Constipation in Children

Monika Pis, PhD, CPNP

Constipation, defined as hard or infrequent bowel movements (3 or less a week), is a very common phenomenon during childhood. The most likely cause is diet, although some children inherently have a slow peristalsis leading to constipation. There are many medical reasons for constipation, but I will not be addressing those in this article.

As children are transitioned from baby formula to cow’s milk, and from baby to table foods, certain feeding practices contribute to the development of constipation. Many parents think that a child should drink as much milk as formula, when actually, only 16-24 ounces of cow’s milk a day are necessary for healthy growth. While milk contains vitamins A and D, as well as calcium and fatty acids necessary for a healthy development of the brain, milk and its derivatives (cheese, yogurt, ice cream) are constipating in nature. Therefore, most children consuming large quantities of dairy products develop constipation.

Another feeding practice that leads to unhealthy elimination is catering to your child’s dietary whims. If allowed, most children would prefer to eat pizza, macaroni & cheese, noodles, chicken nuggets, and hot dogs instead of fiber-rich foods like fruits, vegetables, and beans. Processed foods high in carbohydrates lack fiber that is necessary for regularity. Therefore, diets high in carbs and low in fiber often result in hard, difficult to pass stools.

Unresolved constipation leads to chronic abdominal pain, feeling bloated, nausea, decreased appetite, heart burn, rectal bleeding from straining, urinary tract infections, vomiting, intestinal obstruction, and even bowel perforation that may result in death.

Toddlers who get constipated may become frightened of heaving another painful bowel movement. They may begin holding the stool in, which in turn causes even more constipation.

Prevent constipation in your child by serving fruits and vegetables with every meal and snack. Offer 16-24 ounces of milk daily, and limit cheese to a couple of slices a day.

The American Heart Association recommends that children older than 2 years should gradually adopt American Heart Association dietary recommendations. That means saturated fat intake should be less than 7 percent of total calories, trans fat intake should be less than 1 percent of total calories, and dietary cholesterol should be limited to no more than 300 mg daily. Children should also get the majority of calories from complex carbohydrates high in fiber.

Both children and adults should consume 14g of fiber per 1,000 calories consumed. Read the nutrition facts panel on food labels to determine how much fiber is in the food you are choosing. According to the Food and Nutrition Board of the National Academy of Sciences Research Council, the dietary fiber intake is summarized below:

Needs for Dietary Intake of Fiber


Children 
1-3 years 19 g 
4-8 years 25 g 

Males 
9-13 years 31 g
14-18 years 38 g 
19-50 years 38 g 
51+ years 30 g 

Females
9-13 years 26 g
14-18 years 26 g 
19-50 years 25 g 
51+ years 21 g 

Pregnancy
<18 years 28 g 
18+ years 28 g 

Lactation
<18 years 29 g 
18+ years 29 g

To increase fiber in your diet, follow these tips presented by The Mayo Clinic:

• Start your day with a high-fiber breakfast cereal — 5 or more grams of fiber per serving. Opt for cereals with "bran" or "fiber" in the name. Or add a few tablespoons of unprocessed wheat bran to your favorite cereal. 

• Add crushed bran cereal or unprocessed wheat bran to baked products such as meatloaf, breads, muffins, casseroles, cakes and cookies. You can also use bran products as a crunchy topping for casseroles, salads or cooked vegetables.

• Switch to whole-grain breads. These breads list whole wheat, whole-wheat flour or another whole grain as the first ingredient on the label. Look for a brand with at least 2 grams of dietary fiber per serving.

• Substitute whole-grain flour for half or all of the white flour when baking bread. Whole-grain flour is heavier than white flour. In yeast breads, use a bit more yeast or let the dough rise longer. When using baking powder, increase it by 1 teaspoon for every 3 cups of whole-grain flour. 

• Eat more whole grains and whole-grain products. Experiment with brown rice, barley, whole-wheat pasta and bulgur. 

• Take advantage of ready-to-use vegetables. Mix chopped frozen broccoli into prepared spaghetti sauce. Snack on baby carrots. 

• Eat more beans, peas and lentils. Add kidney beans to canned soup or a green salad. Or make nachos with refried black beans, baked tortilla chips and salsa. 

• Eat fruit at every meal. Apples, bananas, oranges, pears and berries are good sources of fiber. 

• Make snacks count. Fresh and dried fruit, raw vegetables, low-fat popcorn, and whole-grain crackers are all good choices. 

Click here for more sources of fiber.

Preparing Your Child for Surgery

Anna Tielsch-Goddard CPNP-PC

Life may bring unexpected events to our lives, and one of them may be surgery. Surgery of any kind can be very scary and stress provoking for children and parents.  However, being prepared will help alleviate additional stress for caregivers and help the child relax for the upcoming surgery as well.

Parents should never hide from the child that he or she will have surgery. Children benefit from honesty and simple explanations of what will happen to them when they arrive at the hospital. Children will cope best if they know what to expect.

Let your child ask any questions he or she might have and try your best to answer them with simple explanations. For example, "The doctor needs to take a special picture of your head," if your child is getting an MRI, or "The doctor and nurses are going to fix your ears today," if the child is scheduled for ear tubes. Books about surgery or the hospital can be very useful in preparing children for surgery or helping them understand their diagnosis. Make sure to tell your child that he will get special medicine called "anesthesia," so that he will not feel anything or have any pain during the surgery.

Medical play may also help children prepare for their surgical day. Children from 1-4 years old may benefit by pretend medical equipment toys. Allow them to examine a stuffed animal or doll. School aged children (5-12 years old) can prepare by looking at pictures of what will take place that day. For example, pictures of the hospital or of the preop room which can usually be found on the hospital website.

Try to keep your child's routine as close to normal as possible the day before surgery.

Medical preparation

You may need to bring your child in for blood or urine tests prior to the scheduled surgery; however, not all children need preoperative testing. If your child is taking any medications, including those over-the-counter, talk to your primary care provider or surgeon about taking these medications before surgery.

Most hospitals will call you to let you know when they want your child to stop eating and drinking, usually the night before surgery. Do not let your child eat or drink anything (this includes chewing gum or sipping water) after these times or the surgery will most likely get canceled. This precaution is to reduce the possibilities of complications from anesthesia, such as aspiration pneumonia, which can be caused from having liquids in the belly while being put to sleep.

If your child has a fever, respiratory (lung) infection, or rash a week or two before their scheduled surgery, the surgery may need to be postponed. Call your surgeon’s office to ask.

Make sure you find out if your child will be staying overnight after the surgery or going home. Arrange for a ride to and from the hospital if you do not have transportation.

Day of surgery

Bring a familiar item with your child such as a blanket or special stuffed animal.  School age children might benefit from something to distract them, such as a word game, puzzle, or some drawing materials.  Have your child dress in comfortable clothes to feel more at ease. The child will have to change into a hospital gown or scrubs after arriving at the hospital or surgery center.  Remove any jewelry or metal your child might have including hair clips and earrings.

Make plans for at least one parent to be with your child for the surgery and possible hospital stay.

Preparing yourself as a parent/caregiver

Although every hospital or outpatient surgery center is a little different, there are some main things that you can expect that are universal. On the day of your child's surgery, you should arrive at the time you were told or slightly earlier. You will be checked in and your child will get an ID bracelet that he or she must wear during the entire hospital stay. A nurse or medical assistant will take vital signs, which are a temperature, a heart rate, a blood pressure reading, and a respiratory rate. They will also obtain a current weight on your child.

Your child will have a presurgical assessment which consists of a history and physical examination usually done by a nurse practitioner or physician assistant. Sometimes your child may have already had the presurgical assessment prior to the day of their surgery. You will meet with your surgeon and anesthesiologist who will explain exactly what they will be doing and have you sign an informed consent form. This is your time to ask any questions you might have to the doctors including any potential complications, length of the surgery, and recovery time after the procedure.

Your child may be given Versed, which is a pre-op medication sometimes called "silly juice" or "goofy juice." Versed will make your child drowsy and less anxious to help her not remember leaving you when she is taken to the operating room. Versed is not given to all children and is usually prescribed on a case-by-case basis.

When your child is taken back to the operating room, you will be escorted to a waiting room or the post operative area where you will meet with your child after the surgery. Your child will never be left alone while in the operating room. There will always be a doctor, nurse, or other medical staff with your child. Your doctor will meet with you when the procedure is over to tell you how the surgery went and give you post operative instructions, such as a pain medication prescription or antibiotic, directions on how to take care of the wound, and when to come back for a follow-up. In some cases, you may need to spend the night at the hospital. (You will usually know this before the day of the procedure).

Many children's hospitals employ Child Life Specialists, clinicians, who meet with kids and help alleviate specific fears or concerns relating to their health such as surgery or the hospital. You can call ahead and ask if your surgical center will have a Child Life Specialist available.

Always ask your doctor, nurse practitioners, and nurses any questions you might have and what to expect for your child's procedure. Some hospitals and outpatient surgery centers will allow you and your child to come and view the rooms and where the preoperative assessment areas are so that your child can become familiar with the facility before their procedure.

Recommended Readings:

Bridwell, Norman: "Clifford Visits the Hospital"
Jennings, Sharon: "Franklin Goes to the Hospital"
Zelinger, Laurie: "The "O, My" in Tonsillectomy and Adenoidectomy: how to prepare your child for surgery, a parent's manual"

Further Readings:

Preparing your child for surgery.http://kidshealth.org/parent/system/surgery/hosp_surgery.html

Preparing a child for surgery. https://www.chp.edu/CHP/P03032

Preparing for Your Child's Surgery and Anesthesia ... A Parent's Role http://www.aana.com/ForPatients.aspx?id=325

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.

Headaches in Children

Monika Pis, PhD, CPNP

Headaches are common in children. However, they are always a reason for concern for parents, because their children may not be able to describe their headaches. They may become cranky, withdrawn, vomit, or prefer a darkened room. The most common causes of headaches in children are migraines, eye problems, sinus infections, and lifestyle.





Migraines
Research shows that 4% of children between 7 and 15 years of age experience migraines. Before age 10 years, boys are more likely to have migraines, but after puberty, girls are more likely to develop them. A family history of migraines, especially on the maternal side, is present in approximately 90% of children with migraines. In adulthood, 5-10% of men and 15-20% of women experience migraines. 

Factors that contribute to migraines include family history, hormonal changes, stress, bright flashing lights, and foods (see below). History of motion sickness in childhood is associated with migraines later in life as well.

Foods that may provoke migraines:
 Cheese 
 Chocolate 
 Herring 
 Soybeans 
 Nuts 
 Yeast (especially in homemade bread)
 Dried fruits (raisins)
 Mushrooms 
 Salty foods 
 Red plums 
 Ripe avocados and bananas
 Lunch meat (nitrates)
 Caffeine
 Alcohol

A common migraine in children is characterized by a throbbing or pounding headache that usually lasts 1-3 hours, but may persist for up to 24 hours. A migraine headache is often accompanied by intense nausea, vomiting, and abdominal pain. On occasion, children complain about aversion to odors, light, or noise, as well as tingling in the feet and hands during a migraine headache or experience an aura before the onset of the headache. Visual auras are not common in children, but may include blurred vision, distortion of objects, zigzags, or flashes of light. Some children complain about dizziness or light-headedness. 

Eye Problems
Nearsightedness in infants and school age children is not common. Its incidence increases during the school years, especially during the preteen and teen years. However, if your child has been complaining of headaches for a while, and perhaps you’ve noticed that he/she squints to see faraway objects or comes close to the television set, a visit to an optometrist is recommended. Poor vision produces eye muscle strain that may lead to headaches. If your child’s headaches do not go away after their vision is corrected, or if they are ever accompanied by the red flag symptoms (see below), take your child to a health care provider for an evaluation ASAP.

Symptoms to Worry About 
 Rapid onset of the first headache
 The worst headache ever
 Progressive headache lasting for days
 Headache present with straining (during coughing, sneezing, bowel movement)
 Weight loss or fever
 Seizures
 Loss of consciousness
 Stiff neck
 Morning headache, possibly accompanied by vomiting

If your child experiences any of the above symptoms, consult with a health care professional ASAP!

Sinus Infections
On occasion, a cold or uncontrolled allergies may turn into a sinus infection. Usually, cold symptoms are the worst on days 3 and 4 and then gradually improve. A sinus infection should be suspected if your child’s cold symptoms are more severe than usual, or if the symptoms persist for longer than 10 days. Headaches are very common with sinus infections and your child may complain of facial and tooth pain. If you suspect a sinus infection, take your child to her/his health care provider, as antibiotics are needed to treat the symptoms. 

Lifestyle
Many headaches in children can be contributed to irregularities in their lifestyles. For example, sleeping in or staying up late over the weekend, or skipping meals can result in headaches. This can be easily prevented by exercising good sleep hygiene (see below) and eating regular meals: breakfast, lunch, and dinner, and healthy snacks in between (listed below).

Practicing good sleep hygiene:
 Go to bed and wake up at the same time each day
 Avoid napping during the day
 Avoid caffeine 4-6 hours before bedtime
 Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime
 Exercise regularly, but not right before bed
 Try a light snack before bed
 Establish a pre-sleep ritual

Healthy snacks:
 Fresh fruit
 Cheese packs or cubes
 Yogurt
 Cheese or peanut butter on low-fat crackers
 Pretzels
 Trail mix
 Dried fruits
 Granola bars
 Whole wheat pizza w/hummus
 Low-fat, microwave popcorn
 Veggies w/low-fat dip or yogurt
 Bananas or apples w/peanut butter and cream cheese
 Baked taco chips w/salsa

Soothe Your Sore Throat!

Monika Pis, PhD, CPNP

When the flu season is upon us, other viruses circulating in our communities contribute to cold symptoms such as sore throats, which make us feel cranky and uncomfortable.

Since viruses are the major cause of sore throats, there are no medications to alleviate them, however, there are certain natural remedies that will make your sore throat feel better while your body fights off the infection.

First of all, stay hydrated. If your sore throat is accompanied by other upper respiratory symptoms, such as runny nose, nasal congestion, or cough, drink chicken broth a couple times a day. Recent research confirmed what moms always told us about chicken soup: it definitely helps when we're sick! According to the scientific findings, chicken broth thins mucus in the respiratory system, stops excessive mucus production, and relieves nasal congestion. Therefore, chicken broth will lessen coughing and might decrease postnasal drip that often results in a sore throat.

Excessive coughing can also cause a sore throat. Since cough medications are ineffective in battling the cough, reach for honey. Any honey will do, however, researchers studied buckwheat honey and announced that it is more effective in cough control than dextromethorphan, the DM component of over-the-counter cough suppressants. I recommend that my patients take 1 teaspoon of honey 4 times a day. It can be eaten off the spoon, ingested with warm water or tea with lemon, or drizzled on toast with butter, pancakes, or graham crackers. (Note: honey should not be given to children younger than 1 year as it may cause botulism).

Consider these remedies to relive your sore throat:

 Gargle with chamomile tea--it has anti-inflammatory properties.

 Drink orange juice. It might sting, but the vitamin C will numb your throat instantaneously.

 Munch on raw almonds. They contain an aspirin-like compound that works wonders, not only to relieve migraine headaches, but also sore throats.

 Eat fresh or canned pineapple. Pineapple contains bromelain, an enzyme with anti-inflammatory properties.

 Sip on a warm tea with honey and lemon. Honey will coat your throat and the lemon juice will quickly numb it.

If your sore throat persists beyond 3-4 days, or is accompanied by a fever, rash, or bad headache, you have a difficult time swallowing your saliva, or you choke on food, see your health care provider ASAP.