But I Can’t Go! Understanding Constipation in Kids

By Daniel Lustig, MD, and Lisa Philichi, ARNP,  MultiCare Mary Bridge Children’s Hospital & Health Center

If your child is constipated, chances are it’s frustrating for both of you. Constipation—difficulty passing stool or a longer-than-normal time between bowel movements—is common in children and can sometimes be a cause for concern.

What is normal?
The frequency and consistency of bowel movements in infants and children depend upon age and diet, and an individual child’s patterns can vary widely. “Normal” for an infant could mean a bowel movement every time they eat or only once a week. An older child may go three times a day or once every three days.

When is it constipation?
Your child may be constipated if he or she has had less frequent bowel movements—or difficulty passing stool—for more than two weeks. It’s important to note that even children who go with normal frequency can still have symptoms of constipation. Small, hard or rocklike stools passed daily or very large, firm stools that clog the toilet once a week can both be signs of constipation.

Stool withholding—trying to keep from having a bowel movement—is also a clear indicator that your child is constipated. Infants may arch their back, tighten their buttocks and cry. Toddlers may rock back and forth while stiffening their buttocks and legs, arch their back and wriggle or fidget, squat, or get into other unusual positions. They may also hide in a corner or a special place.

Children withhold because they are afraid passing stool will hurt, and it can be a difficult habit to break. Unfortunately, repeated withholding can make the problem worse.

Young infants may appear constipated or in pain because they strain and get red-faced when they go. This is usually because the muscles used for defecating are still uncoordinated in infants less than 6 months old. A baby is unlikely to be constipated if he or she passes soft stools within a few minutes of straining.

How do I make it better?
Diet changes, illness, stress, toilet training, lack of exercise or unwillingness to stop playing for a bathroom break can all lead to constipation.

The good news is most children with constipation do not have an underlying medical problem. Treatments may include stool softening medications (oral or rectal) to make it easier for the child to go to the bathroom, dietary changes and behavior modification.

Parents should put any toilet training activities on hold until after their child’s constipation has been resolved.

In some cases, constipation can be a symptom of a more serious problem, such as hypothyroidism, Hirschsprung’s disease, celiac disease, spinal cord dysfunction or an adverse effect of some medications. So it’s a good idea to check with your pediatrician before starting any treatment.

Help for a going problem
The MultiCare Mary Bridge Pediatric Gastroenterology and Nutrition Clinic has outpatient clinic locations in Tacoma, Gig Harbor, Covington, Olympia, Puyallup and Silverdale, offering close-to-home services.

Our team provides consultation to referring physicians and comprehensive care for children with a broad range of gastrointestinal, liver and nutritional problems, including:

• Abdominal pain
• Constipation
• Failure to thrive
• Inflammatory bowel disease
• Acute and chronic liver disease

Visit the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition website at www.naspghan.org for more information on gastrointestinal disorders.

A Gluten-Free Birthday

There’s nothing like a decorated cake bright with candles to make a kid feel special on his or her birthday. But what if your child has celiac disease? Are they doomed to cake-free birthday celebrations forever?

People with celiac disease have an immune reaction to gluten, a protein found in cake, bread, pasta, cookies and many other foods containing wheat, barley or rye. This reaction can cause some pretty unpleasant symptoms in both adults and children, like abdominal bloating and pain, chronic diarrhea or constipation, and excess gas.

More seriously, celiac disease damages the small intestine so it can no longer absorb certain nutrients. This can lead to vitamin deficiencies that eventually cause other illnesses, as well as stunted growth in children.

Shifting to Gluten-Free

While there is no cure for celiac disease, it can be managed well through diet changes. So your child’s diagnosis of celiac disease means making some permanent changes in the foods your child—and perhaps your whole family—eats.

“One of the biggest challenges parents have once their child’s been diagnosed with celiac disease is making the decision whether the whole family should go gluten-free at home,” says Judy Tuider, a clinical dietitian with the MultiCare Mary Bridge Gastroenterology and Nutrition Clinic.

Tuider advises families to use mostly naturally gluten-free foods, such as meat, cheese, most yogurts, eggs, peanut butter, milk, rice, potatoes, corn tortillas and corn chips. This helps avoid depending too much on gluten-free products, which can be pricey.

Recipes for Great Birthdays

The good news, though, is that when you do need a gluten-free product—like a birthday cake mix—it’s easier than ever to find one. Betty Crocker, for example, now offers a line of gluten-free baking mixes that are available at many major grocery stores (www.bettycrocker.com/products/gluten-free-baking-mixes). For do-it-from-scratch types, a search on “gluten-free” at recipe websites, such as www.allrecipes.com, yields a long list of recipe choices.

When it comes to a special occasion such as a child’s birthday, it’s nice to know that a gluten-free lifestyle is no barrier to making your child’s memories happy ones.

Kids with Celiac Disease?

You’re not alone. Reaching out to others can be one of the best ways to get support and learn how to manage your child’s celiac disease. Connect with the MultiCare Pediatric Celiac Disease Support Group on Facebook at www.facebook.com/#!/SouthSoundCeliac.

Program Educates New Parents to Prevent Shaken Baby Syndrome

In an effort to reduce the increasing incidence of abuse and shaken baby syndrome in Pierce County, MultiCare Tacoma General Hospital and MultiCare Mary Bridge Children’s Hospital & Health Center have launched a campaign to help new parents better understand their babies’ crying.

Parents of every baby born at MultiCare Tacoma General Hospital are shown a 10-minute DVD, presented by the National Center on Shaken Baby Syndrome, called The Period of PURPLE Crying (see the key below). The program by the same name teaches parents about the dangers of shaking a baby and offers them coping strategies for when they’re frustrated.

The goal of early parent education is to prevent occurrences of abuse. The push for a proactive educational campaign began after six children died as a result of abuse in Pierce County in 2008.

The video features segments such as “Why shaking a baby is dangerous” and “Consequences of shaking a baby.” It also shares stories from parents whose children died as a result of being shaken.

Additionally, volunteers are donating handmade purple hats to send home with babies born at Tacoma General to help remind parents to keep their baby safe.

The information in the video is based on more than 25 years of research on infant crying and normal infant development conducted by Ronald G. Barr, MDCM, and other scientists. The Period of Purple Crying concept was developed by Dr. Barr, professor of pediatrics at the University of British Columbia in Vancouver, B.C.

To learn more about the Period of Purple Crying program, go to www.purplecrying.org.

Period of PURPLE Crying Key

Peak of crying: Your baby may cry more each week— the most at 2 months, then less at 3 to 5 months.

Unexpected: Crying can come and go, and you don’t know why.

Resists soothing: Your baby may continue to cry no matter what you try.

Pain-like face: Crying babies may look like they are in pain even when they are not.

Long-lasting: Crying can last as much as five hours a day or more.

Evening: Your baby may cry more in the late afternoon and evening.

Is Your Child At Risk for Diabetes?

We all want to pay close attention to our children’s health. But sometimes, in order to care for them, we may have to take a step back and try to look at them the way a doctor might.

You may have heard that type 2 diabetes is increasingly being diagnosed in young people in America. But is your child at risk for diabetes?

Take the time to ask some difficult questions about your child’s health habits: Does your child eat a healthy diet? Is he or she active enough? Is he or she overweight?

“Parents need to pay attention to the habits their children are learning and make sure they are healthy habits,” says Barbara Marshall, MD, pediatric endocrinologist at the MultiCare Mary Bridge Pediatric Endocrine and Diabetes Clinic.

Healthy habits matter. Being overweight and inactive are risk factors for developing type 2 diabetes. family history and ethnicity also play a role for some children. If you do see risk factors, take heart.

“The positive thing we are learning about type 2 diabetes in young people is that lifestyle changes can make a difference,” Dr. Marshall says.

Healthy eating habits
“All children need to eat a healthier diet,” Dr. Marshall says. “The first thing I recommend is cutting out soda and juice because kids are drinking far too many calories a day.”

She also advises parents to:

• Serve fruits and vegetables.
• Watch portion sizes.
• Set regular eating times.
• Avoid skipping meals.
• Have meals sitting down at a table.

Exercise
Kids should get at least 60 minutes of activity a day, Dr. Marshall says. “It does not need to be formal exercise,” she says. “Playing on the playground counts.”

You can help boost activity levels by reducing TV and computer time. When kids spend more than an hour a day in front of the screen, their risk for diabetes increases.

To help keep kids active, you can:

• Assign active chores.
• Have kids walk or ride their bikes to school.
• Find a physical activity the whole family enjoys.

Working together
Healthy habits can also help keep weight at a healthy level, which is crucial for diabetes prevention.

“Weight loss decreases your risk of diabetes, but studies have shown that for young people who are heavy, even weight maintenance reduces risk,” Dr. Marshall says.

Families have an important role to play. “Lifestyle changes have to be family changes,” Dr. Marshall says. “Success comes when the family works together to have a positive impact on their health.”

Diabetes Care at Mary Bridge
Type 2 diabetes is increasingly being diagnosed in young people, but type 1 diabetes still accounts for many cases of diabetes among children.

The good news is that management strategies can help children with type 1 diabetes live healthy lives. The care team at the Mary Bridge Pediatric Endocrine and Diabetes Clinic are specially trained to provide the education and support you need to manage the disease.

The Clinic offers individual education with a nurse-certified diabetes educator and a support group in a child- and family-friendly environment. For more information, visit our Mary Bridge Diabetes Education Program online or call 253.792.6630.

Diabetes: Your Questions Answered

 Each day, more than 4,000 Americans learn they have diabetes. it can be startling news. 

“They each want to know how this diagnosis will change their life,” says Ronald J. Graf, MD, FAACE, an endocrinologist with MultiCare Endocrinology Specialists – Tacoma. That leads to questions—about diet, medications, the risk for complications and more. 

These questions are often most fully addressed in diabetes education classes. But a few frequently asked questions are briefly answered here. 

Will I have to give up sweets?
A healthful diet is crucial. It’s low in saturated fats and trans fats. And it contains balanced portions of proteins and carbohydrates, including sugars. 

“It’s the carbohydrates that have the major effect on one’s blood sugar level, but even simple sugars and sweets are allowed in limited amounts,” Dr. Graf says.

Why is exercise important?
Exercise can lower blood sugar levels and help with insulin resistance, which occurs with type 2 diabetes—the type often related to obesity. Insulin resistance means the body has a hard time using the insulin it makes. 

“Exercise can overcome much of that insulin resistance, as well as burn some of the calories we consume in our diet and store in our fat,” Dr. Graf says. That can lead to weight loss, which in turn may lead to less insulin resistance. It may also improve high blood pressure and abnormal cholesterol levels, which often occur in people with diabetes.

 Will I need to take medication?
People with type 1 diabetes must take insulin. People with type 2 diabetes often can control their disease with proper diet and exercise. With time, though, they may need one or more medications.

“Frequently, even those with type 2 diabetes will eventually require insulin treatment to help control elevated blood glucose levels,” Dr. Graf says.

 Will I be able to avoid diabetes complications?
Most people who follow their health care team’s advice can have relatively healthy lives. Says Dr. Graf: “Living with diabetes usually means making some lifestyle changes and some sacrifices. But these changes are usually for the better and can lead to a healthier and longer life.”

MultiCare offers support to people with diabetes
MultiCare’s Chronic Disease Management Program is currently focused on working with patients who are managing diabetes. We offer a number of support services as part of their ongoing care, including:

• Phone calls to patients to schedule follow-up appointments
• Completing lab work and other tests before appointments so patients get results sooner
• Group visits that offer patients the chance to interact with others managing diabetes
• Free “Living Well With Chronic Conditions” workshops

For more information about MultiCare’s Chronic Disease Management Program, call 253.792.6710. For more information about diabetes care services at MultiCare, visit multicare.org/diabetes-care.

 

Back-to-School Time Means Immunization Time

Even though it may feel as if summer has just started, the back-to-school immunization rush is just around the corner.

You can find the 2011-2012 vaccine requirements to attend school and child care at www.doh.wa.gov/cfh/immunize/schools/vaccine.htm.

New this year is an exemption law that took effect July 22, 2011. The new law changes the way in which parents or guardians can get their child an exemption from required immunizations.

The new process requires parents or guardians to get information from a licensed health care provider on the benefits and risks of immunizations before claiming a medical, religious or philosophical exemption. Health care providers verify parents or guardians have received the information by signing a letter stating such or by signing a Certificate of Exemption (COE) form.

The COE form, Frequently Asked Questions, and other information on the new law can be found at www.doh.wa.gov/cfh/immunize/chools/exemption-info.htm.

MultiCare Mary Bridge Mobile Immunization Clinic offers free vaccines to all children from birth to 18 years of age. You can view the clinic’s current schedule here.

MultiCare’s Mobile Health Services also offers vaccines to children through age 18 for free (An administration fee of $15.60 per vaccine will be applied for children not covered by insurance). You can view their current immunization schedule here.

Add Immunizations to Your Child’s Summer To-Do List

By Carolyn Cook, RN Mobile Immunization Clinic at Mary Bridge Children’s Hospital & Health Center

As school lets outs for summer, now is the perfect time to get a jumpstart on childhood vaccinations required before schools starts again this fall.

While shots aren’t as fun as chasing the ice cream truck or splashing around at Owen Beach, it’s smart to get vaccinations out of the way rather than wait until the last minute, when procrastinating parents rush to get their children caught up on vaccinations required by the state of Washington.

A new federal study says that Washington state has the highest rate of parents exempting their children from vaccines. The report by Centers for Disease Control and Prevention, a first of its kind, says that 6.2 percent of kindergarteners in the state have parent-signed exemptions for one or more vaccines for diseases such as polio, whooping cough, measles hepatitis B and chickenpox.

Why get vaccinated now?

In the week before school starts, many doctor’s offices don’t have appointments available and some clinic wait times can stretch into hours. Take advantage of the lull of summer: there’s more time for personal attention. We can help answer any questions and explain which vaccines are required at which ages. If you’re looking for added incentive, the office is air conditioned and kids leave with a lollipop.

What if I don’t have health insurance or can’t afford it?

For people who don’t have health insurance or worry about cost, free vaccinations are available.

The MultiCare Mary Bridge Children’s Hospital Mobile Immunization Clinic travels throughout Pierce County and provides free immunizations to all children from birth through 18 years of age. For more information about the Mobile Immunization Clinic, call 253.403.1767 or visit multicare.org/marybridge/mobile-immunization-clinic. There are no fees and no insurance co-pays. These vaccines are completely free.

MultiCare Mobile Health Services offers health screenings and immunizations for adults and children. Vaccines are offered at a low or no-cost basis if income qualifications are met. More information is avialable by calling 253.697.4010 or visiting multicare.org/mobile-health-services.

Are there any free vaccines for adults?

Whooping cough vaccine is available at no charge from Mary Bridge to anyone caring for an infant younger than 1 who is uninsured or cannot afford the vaccine. It is important that all caregivers are immunized so they do not pass on the disease to babies.

What ages are required to be vaccinated?

Children are due for a series of immunizations between the ages of 4 and 6, and again at between the ages of 11 and 12, according to guidelines from the Centers for Disease Control and Prevention. Some vaccines due at these ages are also required by the state Department of Health before the first day of kindergarten and before the start of sixth grade.

Children must be at least 4 years old to receive their kindergarten shots, and at least 11 years old to obtain their sixth-grade shots.

Are there any new vaccinations that are recommended for older children or teens?

For teens younger than 19 who are about to head off to college this fall, the CDC now recommends a second dose of meningitis vaccine. The vaccine for HPV (human papillomavirus) is also available for both girls and boys.

Why do some people not get vaccinations?

Some parents might be overwhelmed, may be new to the area, or perhaps they haven’t kept up with regular physician visits for their child. They may lack health insurance or fear there’s a cost. Others might have unanswered questions about vaccines. Not having a regular family doctor, a lack of medical insurance and a lack of transportation are not barriers to getting children’s immunizations. The most important thing to understand is that there are risks to not immunizing your child. There’s real danger. I recommend that all children be immunized against all 14 serious diseases that the CDC recommends.

What if I don’t want to get all the vaccines recommended by the CDC?

I see some people who don’t want to get all their vaccines, only what’s required in school, which I don’t support because school vaccines are minimal and they’re not according to the medical recommendations. The medical recommendations are designed to protect your child. School requirements are designed to prevent disease from spreading to other people. So you want to do everything you can to protect your child.

If you do exempt your child, if there is an outbreak of something, your child has to stay out of school until two weeks after the last person is diagnosed with the disease. This past year, there was an outbreak of pertussis in several Tacoma schools and they had to cancel a lot of sporting events to prevent the disease from spreading.

What does state law say about childhood vaccinations?

This month, Gov. Chris Gregoire signed a bill requiring a parent or guardian to show that they have received information from a health care provider on the benefits and risks of immunization before opting out of school vaccination requirements. Beginning July 22, 2011, parents or guardians who want to exempt their child from school or child care immunization requirements must fill out and submit the updated Certificate of Exemption form to their school or childcare.

A health care provider does not need to sign the Certificate of Exemption form for parents or guardians who show membership in a church or religious group that does not allow a health care provider to provide medical care to a child.

Why are vaccinations important?

Unvaccinated kids are more likely to catch and spread serious illnesses like whooping cough and measles, which can be prevented by vaccines, according to the state Department of Health. Making sure kids have all recommended immunizations protects them, their classmates, friends, and families from preventable diseases. Kids who aren’t fully immunized may be excluded from attending school, preschool, or child care if a disease outbreak occurs.

“Childhood immunizations save lives and are one of the most effective ways to protect kids from serious, preventable illnesses,” said state Secretary of Health Mary Selecky. “There’s a lot of confusing information about vaccine circulating around, this law makes sure that parents will get reliable facts from one of their most trusted sources — a health care provider.”

What should I bring with me for vaccinations?

Please bring your child’s shot record with you. For the safety of your child it is important for the immunization nurse to know what shots your child has already received and when they were given. If vaccines have been missed in the past, it’s never too late to get children caught up.

Carolyn Cook, RN, runs the MultiCare Mary Bridge Mobile Immunization Clinic for MultiCare Health System.

An Injury-Free Summer for Your Kids

When summer’s warmth seeps in (it will eventually, really), kids go outdoors to play. While sports and recreation are fun and healthy pursuits, they carry some risks.

See if you can relate to any of the following parenting concerns, and then check out the advice from experts that can help make your summer fun less frantic. 

Helmet headache:

My teen skateboards everywhere—but not always with a helmet.
Try this plan: He should definitely wear a helmet and wrist guards. Your message may get through once your child knows the risks. Your pediatrician might help with this.

“Children respond better when they understand what happens to the brain during an impact injury,” says Andrea Gravatt, MD, a pediatric physician in the Emergency Department at MultiCare Mary Bridge Children’s Hospital.

Helmets are a must when riding skateboards, bikes, inline skates—anything that might put kids at risk for falling and landing hard, adds Robert Kregenow, MD, a pediatric emergency physician with Mary Bridge Children’s Hospital. Head injuries can have lasting effects. “Unlike the rest of your body, if you break your brain, we can’t fix it,” Dr. Kregenow says.

Take-away tip: Helmets help prevent brain injuries—by 85 percent in cycling. If your child’s not excited about wearing a helmet, here’s a hint: Kids are more likely to wear one when they like how it looks.

Tempted by a trampoline:

My daughter wants a trampoline. Aren’t they risky?
Try this plan: It’s hard to say no to this fun form of play, Dr. Gravatt notes. “Last summer for several weeks, it seemed like there was a trampoline injury almost every night,” she says. So parents should know the risks—including sprains, strains, fractures and cuts due to colliding jumpers and falls.

Take-away tip: Think twice. The American Academy of Pediatrics says trampolines should only be used in supervised training programs or for competition sports.

Bothered by bugs:

I’m concerned my curious kids will be bitten or stung outside near our home.
Try this plan: Remind kids to steer clear of hives and nests and to report any they find. Don’t give them scented sunscreens, which may attract insects. Stings can be dangerous if your child is allergic, in which case an EpiPen should be handy.

Take-away tip: There’s always a first time for severe sting reactions, Dr. Gravatt notes. Call 911 at first sign of lip or face swelling or trouble breathing or swallowing.

Spot a teachable moment

When you can, point out to your child anything you see that might be dangerous—whether it’s wild mush rooms on the trail or little things like sandthrowing on the playground, Dr. Gravatt says.

“Each day is an opportunity to teach kids something about safety,” she says.

Are your kids prepared for emergencies?

We all worry about how our kids would handle an emergency when we’re not around. Visit multicare.org/kids-emergency with your kids to help them learn how to tackle an emergency situation head on.

Healthier Food at Wal-Mart?

Recently, Wal-Mart announced a five-year plan to offer healthier, affordable food options in its stores across the country.

The plan includes a commitment to reduce the unhealthy salts, fats and sugars in many of its packaged food offerings, as well as to drop prices on fruits and vegetables.

In today’s Room for Debate feature on the New York Times, various experts debate the topic, “Can Wal-Mart Make Us Healthier?” (Note: The New York Times online requires free registration to access content.)

What do you think about Wal-Mart’s plan? Will it help people be healthier? Use the comments section below to share your thoughts.

Technology Friday: Mobile Health

At its most basic, Mobile Health can be described as using Internet connections and video cameras for telemedicine – or it could be accessing an electronic health record (EHR) from a mobile device, reading and responding to questions from patients via email, or secure messages reminding patients about appointments.

MultiCare Health System’s Maternal Fetal Medicine (MFM) became the first clinic in our system to use telemedicine for clinical practice, using a webcam, computer and a special monitor that allows Becky Crosetto, Genetic Counselor from Tacoma’s MFM clinic, to provide genetic counseling to expectant mothers and their families at our Olympia MFM site. This pilot program launched on Tuesday, Nov. 2, and is ongoing.

Crosetto is able to make eye contact with patients, educate them through a presentation, answer questions, and have a conversation, just as if she were in the same room.

“I kind of expected that there might be some resistance but patients have been asking all the right questions at the right times, just as if they were in the room with me,” said Crosetto. “It’s been really seamless.”

Following this first launch, telemedicine genetic counseling visits took place between our Tacoma MFM clinic and the Covington satellite MFM clinic, where five patients were seen on the initial launch day, including three visits with interpreters via teleconferencing.

One unintended consequence of this telemedicine pilot has been increased patient engagement.

“Patients seem to be paying attention – or even more attention than an in-person visit,” commented Crosetto. “The presentation is very engaging.”

On Friday, Dec. 3, MultiCare’s Neurology department launched a telestroke pilot that connects our interventional neuro-radiologists with our Emergency Departments to provide consultations to stroke patients. Using telemedicine allows Neurology specialists to get in touch virtually with doctors located anywhere within our health system to provide support and medical insight by viewing the details of the stroke patient via teleconferencing technology.

Our Pediatric carelines also launched telemedicine for endocrine follow-up visits. This will allow patients to get appropriate follow-up care, without necessarily visiting Tacoma from Olympia or farther away.

“These pilots have enabled us to deliver the right care at the right time to our patients, while minimizing the need for them to travel to receive this care,” said Florence Chang, CIO and Senior Vice President – Clinical Support Services.

This is an exciting time at MultiCare as we continue to provide easier patient access to specialty care, real-time complete clinical data to providers and convenience for providers and patients.

For updates on our work expanding mobile health services, stay tuned to this blog and to multicare.org.