The Montreal Children's Hospital

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Ask the expert

Dr. Richard Haber, Director of The Pediatric Consultation centre at The Montreal Children's Hospital, along with his colleagues answer your questions about kids' health. We feature sample questions and answers every month in our e-newsletter, Where Kids Come First.

Q: My daughter is in her teens. Her doctor said she should learn to do breast self-exams. Should she really start now?

A: A teenage girl’s chances of developing breast cancer are extremely low, but that doesn’t mean she shouldn’t get into the habit of doing monthly breast self-examinations (BSE). Although a teenage girl is still developing—and her shape may change significantly as she approaches her 20s—starting BSEs early will help her get to know how her body feels normally. Over time, she’ll be in a better position to recognize changes in her body.

When teenage girls start to do regular monthly self-exams, they sometimes discover cysts in their breasts. Cysts are rarely cancerous however it is still a good idea for teenage girls to learn how to recognize them. A cyst is a fluid-filled sac that is usually round or oval; they can feel either soft or hard to the touch. Cysts can sometimes cause pain or tenderness in the breast but this tends to increase and decrease with the monthly cycle.

To get into the habit of doing monthly BSE, it’s recommended that your daughter do the exam at the same time every month. Ideally, that would be a few days after her period ends, which is a time when breasts are less tender. Your daughter can talk to her doctor if she notices any changes in her breasts over time.

Q: My daughter regularly complains about her ears being blocked. The doctor assures me that everything is normal and that there’s no impacted earwax buildup. What could be going on?

- Concerned mother

A: Blocked ears are often associated with what is called Eustachian tube dysfunction, defined as the failure of the Eustachian tube—the narrow tube that connects the middle ear to the back of the nose and throat—to function properly. This tiny tube is responsible for equalizing the pressure on either side of the eardrum. When a person is congested, the Eustachian tube becomes blocked and the resulting air pressure imbalance leads to a feeling of blocked ears.

Eustachian tube dysfunction is very common in children aged 0-5 years due to immature tubes. In fact, the shorter and more horizontal Eustachian tubes predispose young children to a higher incidence of blocked ears. While some kids with severe Eustachian tube dysfunction don’t complain, it is important to know that they may nonetheless experience temporary hearing loss and may be more susceptible to middle-ear problems (e.g. otitis, fluid build-up behind the eardrum).

What can be done to improve Eustachian tube function?

There are a few techniques to force this tiny tube to open, but it’s important to start with the basics, such as blowing your nose. Then, try swallowing or yawning to open up your Eustachian tubes and relieve the pressure inside your ears (i.e. the popping sound you hear each time you swallow or yawn). Unfortunately, inflammation due to nasal congestion may prevent the tube from opening and closing properly, and cause increasingly unpleasant pressure inside the ear. When this happens, the only thing to do is be patient and wait for the cold to pass. However, if the problem persists, you may need to consult an ear, nose and throat (ENT) specialist.

Q: Has a heart transplant, like the one Vincent Lambert will need, ever been performed at The Montreal Children’s Hospital?

- Curious Laval teen

A: Yes. In 2002, a multidisciplinary team from the MUHC's joint pediatric and adult transplant team performed the first mechanical heart procedure in Canada, using the Berlin Heart. Although the members of the team had some experience in certain aspects of this procedure, most had a weekend to learn how the device worked, how to perform the procedure on a child and what follow-up care was required.

The Berlin Heart kept two year-old Émile Jutras alive for 109 days until he was able to receive a heart transplant. Today, he is cared for by the MCH Intensive Ambulatory Care Service and is doing very well. Altogether a team of about 100 people were involved in the care of Émile and his family. It is this kind of leading-edge training experience that makes The Children's an outstanding place for new generations of healthcare professionals to learn and practice medicine.

Q: At home, we’re in the habit of having a glass of wine with dinner. Since our daughter turned 16, she has been asking us if she’s allowed to have a glass too. When we say no, she comes back with the well-known argument that a glass of red wine per day is good for the heart. Is this true?

A: A modest intake of red wine has been shown to have benefical health effects. I do not think it is harmful for your 16 year old to have one glass of wine with you during meals together . This will teach your daughter the proper use of alcohol in a social context; better that she drink it with you than binge drink with her friends on weekends. I would not recommend this on a daily basis but perhaps reserve it for weekend meals together and special occasions. A 16 year old needs to have her wits about her as she deals with homework and school projects during the week. I think you should be happy that your daughter communicates with you and trusts you enough to make such a request. You must be doing something right!"

Q: My son suffers from frequent nose bleeds during the winter months. Can I do anything to try and prevent them?

- Mom in Laval

R: Almost everyone has nosebleeds from time to time, especially during the winter months, as the air tends to be drier. Most nosebleeds are associated with dry, fragile nasal mucosa, a minor injury to the nose, colds or allergies. Other causes include violent sneezing, blowing the nose too forcefully or a foreign object in the nose. The blood vessels in the nose are near the surface, so even a slight injury can cause bleeding.

To try and prevent nosebleeds, teach your child to avoid picking at the nose or blowing it vigorously, especially during cold season. It is also recommended to use a humidifier to increase humidity in your home as the weather gets cooler, as this can help infuse drier air pockets with much needed moisture.

If your child is suffering from nasal dryness and irritation, you may gently apply a thin layer of bacitracin or petroleum jelly just inside the nostrils one to two times s day for some relief. Stuffy noses can be relieved by putting two to three drops of warm saltwater in each nostril before gently blowing a child’s nose. Use an over-the-counter brand such as Ocean or Salinex or make a homemade solution by dissolving 1/4 teaspoon salt in a lukewarm cup of water to help with decongestion.

For more information on nosebleeds, click here.

Q: I have been hearing a lot about measles and the current school-based vaccination campaign. Why is measles making a resurgence right now?

- Curious Dad

R: While measles was once nearly unheard of in North America, it never completely went away. Last year, there were thousands of cases of measles, though they were mostly limited to countries where children went unvaccinated or incompletely vaccinated. Still, a recent resurgence of the disease has been observed throughout Europe over the past years, and more particularly in France, where children and adults have not been immunized sufficiently against the disease.

The Quebec Institute of Public Health has determined that measles likely made its way to this province in the last year through one individual vacationing abroad. This person, upon returning home developed and subsequently transmitted the disease here. It has been estimated that there were 751 measles cases as a result in 2011.

The reasons why such an outbreak occurred in Quebec are not clear. However, parental hesitancy to vaccinate against measles has increased following Wakefield’s study published in 1998 in The Lancet alleging that the measles (MMR) vaccine was linked to autism spectrum disorders in children. The publishing of this study led many parents in Europe and elsewhere to forego vaccinating their children against this disease. As Dr. Caroline Quach, Infectious Disease Specialist, explains when immunization rates drop below the coverage needed to prevent an epidemic of measles, the risk of an outbreak greatly increases, as we are now seeing in North America and throughout Europe.

Dr. Caroline Quach will be giving a talk on measles during the 2012 edition of Kids’ Health 101 Webinars. Registration has begun and space is limited. Our free webinars are offered in English starting March 13th and in French starting January 24th. Interested parents and caregivers can register by emailing info@thechildren.com or can obtain more information by calling 514-412-4307.

Q: My grandson is very active and curious, so much so that he has started putting nearly everything in his mouth. I am worried about his safety and am also wondering what I should do in the event that he swallows something harmful. What can I do to discourage this behavior and keep him safe?

- Troubled Grandmother, Montreal

R: It is quite normal for children to put things into their mouths when they are still very young. By school age, many kids have started to outgrow this method of learning about the world. If you find that your grandson is still in this habit at school age, you may be able to convince him that it's not such a great idea. Tell him about germs on toys and about how dangerous it can be to swallow something that shouldn't be in his mouth. Then give him gentle reminders as needed.

While most products like Play-Doh and crayons are non-toxic and are designed to be safe for children, the risk of choking on large chunks of such products can present a danger. Adult supervision is therefore the first way you can limit and control the products that your grandson puts in his mouth. The second is keeping potentially hazardous products and chemicals away from the reach of children.

Because young children haven’t yet developed the ability to chew, it is important to pay attention to the size of food items and household products. While a piece of hot dog may be harmless to a small child, a large enough piece in the right shape can potentially block a child’s airway.

Dangerous products such as nails, pins, needles and tacks, coins, rocks, buttons, batteries, magnets and pieces of jewelry should always be kept out of the reach of small children, as ingestion of these items could result in serious injury requiring emergency surgery.

Other very dangerous substances including vitamins, medicines, supplements, alcohol, poisons and chemicals can be accidentally ingested by young children and should therefore be kept in a designated area, under lock and key, far away from children.

Whenever you are in doubt, a call to the Québec Poison Control Centre at 1-800-463-5060 is recommended. They can also be reached by dialing 811.

Eventually, when children are old enough, it’s a good idea to teach them the exact risks of certain substances. One last thing is that if you no longer need chemical products that are stored in your home, dispose of them safely.

Q: Hello. I have a 13-month-old baby that eats really well; should I give him vtamins?
Thanks

A: For a healthy child with a normal diet there is no need to give vitamins. There is no ‘vitamin pill’ that can replace a normal healthy diet rich in fruits and vegetables. Having said that, there is an argument for giving additional Vitamin D during the winter months in our northern latitude. I would recommend Vitamin D 400IU per day.

Q: Hi there,

My newborn son is 5 weeks old and has started to cry uncontrollably, mostly in the evenings. He often seems inconsolable and often gets red-faced, and draws his legs up. I have tried everything and nothing seems to calm him down. I have read up on infantile colic, but I’d like to separate fact from fiction. Is there a cause for infantile colic? Do any alternative treatments really work, and which ones do you recommend?

Thank you,

Tired Mom

A: Unfortunately, we don’t know the cause of colic, and we still don’t have a remedy. In my practice, I usually stress four things: first, we don’t know the cause of colic but it’s self-limiting and has no long-term consequences that we know of; second, I try to encourage the new mother to get some relief as it can be exhausting for a first-time mom who may also be trying to breastfeed; third, if the caregiver is feeling that he/she is “losing it,” I would recommend having her put the baby down in the crib and go for a walk. This latter piece of advice is necessary because the “shaken baby syndrome” is a risk in these situations.

Finally, I don’t object if the parent wishes to try a harmless remedy such as simethicone drops (Ovol), or gripe water, which is water with a variety of different ingredients including one ore more of the following: sodium bicarbonate, alcohol (not recommended), chamomile, fennel, caraway, ginger, peppermint, aloe, lemon balm, sucrose, fructose, clove and others. Gripe water is manufactured under many different brand names and the ingredients are considered harmless. Some parents claim that Ovol or gripe water help relieve the colic (placebo effect) but again, we just don’t yet have any evidence-based recommendations for the treatment of infantile colic.

Q: I have a teenage daughter has recently expressed interest in getting a tattoo or a piercing. I am not completely opposed to the idea, but I do worry about the safety of body art and whether or not there can be any medical consequences associated with it. What is your opinion?

- Body Art-Free Mom

A: This is an excellent question and raises some interesting issues. It’s clear that body piercings and tattoos have spread more widely in our culture and are increasingly accepted by the mainstream.

Piercings and tattoos have been associated in adolescents with risky behaviours. One study assessed 484 adolescents aged 12-22 attending an Adolescent Clinic in California. There were 13.2% reported tattoos with 5.25% having more than one; 26.9% had body piercings excluding the ear lobes; and 11.8% had more than one piercing. The most common piercings were ear cartilage (excluding the lobe) – 13.6%; mouth/tongue – 11.2%; navel – 10.7%; nipple – 1.2%; and genitals – 0.8%. Teenagers with tattoos or piercings were more likely to have disordered eating, alcohol or marijuana use, hard drug use, higher scores on a Sexual Behaviour Index measuring age at first intercourse, number of partners and contraceptive use, and higher suicide rates.

Medical complications

In addition to the behavioural components of body art, there are clear medical complications associated with it. These include infections such as hepatitis B and C, HIV, staphylococcal infections, Pseudomonas infections and others. As well, depending on the body site pierced, there can be complications of bleeding, cyst formation, and dental problems, among others. Difficulties associated with piercing the soft part of the ear can be: infections, bleeding, keloid scars, ear lobe deformity and cyst formation. Nose and ear piercings can be infected with Pseudomonas and this can lead to cartilage necrosis and resultant deformity.

Contact dermatitis isn’t uncommon, particularly with nickel earrings, but it may occur even with gold earrings. Generally these reactions are mild but sometimes may be more serious causing diseases such as bacterial endocarditis (infection of the heart). One study reported a 30% complication rate from simple ear piercing, the most common being minor infection, followed by allergic reaction. If the cartilaginous part of the ear is pierced there can be destruction of cartilage requiring plastic surgery to correct the defect. The Centres for Disease Control and Prevention lists the practices that need to be followed in order to avoid the infectious complications from piercings and tattoos.(http://www.cdc.gov/Features/Body/Art)

It would be wise to immunize teens against hep B before considering piercings. As well, regardless of the age of piercing, one should only have it done in a facility that uses sterile techniques (see CDC guidelines). If you can’t be sure that these guidelines are followed then you should avoid that facility and look for one that does.

Mutual consent

What should the age for ear piercing be? There’s no easy answer to this question but as it’s really a cosmetic procedure, should we not wait until the child is old enough to express an opinion and give informed consent? Adolescents are another story, as peer pressure often leads to rash decisions about body art before parents have time to discuss the issue. Sadly, one teen in my practice had a large tattoo done without discussing it with her parents. Now, several years later, she wishes to have it removed but this isn’t feasible without leaving a scar. Older adolescents and young adults going for job interviews have reported wishing that they did not have an obvious tattoo, which led the interviewer to form an unflattering opinion of their application, even if this isn’t justifiable.

Body art has been with us for centuries and will remain but caution should be exercised, particularly with children and teenagers, who may not always be able to give completely informed consent. It’s also vital that the body art be done in a reputable facility following the CDC or similar guidelines.

Q : After one of their classmates came into school with a henna tattoo, my children, aged 8 and 12 are begging me to let them get one too. A family friend, however, told me that her daughter had an awful reaction to one and I am concerned that they may not be safe for children. What is your take on them, and what should I do?

-Tattoo-free Mom

R: The temporary tattoos of henna originated in India and the Middle East and were often used in religious ceremonies, such as weddings. Henna itself is harmless, made from the ground leaves of the plant Lawsonia inermis whose active ingredient is a naphthoquinone mixed with water or oil. When applied to the skin it does not penetrate into the dermis but stains the epidermis a reddish-brown. It doesn’t cause any allergic reactions. The problem comes when the henna is adulterated with additives and in the case of ‘black” henna, this additive is para-phenylenediamine (PPD), which is known to cause a delayed Type 4 sensitivity reaction. These delayed reactions may occur from 1-3 weeks after the tattoo, as in the case of your friend’s child.

PPD penetrates deeper than henna and passes into the dermis where it has access to the blood. Occasionally, it may cause a more severe systemic reaction and in children with glucose-6-phosphate dehydrogenase (G6PD) may result in acute hemolysis (the destruction of red blood cells which leads to the release of hemoglobin from within the red blood cells into the blood plasma).

PPD cross reacts with other drugs including sulfonamides, para-amino benzoic acid (PABA-used in sunscreens), benzocaine and para-aminosalicylic acid (PAS), used in the treatment of tuberculosis. If someone was allergic to one of these, they’d be at risk to react to PPD in henna tattoos.

Other additives used in henna to achieve different colours such as lime, lemon, fig, celery, carrot or parsley contain compounds known as psoralens, which are converted to quinones by sunlight and can cause a photosensitivity rash.

Parents should therefore be extra cautious when the family is lying on a beach and is approached by a vendor wishing to sell a henna tattoo!

Q : I found a very inappropriate text on my 16 year-old daughter’s cell phone and am quite concerned that she is getting involved in some risky behavior with a boy at school (i.e. ‘sexting’). What can I do to make her understand the dangers of sending out these racy texts without alienating her?

Thank you,
Alarmed Mom

R: Sexting is a recent phenomenon fuelled by the tremendous advances in technology and young adolescents are sending sexually explicit photos of themselves over the net to selected friends. How widespread this phenomenon is isn’t well established, but one survey2 suggested 20% of teenagers, of whom 11% were young teens (13-16), were sexting. The same survey showed that 39% of teens sent sexually suggestive messages. Adolescence is a time of searching for one’s identity and especially the meaning of one’s sexuality.

When sexuality loses its meaning as a profound interpersonal communication in a committed relationship, then the dangers of unwanted pregnancies and STIs, with all their consequences, are the result. Recent statistics indicate that the rate of STIs is increasing including some, such as syphilis, that we thought had almost disappeared. Chlamydia, for example, is often symptomless in girls and yet may lead to scarring and fertility issues later in life. Many parents have little or no control over their child’s use of the internet, where anything can happen.

How can we help?

We know that adolescence is a time of experimentation and this can lead to unwanted consequences. How do we deal with such risky behaviours? How can we enable our kids to have a healthy attitude towards their sexuality? Clearly, there are no simple answers. Education that incorporates harm reduction strategies is useful.

Responsible parenting may mean at times supervising a teenager’s use of the net. Parents always need to keep the lines of communication open with their children and be available for frank discussions on risky behaviours. Most importantly, since teenagers are very sensitive to the behaviour of the adults in their lives, parents can help by modelling a healthy, committed relationship.

Q: Hello,

Our 3 year old daughter (turning 4 in June) has trouble pronouncing the letter "s" (her tongue is in the way). Is there a specific age at which we should start being concerned? Is there a specific number we could call for advice?

Thank you greatly in advance,

Concerned Mom

R: Difficulty with correct tongue placement during production of /s/ or /z/ is usually referred to as a “lisp". If the tongue is placed between one’s front teeth and the air is directed over this area, then /s/ sounds more like /th/ and this is referred to as a “frontal” or “interdental” lisp (like Sylvester the Cat’s speech). If the air is directed over both sides of the tongue near the cheeks, then this is referred to as a “lateral” lisp (like Daffy Duck’s speech). Finally, if the air is directed over the hard palate or roof of the mouth, then this is referred to as a “palatal “lisp.

Many children will produce a frontal lisp until age 5 or 6 and subsequently outgrow this on their own. However, a lateral or palatal lisp is usually not outgrown developmentally and as such, caregivers may wish to consult a speech-language pathologist for this.*

*Please note that lisps are not considered part of the tertiary care mandate of The Montreal Children’s Hospital. Parents should consult their family doctor or pediatrician who can refer them to an appropriate specialist or resource.

Lisa Massaro
Speech Language Pathologist
The Montreal Children’s Hospital

Q: Hello,

I have a 5 year old son. Although he decided to bid adieu to diapers right before he turned 3 years old, he still wets his diaper every night. He tells me he wants to stay dry overnight, but it’s as if it’s beyond his control and that he doesn’t feel the urge to urinate. I’m wondering if there are tricks or things that I can do to help teach him to avoid wetting his bed at night. Should I simply let time pass? How long should I wait before worrying that this might be a bigger problem? I’d like to know what I can do to help.

Thanks,
Apprehensive Mom

Dear Mom,

Wetting the bed is a very unpleasant experience for your child, but it is an involuntary, unconscious and generally harmless phenomenon. In the vast majority of cases, wetting the bed is not a medical problem, but a developmental issue. Your child will grow out of it.

The medical term for wetting the bed is nocturnal enuresis. Wetting the bed is very common, especially in boys. About 20 per cent of five-year olds are regular bed-wetters, but the problem invariably resolves itself as the child grows up.

Wetting the bed is often hereditary. In rare cases, it may be related to a medical problem. You should consult a doctor if your child begins wetting the bed after months – or years – of dry nights, or has daytime wetting as well.

How to help your child stop wetting the bed

Because wetting the bed is involuntary, punishing or scolding your child will only make the condition worse. If you have a positive attitude, you can help your child a lot. Let your child know that many children wet their beds and that eventually the problem will stop. You can also help reduce your child’s anxiety by suggesting he bring his wet pajamas and bed linens to the laundry area in your home.

Finding solutions

Overcoming constipation can sometimes help end daytime and nighttime wetting.

For some children, medication may provide temporary relief, which is useful for vacations and overnight stays at a friend’s home. This is especially important to consider for older children and adolescents.

Children aged eight and older can use an alarm, specially designed to stop bed-wetting. It costs about $100 at medical supply stores. The alarm rings to wake your child as soon as the first drops of urine complete an electrical circuit. The treatment, which lasts one to three months, can be demanding on your child, and on you, as you may have to accompany your child to the bathroom. In the event of a relapse, the treatment can be repeated.

Remember, instant success is rare since it takes time to change your child’s behaviour. If the problem persists despite all your efforts, consider putting aside the training program for a while and trying again in a few months.

To consult our brochure on wetting the bed, or to print our a copy, please click here.

Q: Hello,

I have an 11 month old baby. She has been eating pureed food since she was 6 months old without any problems. However, at 9 months, I started introducing small bites of solid foods: soft vegetables, bits of fruits, little bits of pre-cut pasta, soft cookies and crackers and small bits of cheese. She chews on them, but she refuses to swallow anything. If she happens to swallow something by accident, she chokes. Nevertheless, she wants to eat everything on her plate. Is this normal? What should I do? Should I continue with pureed foods and wait a little bit longer, or should I keep up my attempts at introducing solid foods?

Thanks,
Worried Mom

A: Dear Worried Mom,

My best advice to you is to stop introducing pieces solid food for now and keep feeding her purees, even though she seems interested in solid foods. I would also strongly advise you to bring your daughter to her paediatrician and with the above details, including all the symptoms (especially choking) that you have mentioned above. Your doctor will be able to assess her and decide what to do next and may refer your daughter to an occupational therapist for an evaluation of her oral-motor skills, or may opt for a swallowing assessment.

Sincerely,

Emilie Cadorette

Nutritionist

Q: Hello,

My 5-year-old son often stutters when he speaks. His pediatrician gave me your brochure about stuttering when I brought up my concerns about the issue when he was 4 years old, and told me not to worry. Nevertheless, the problem has persisted and he is now in kindergarten. He tends to stutter when he is tired, at school in the presence of new friends or when he is asked to speak in from of his kindergarten class. Even so, 75% of the time he speaks clearly, with no stuttering or hesitation.

We are worried that his stammering may get worse with time, and are especially concerned about his classmates, who may not always be kind or accepting of his speech impediment. We believe this could even affect his self confidence.

In short, should we follow the brochure’s guidelines and consider this a phase, or should we consult a Speech-Language Pathologist?

Thank you for your advice,
Jacob’s mother

R : Dear parent,

Research evidence suggests that 45-80% of all individuals who stutter will spontaneously recover, with or without therapy. Unfortunately, research has failed to reveal specific markers of who will spontaneously recover and who will not, but we do know that the following factors place a child at higher risk for persistent stuttering:

Being a boy
Having a family history of stuttering, especially on the mother’s side
Presenting with a language delay (even a mild delay) at the onset of stuttering
Presenting with a phonological delay (difficulty producing speech sounds) at the onset of stuttering
Onset of stuttering at 36 months of age or later
Presenting with a lower IQ

Stuttering experts agree that intervention is warranted for any child who has been stuttering for more than 6 months, whether or not any of the red flags are present and despite the fact that transient stuttering can last anywhere from 6 months to 2 years. The reason for this is that it may be more difficult to treat someone who has been stuttering for a longer period of time (i.e., they are more resistant to intervention) and it is important to capitalize on the plasticity of the brain (younger = more brain plasticity) as much as possible.

Therefore, it would be appropriate at this time to request that your doctor refer you to your local rehabilitation centre for stuttering intervention for your child.

Sincerely,

Caroline Erdos, M.Sc.(A), S-LP(C)Acting Professional Coordinator
Department of Speech-Language Pathology
The Montreal Children’s Hospital

Q: My son is a type 1 diabetic and the holidays are always a time where sweets and candies make their way into the classroom and our home, especially when we have guests over. As my son is only 5, he sometimes gets upset when all the other kids are allowed to eat chocolates and goodies and I only allow him to eat a very small amount. Do you have any tips for making the holidays a happy time for feasting, without battles and rising blood sugar levels?

- Mom in DDO

A: Dear Mom,

Having diabetes should never be a reason to deny a child the pleasures of the holiday, and having higher blood sugars for a short period of time will not cause harm to your child over the long run.

For the classroom treats: speak to the teacher(s) about letting you know ahead of time if there will be sugary foods at school. That way, you can use these treats in the place of the snack, or as part of the lunch. If the blood sugars are higher at supper, they may be also be corrected at that time. You might also want to send some non-food treats to school for your child to share!

Treats at home can also be managed the same way, but depending on the type of insulin regimen your child is using, there may be other ways of managing extra food. Speak with your diabetes education team: your doctor, nurse and/or nutritionist for more specific details. They have dealt with this many times before, and will be able to give you specific information based on your child’s insulin regimen.

Remember too, that active play also may need extra carbohydrate-containing food, so organizing an activity such as tobogganing, skating, or just playing in the snow can help manage those extra treats!

Evelyne Pytka PDt, CDE

Anne Bossy BSc(N), CDE

Q: My 12 year old son has developed a few nervous tics. He has gnawed at the fingers for the past 5 years has now started cracking his jaw recently. I have read a lot about his behaviors, and have learned that it is best to let him be, but I feel like these tics are quite severe. I know that they are likely caused by anxiety but my son does not seem anxious and has told me that nothing is bothering him. What can I do? -Worried Dad

A: Dear Worried Dad,

From your brief description it is difficult to determine whether your son is indeed having tics or whether he has developed a “nervous habit,” for example, nail biting.

Tics are described as abrupt, purposeless, stereotyped movements or sounds. They are involuntary experiences exhibited by patients and occur in response to an irresistible impulse, similar to an inch and a need to scratch, thus having a tic provides a relief. Tics can be suppressed with effort which often children try to do at school. Fatigue, stress and any strong emotions may contribute to an increase in the frequency of ticks. Over the course of time, a pattern of waxing and waning of tics is common.

There is a wide range of symptoms among the affected children; from simple tics that occur in phases in a large number of school aged children to more persistent and severe varied motor and vocal tics, such as Tourette’s Disorder. Therefore, a careful observation by the parent is important to provide a description of the symptoms and the situation in which they are most likely to occur.

You may consider speaking with your pediatrician and asking if you should be referred to a specialist.

There have been recent successes, like so called “habit reversal training” in the treatment of tics. This technique suggests that patients can alter or eliminate tics (or habits) by replacing them with a more “socially acceptable” voluntary motor action. For example, your son could be encouraged to squeeze a stress ball rather than gnawing at the fingers.

For more information, you could refer to the following website: www.oup.com/us/ttw.

With hopes that this answered some concerns,

M. Kapuscinska, Child Psychiatrist

The Montreal Children’s Hospital

Q: My son is a young teenager in high school with a severe peanut/nut allergy. I have been told these are the dangerous years. Now how can I help him avoid contact through a shared desk, computer, banister? He does not put his hands in his mouth, yet washing his hands extensively has caused his eczema to explode, and I am really worried about the peanut contact. - A.

A: I certainly understand your concern for your son. While it is true that peanut allergy is one of the more severe allergies, we have to use our judgment because we cannot put your son in a ‘bubble’ and protect him from every possible exposure. The most severe allergic reaction is anaphylaxis and this only occurs after peanut antigen is introduced to a mucosal surface such as the mouth or respiratory tract. While we have all heard apocryphal stories of someone having a severe anaphylactic reaction and dying after touching a surface, there are no case reports documenting this. In one study, children allergic to peanut had peanut butter painted on their backs. There were no anaphylactic reactions. The reaction that was seen was a rash where the peanut butter had been applied. What can you do? First,washing with soap and water will remove peanut antigen from the hands. Secondly,your son must certainly avoid foods offered to him by a friend and in the school cafeteria he can make certain that there is no peanut sauce involved . In my opinion, the most important precaution is making certain that your son carries with him an epinephrine auto-injector such as an Epipen or Twinjet. He must know how to use it and your allergist can certainly help with educating him. In one study, a large number of allergic individuals, having an allergic reaction, failed to use their Epipen even though they had one. The message is: don’t hesitate to use the Epipen or Twinjet if you think you are having a reaction; if it turned out not to be necessary, no harm done but if it were necessary it could be life saving! Taking the above precautions, your son should be able to participate fully in his school activities with minimal risk of a serious reaction.

Q: My toddler has been going to the potty for two weeks to pee. However, she doesn't ever want to pass stool on the potty or the toilet, and only has bowel movements in her diaper or while she is sleeping. It almost seems like she is holding it in all the time and she becomes constipated. What can I do?

A: The age of your toddler is not mentioned but I am guessing around 2-2.5 years old. As you are attempting to ‘potty train’ your child, withholding stool or retentive behaviour is not uncommon. Nor is it uncommon for a child to be trained for urine and not stool. Naturally, if the child is displaying retentive behaviour she will become constipated. Again this is not uncommon and I see many children with constipation which began at the time of ‘potty training’. Selma H. Fraiberg, a child psychiatrist, describes what is going through the mind of a child who is being potty trained in her wonderful book, The Magic Years. It goes something like this: whenever I have a stool in the toilet my mother or father, the sun of my existence, tells me what a good little girl I am because I have produced this wonderful thing in the toilet—why then do they flush it away? If my stool, something wonderful I have produced, can be flushed away, then that horrible vortex of water could also flush me away! My advice is as follows. First, if your child is reluctant to stool in the toilet/potty then leave her be for a time. Then, gently try a program of putting her on the toilet after each meal for a few minutes to try and develop a regular time for a bowel movement. Be relaxed about it and when nothing happens let her jump off the toilet. Once a time is established try to make certain that you encourage your child to go to the bathroom at this time each day. If you see her manifesting retentive behaviour, try and gently lead her to the bathroom and place her on the toilet. Do not overly praise her if she succeeds in stooling in the toilet and do not punish her for failing to do so. Another counsel is to take the child to the bathroom with you when you are toileting to let her see that this is a normal and natural part of our lives and there is nothing to be afraid about. Some small details that are important: if you use a potty seat on the toilet, make sure your toddler has a little stool (piece of furniture not the bowel movement!!) to place her feet on as this makes performing a valsalva movement (forcing down when we evacuate our bowels) possible. Finally, encourage lots of fruit and vegetables (lots of fiber) to keep the stool soft and easily passed. Take courage 99.9% of children eventually become trained for both urine and stool!

Q: If we get our daughter's ears pierced, is there a risk that she'll get hepatitis B or C?

A: This is an excellent question and raises some interesting issues. I will broaden your question to include not only simple ear piercing but also body art in general. It is clear that body piercings and tattoos have spread more widely in our culture and are more accepted by the mainstream.

Tattooing and body piercings have a long history in multiple cultures and there is archaeological evidence for body art going as far back as 60000 BC. In Europe the practice of body art died out by the 17th century but it started up again among sailors in the 18th century who often had their ear pierced for an earring. Since this population was generally associated with unacceptable behaviours (alcoholism, brawls, debauchery etc), piercings began to be associated with unsavoury characters and criminals. Since the 80’s and 90’s, however, body art has become more popular in Western culture and has become socially more acceptable.

However there are medical complications associated with it, including infections such as Hepatitis B and C, HIV, staphylococcal infections, Pseudomonas infections and others. As well, depending on the body site pierced there can be complications of bleeding, cyst formation, dental problems among others. Complications associated with piercing the soft part of the ear can be: infections, bleeding, keloid scars, and cyst formation. Contact dermatitis is not uncommon particularly with nickel earrings but it may occur even with gold earrings. Generally these reactions are mild but sometimes may be more serious causing diseases such as bacterial endocarditis (infection of the heart). One study reported a 30% complication rate from simple ear piercing, the most common being minor infection, followed by allergic reaction. If the cartilaginous part of the ear is pierced there can be destruction of cartilage requiring plastic surgery to correct the defect. The Centers for Disease Control and Prevention lists the practices that need to be followed in order to avoid the infectious complications from piercings and tattoos. http://www.cdc.gov/Features/BodyArt/

More specifically in answer to your question it would be wise to be immunized against Hepatitis B before considering piercings. Regardless of the age of piercing, one should only have it done in a facility that uses sterile techniques(see CDC guidelines). If you can’t be sure that these guidelines are followed then avoid that facility and look for one that does. I have one last comment. What should be the age for ear piercing? There is no easy answer to this question but since it is really a cosmetic procedure, shouldn’t we wait until the child is old enough to express an opinion and give informed consent??

Q: My 29-month-old son has recently become afraid of the moon. It probably started because of a scary scene he saw in a kids' movie that had a bright light in it that he called the moon. Now he is scared to look outside the windows at night or walk outside in the dark if he sees the moon in the sky. What is the best way to help him deal with this fear? Should we simply console him and wait for him to outgrow it? - Anita, Mom

A: I would not make too much of this "phobia" as it will undoubtedly pass. One way of desensitizing your son would be to buy a children's book, e.g. nursery rhymes, featuring colourful pictures of a happy, anthropomorphic moon and reading to him pointing out the benign nature of the moon. Another suggestion would be to use a colourful yellow ball and call it the moon and play with him using the "moon". If he does act fearfully when he sees the moon outside, console him and reassure him that the moon is a friendly "person".

Q: My little girl who is 18 months old had an infection on her vulva; I applied an antifungal ointment and a cortisone cream prescribed by her doctor (3 days for the cortisone and 3 weeks for the other one). It stopped the infection but from time to time there are little dots that appear. I reapply the antifungal and when there are red spots, the cortisone. Will these go away once she is out of diapers? Am I doing the right thing by reapplying the cream even if I haven’t been back to see her doctor?Irina, Blainville

A: Diaper rashes are very common in infants wearing diapers. Most of these are caused by the ‘burning’ effect of stool and urine which together form an acidic mixture. This can lead to erosions of the skin and redness. The diaper area is also warm and humid and an ideal habitat for candida . A simple diaper rash can become overgrown with candida causing a fungal rash which is usually more confluent and redder. General measures for dealing with a diaper rash are frequent diaper changes, washing the area with mild soap and warm water and applying a barrier cream, the commonest of which is zinc oxide. Zinc oxide is contained in varying percentages in most common diaper creams. If your doctor diagnoses a fungal diaper rash then one can apply an anti-fungal cream on top of which one can apply zinc oxide. Usually one treats the fungal diaper rash until it resolves and then you return to the simpler measures mentioned above. Steroid creams may be added to the antifungal cream to reduce the redness and irritation but should not be used alone for long periods of time. With these simple measures most diaper rashes resolve easily. Of course, once the child is out of diapers the problem of ‘diaper rash’ disappears.

Q: Hi! Great idea to have "Ask the expert". Is it dangerous to let your toddler watch videos on the laptop? Is there any radiation or anything that could be bad for him? My son loves videos of cats but my wife says it can be bad, same for cell phones...What does the expert think? – Yorge, Dad

A: There is no strong evidence that computer or television screens are dangerous from the point of view of electromagnetic radiations. HOWEVER, there are major concerns about the influence of TV, computers and internet on the psychosocial development of toddlers, children and adolescents which have nothing to do with ‘radiation’. Recent Canadian Pediatric Society Guidelines (www.cps.ca) suggest that, from a developmental point of view, toddlers 2 years and under should not be placed in front of television/computer screens. Television programs do not enhance development and may be detrimental if a parent uses the television as a means of amusing the child or for ‘babysitting’ purposes instead of being with and present for the toddler. Babies develop best through their contact with a loving, nurturing adult. For older children, one hour of screen time per day is the current recommendation (screen time = TV, computer, video games, etc.). There is evidence that older children are influenced by the content of many television programs to be more aggressive or more sexually promiscuous (teenagers). Sitting with your child while watching a television program is a better idea since you're in a position to provide a counter-balance to the material presented. There is also evidence linking obesity to screen time. Raising children in this new communication era with computers, internet and smart phones is particularly challenging for parents with adolescents who are at risk of predators using the internet to lure children and adolescents into dangerous situations.

Q: My teen (14) was a very happy child, but since the begining of the school year she became very serious, closed, doesn't laugh as she used to, eats less. How do you know if it's depression? - B.T., Beaconsfield

A: Depression is common among adolescents. The symptoms you are describing suggest a mood disorder and she should be evaluated by your pediatrician or family doctor. Here are some books dealing with the topic of depression in adolescents: “Helping Your Teenager Beat Depression: A problem-solving approach for families” by Katharina Manassis and Anne Marie Levac, Woodbine House, 2004; and “Rescuing Your Teenager from Depression” by Norman T. Berlinger, Collin Living, 2005.

Q: At what age should a child start to go to the dentist? - Liz, Mtl

A: I would suggest that a first visit should be around the age of 12 months. This is an opportunity for the dentist to meet your child and provide prophylactic fluoride treatment as well as giving advice about good dental hygiene.

Q: Hello. I am constantly thinking about what I need to do with my son. My son is 18 months old and therefore I do not know if we should get him vaccinated. What is the opinion of the Children’s Hospital?

Thank You.

A: Children appear to be more susceptible to the H1N1 virus and the best thing you could do to protect your son would be to have him vaccinated as soon as possible. You can consult www.pandemiequebec.gouv.qc.ca to locate the clinic nearest to your home.

Q: My grandson turned one on November 4 and we celebrated his birthday on the 1^st. We noticed that when he wants to see things higher up he’s lifting his head and his neck up instead of looking up with his eyes. When we’re sitting at his level though, everything is fine. Is there a problem with his eyes, or his eyelids? His eyesight is very good otherwise. Thank you, - Jean, grandfather

A: Without examining your grandson it is difficult to give a precise answer. Although he sees well, your description suggests an abnormality of the nerves/muscles involved in eye movement. I would certainly recommend that you consult a pediatrician and/or pediatric ophthalmologist (you would need to get a referral from your pediatrician for this).

Q: My little 13 month old puts her finger in her throat as she was going to make herself vomit. She seems to find it funny, since she laughs. We find it troubling! Why is she doing that? – Carmen, Laval

A: Self-induced vomiting in a toddler or young child is known as rumination. It is considered as a self-gratifying type of behaviour and is usually benign. The infants are not sick and appear to enjoy the vomiting. The literature reports that sometimes rumination is linked to some disturbance in the mother-child relationship. Without knowing more about your situation, one can only speculate. Perhaps this began when mother returned to her employment and the child was put in Daycare or perhaps there has been a major change in the family. If there is an underlying psychosocial cause, then addressing it should correct the situation. This should be discussed with the child’s physician to make certain the child’s growth is normal and there are no nutritional deficiencies caused by the rumination.

Q: My son is two years old. He is very solitary. I'm afraid this will not help him as he grows up. What can I do? – Gwen, Montreal

A: The answer to your question is difficult without more information. The diagnosis ranges between shyness (a temperamental characteristic) and a developmental problem. Does he have difficulties with social communication in the family? Outside the family? Is his language development normal? Does he hear well? Is his overall development normal? Are there any psychosocial problems in the family? Perhaps the best solution would be to first have him evaluated by a pediatrician in order to rule out any developmental disorders that require intervention. If this evaluation is normal, then your son’s shyness is part temperament and part immaturity that should improve with maturation.

Q. Hello. What do you think about a girl that is almost 2, doesn't have any hearing problems, that understands all we say, that can point objects we call but only says mama, caca and papa. She communicates by babbling and gestures!

Thanks in advance!

A: In your description of your two-year-old girl, she appears to have a few single words, “mama” “caca” “papa” but no two-word phrases although she does babble and express herself with gestures. She also understands well. She also hears well and sees well. Does she respond to her name? Is she exposed to more than one language? My opinion is that she is probably within normal limits for language development and my expectation is that she will gradually increase her vocabulary and phrases over the next six months. If this does not occur then definitely an assessment by a speech and language pathologist would be indicated. As well, although you believe she hears well, it would be prudent to consider a hearing test to be certain.

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