks) after their surgery. Make sure your child is drinking adequately. Sometimes the throat can be sore and your child might not want to take fluids. It is important to make sure you give your child the prescribed pain medication, so that he or she will maintain appropriate fluid intake.
If you have any questions or concerns after your child’s tonsillectomy and adenoidectomy, you should contact your physician or nurse practitioner who is involved with their care.
References:
The American Academy of Otolaryngology- Head and Neck Surgery: Tonsils and Adenoids. Available at: http://www.entnet.org/HealthInformation/tonsilsAdenoids.cfm
Drake, AF., Carr, M. (2011).  Tonsillectomy. eMedicine Available at Medscape at: http://emedicine.medscape.com/article/872119-overview
United States National Institute of Health. Tonsillectomy. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003013.htm
Wetmore RF. Tonsils and adenoids. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 380
ANNA TIELSCH-GODDARD CPNP-PC

Anna Tielsch-Goddard CPNP-PC is a Pediatric Nurse Practitioner for Children’s Medical Center Dallas at Legacy. She practices on the Perioperative Surgery teams in both presurgical assessment and pediatric-surgery.