by Dr Perry Lau

M, AN EIGHT-YEAR-OLD girl, was born with a developmental disorder of her kidneys, resulting in kidney failure and requiring dialysis since she was seven years old. After her afternoon school session, she had to rush home to start her peritoneal dialysis session of 10 hours daily. Every night her mother had to inject her every night with a hormone that can help her to grow. In addition, she received another injection every week that could help her to build more red blood cells so that she would not feel tired easily during physical activities. M hated the chalky medicine that she had to take during every meal. She was told that her kidneys could not clear the phosphate found in food, hence she required this chalky medicine, and she had to avoid foods like chocolate and peanut butter which her siblings and friends enjoyed.

All these restrictions in her life changed after she received a kidney from her father when she was eight years old. She no longer required peritoneal dialysis every night, and her parents could bring her out to play with her siblings until late into the night. This is just one example of a child with kidney failure whose quality of life improves dramatically after a kidney transplant. Kidney transplantation is the treatment of choice for children suffering from irreversible kidney failure as it results not only in better survival rates but also better quality of life compared to dialysis.

Paediatric Kidney Transplant in Singapore

In Singapore, the first paediatric kidney transplant was performed in a three-year-old kid in February 1989 at the Department of Paediatrics, National University Hospital. This first child transplant recipient is currently a young man who has just finished his post-graduate degree in biomedical science, and his transplanted kidney is still functioning normally. Up to the end of 2012, there were about 60 children and adolescents who had received kidney transplants in Singapore.

The common causes of irreversible kidney failure in children are congenital abnormalities of the kidneys and urinary tract and immune disorders affecting the kidneys. Around two-thirds of the paediatric kidney transplant recipients received their kidney from living donors, and the majority of the living donors were their parents. For these children, the average time from start of dialysis to getting a kidney transplant was less than a year. In fact, some of these children were able to do the transplant once their kidneys had failed completely, without having to start dialysis. One-third of the paediatric kidney transplant recipients received their kidney from donors who had died, and their average waiting time on the national deceased donor kidney organ list was seven years.

Donation and Transplant Operation

With regard to living donation, anyone in the family can donate their kidney so long as they are at least 21 years old, in good health, and have a blood type that matches the child. It is a myth that a kidney from an adult is not suitable because it is unable to fit into the small body size of a child. Studies have shown that a kidney transplanted from an adult donor into an infant or small child has equal chance of success as other age groups receiving the kidney transplant. In Singapore, one-tenth of the paediatric kidney transplant recipients received their kidneys before five years of age, and the youngest child to receive a kidney transplant was two and a half years old.

Before a child has a kidney transplant, he or she needs to be prepared physically and psychologically. The child has to undergo a series of investigations and complete the immunisations. Parents and children are encouraged to control the complications of kidney failure well and keep healthy. The child psychologist and child life therapist can help the children to accept the idea and become familiar with the procedures involved in transplant via toys and pictures.

Life after Transplant Operation

After the kidney transplant operation, these children have to take medications for the rest of their lives to prevent their new kidneys from being rejected. These medications work by suppressing the immune system, resulting in a higher risk for infections. These children may have to make minor adjustments in their lifestyle to protect themselves from infections. Children with kidney transplants can also grow better than under dialysis since there are less dietary restrictions with normal kidney function.

Many of the children do quite well after the kidney transplant operation and are able to return to school in two to three months after their transplant. In Singapore, nine out of 10 paediatric kidney transplant recipients who have completed their studies are now working to support themselves and their family. A handful of them participate actively in sports. Overall, the quality of life after the kidney transplant has improved in these children.

Every child is unique and every transplant is different, hence it is difficult to predict how long each child’s new kidney will last. Many of the children have kidney transplants that have lasted for ten years or even longer. In Singapore, around 20% of our paediatric kidney transplant recipients lost their kidney transplants due to rejection or infection. Rejection is a major problem in adolescence due to non-adherence to medications. Thus, it is important to involve the children and adolescents in educational activities that teach them the importance of adherence to transplant medications.

There are still a proportion of children afflicted with irreversible kidney failure and are dependent on dialysis and injections for years. Being an organ donor can make a big difference to the lives of these children. A kidney transplant is likely the best option to give these children a longer and healthier life. To them, a kidney transplant is a gift of a new life.

Dr Perry Lau is a Consultant at the Division of Paediatric Nephrology, National University Hospital.
8th Singapore Transplant Games The Society of Transplantation is organising the 8th Singapore Transplant Games on 20 April at the Toa Payoh Stadium. Please support our local transplant athletes as they compete for a place to represent Singapore in the world transplant games hosted by South Africa in July this year. Lots of excitement, fun and goodies await supporters. Bring your families along for a fun-filled Sunday morning. Registration is free but spaces are limited. To register, go to www.singaporetransplantgames.com .

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by Dr Cindy Ho

CHILDHOOD OBESITY IS an increasing problem and it is a common health problem in Singapore school children. As a society becomes more affluent, there is better nutrition and an increased intake of dietary fat. Compounded by the fact that children nowadays participate more in sedentary activities like computer games, handheld games, and TV viewing, it is no wonder they’re unable to get rid of the excess calories they’re taking each day.

Childhood obesity is linked to many problems. This includes hypertension (high blood pressure), hyperlipidaemia (high cholesterol), Type 2 diabetes, obstructive sleep apnoea syndrome, increased risk of coronary heart disease, degenerative joint disease, and gallstones. Often, it also affects the psychological well-being of the child as they may get teased or bullied in school for being obese.

Obesity in childhood leads to approximately 30% of obesity in adulthood. Many fat adults were fat infants, and the natural history suggests that the obese child who becomes an obese adult will have more severe adult obesity than adults whose obesity began in adulthood. It is therefore paramount to assess and intervene in childhood.

A Health Promotion Board (HPB) survey showed that 60% of adult Singaporeans eat out as often as four times a week, and their children tend to eat out with them. With more money and access to a wider variety of food, Singaporeans began to eat more but less healthily. The same survey also showed that only one in four children aged seven to 12 ate fruit and vegetables on a daily basis. It is very important to make dietary changes in tackling obesity. Other lifestyle measures like getting more involved in physical activity is very important as well.

Ways to Help Your Overweight Child

Be supportive

Overweight children need support, acceptance and encouragement from their parents. They need to understand the reasons behind all the concern and to have a chance to share their concerns with you.

Get everyone involved

Do not isolate your overweight child but get everyone in the family involved in eating healthily and changing their lifestyle to include more physical activity. Family involvement helps to teach everyone good, healthy habits and does not single out the overweight child.

Be a role model

Children are good learners and they learn best by example. Setting a good example for your children by eating a variety of food and being physically active will teach them healthy lifestyle habits that they can follow for the rest of their lives.

Instill healthy eating habits

Do not put your child on a restrictive diet. Limiting what children eat may be harmful to their health and interfere with their growth and development. Parents should offer the whole family a wide variety of food from each of the food groups displayed in the Food Pyramid and have appropriate portions depending on the food group (as shown above). Items in the top part of the pyramid ought to be served sparingly. Plan for snacks and be the gate keeper at home Snacks should be as nutritious as possible, without depriving your child of the occasional chocolate or chips. Parents are responsible for stocking food in the home fridge and pantry. Buy lots of different types of wholesome food for your home. This will help your children learn how to make healthy food choices.

Do not use food to punish or reward

Sending children to bed without dinner will make them worry that they will go hungry. They would then eat whenever they get a chance “in case” they get punished later. Rewarding them with treats will also cause them to perceive that such foods are more valuable. This will send the wrong messages about food that are “freely available” such as rice, fish, fruits and vegetables.

Involve your children in food shopping and preparing meals

Shopping together gives you a chance to teach your children about good nutrition. It also helps you to learn their food preferences. Children get a feeling of accomplishment and may be more willing to try food they helped to shop for and prepare.

Do not eat in front of the TV

Eating in front of the TV makes it difficult to pay attention to feelings of fullness and may lead to overeating. When the children eat slowly, they can also detect fullness better and prevent overeating.

Make sure your child’s meals outside of home is balanced

Children these days eat out a lot especially for lunch and school recess. Find out what is available at the school canteen and help your child make proper food choices. Also, select healthier items when eating out together.

Get active

Take the stairs instead of the lift if you can. Encourage your child to play outdoors instead of watching TV and playing computer games. Provide them with toys that involve physical activity. Get a group of friends together for some games. Get active yourself by playing along! It’s great fun and does wonders for everyone’s health.

If you find all measures taken on your own don’t seem to work, it may be worthwhile getting a doctor’s consultation to make sure there aren’t any pathological problems causing the rapid gain in weight. See a dietitian for more detailed meal plans to reduce caloric intake and even work with a physiotherapist to come up with some exercise regimen to follow.
Dr Cindy Ho is an Associate Consultant at the Division of Paediatric Endocrinology, National University Hospital.

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by Dr Wong Soong Kuan

COLORECTAL CANCER IS the most common cancer in Singapore, having overtaken lung cancer as the top cancer for men and remaining second for women. The lifetime incidence of colorectal cancer in Singapore is roughly one in 50 patients. This means that one in 50 people will have colorectal cancer in their lifetime. While incidences of the cancer peak at 50 to 70 years of age, it doesn’t just strike the old either.

Causes of Colon Cancer in Younger People

According to the data gathered by the Singapore Cancer Registry between 2006 and 2010, colorectal cancer cases are on the rise, and one out of 10 diagnosed with the cancer of the large intestine was aged below 50. Such cases of young patients with colorectal cancer usually have a genetic component to it. It can be due to one of four reasons: familial adenomatous polyposis, cancer family syndrome, a chronic condition called inflammatory bowel disease (IBD) and lastly, sporadic mutation. Familial adenomatous polyposis is a condition where a child is born with his or her entire colon being carpeted by polyps – an abnormal growth of tissue projecting from a mucous membrane.

Hence, by the age of 18 to 30, they have a higher chance of one of the polyps developing into cancer.

There’s another possibility known as cancer family syndrome. Also called lynch syndrome, it is a genetic condition where those affected have an increased risk of developing cancers of the digestive tract. Such patients have a higher risk of developing colorectal cancer – which often manifests between the ages of 30s and early 40s – and can also develop cancers of the breast, ovaries and uterus.

The third possibility is a chronic condition called inflammatory bowel disease, which is very rare in this part of the world but very common in the Caucasian population. This is when a person’s intestine becomes inflamed over many years, increasing the risk of it developing into cancer. Typically, if the process has been going on for more than 20 years, there is a condition called dysplasia that can occur, and this increases the risks of cancer.

The last possibility is sporadic mutation, where a spontaneous mistake in gene duplication predisposes a patient to developing cancer at a young age. Sporadic mutation is the most common cause of colorectal cancer in young patients. The reason is unknown, although exposure to more carcinogens may be a possibility.

Rare but Dangerous

While cases of colorectal cancer in the young are very rare – with the four possibilities combined having less than a 5% chance of occurring in the Singapore population – the problem is that they are often detected late. Statistically, the chances of surviving for at least five years after treatment stands at 90% for those diagnosed at stage 1 of the disease. However, this number drops drastically to 15% if diagnosed at stage 4.

After the cancer has spread to either the lymph nodes or distant organs, surgical removal alone is not an option and chemotherapy becomes necessary. For colorectal cancer, it more or less progresses in a step wise fashion – from the wall, spreading out into the nearer lymph nodes, then the further lymph nodes and finally to the other organs. Hence, especially so for colorectal cancer, the earlier the stage of the cancer, the better the treatment is going to be.

Signs and symptoms include looser stools, as a result of the intestinal wall becoming partially blocked and the blockage being released intermittently. It can also be the other way around, where patients complain of stools becoming increasingly difficult to pass as the passage becomes narrower. Rectal bleeding or unexplained weight loss should definitely be investigated as well. More uncommon symptoms include pain due to perforation of the intestinal wall, as the tumour gets so large that it breaks through the wall.

Unfortunately, by the time a patient shows any obvious signs or symptoms, the disease has likely progressed to the later stages where the prognosis is bleaker. In fact, more than 50% of patients present themselves in stage 3 or stage 4 of the cancer. That’s why everyone above the age of 50 should go for colonoscopy.

The Importance of Colonoscopy

Colonoscopy involves a flexible tube with a small camera inserted via the anus to examine the large intestine. If polyps are found, they can be removed at the same time. Colorectal cancer starts with a pre-cancerous growth called a ‘polyp’, and the pre-cancerous growth progressively enlarges. Once it reaches a certain size – typically up to 2cm to 2.5cm – changes may occur that will cause the polyp to invade and become a full blown cancer.

While the chances of finding a polyp through colonoscopy screening for patients above 50 stands at about 20%, less than 3% of patients test positive for cancer during screening. The aim of a colonoscopy is to find and remove these pre-cancerous growths before they have a chance to develop into early stage colorectal cancer.

About 1,600 new colorectal cases and 660 deaths are recorded per year in Singapore. Yet according to the Ministry of Health, only one in nine men and one in 13 women aged between 50 and 70 have done a colonoscopy at least once. And when symptoms do show, young people tend to dismiss them on the mistaken belief that colorectal cancer only affects the old.

Colorectal cancer screening is normally recommended for those above 50, but if a person experiences anything out of the ordinary with his or her bowel habits, have rectal bleeding or unexplained weight loss at any age, a doctor should be consulted immediately. Change in bowel habits includes diarrhoea, severe constipation and change in the calibre or consistency of the stool such as it becoming more mucous or long and pencil-like.

In addition, if you have a family history of cancer, screening should be done five to 10 years before the youngest age of a first degree (immediate family) relative diagnosed with cancer.

For example, if you have a first degree relative who was diagnosed with cancer at 40, you should start going for a regular screening once you hit 30.

Other Colorectal Cancer Screening Methods

Because of the difficulty in the symptomatic detection of colorectal cancer in the early stages, the focus is now on identifying individuals more susceptible to the cancer. While the gold standard for colorectal screening is still colonoscopy, a new method called faecal occult blood testing (FOBT) is being advocated by polyclinics. This is essentially stool testing where patients handle and send samples of their own stool to a laboratory to be tested for hidden blood. However, the test depends on whether the tumour is bleeding and has a 60% to 70% success rate.

Screening involves either an annual faecal occult blood test or 10-yearly colonoscopy, beginning at age 50 for average risks individuals.

There is also another test called virtual colonoscopy, where X-rays and computers are used to produce two- and three-dimensional images of the colon. However, virtual colonoscopy involves some radiation, and in cases of poor bowel preparation, stool sometimes can be mistaken for polyps and vice versa, increasing the chances of a higher false positive or negative result. In addition, a positive result for both stool testing and virtual colonoscopy will still require a colonoscopy to confirm the findings and remove the polyp. Colonoscopy is medisave-deductable and is recommended for a more precise diagnosis.

Dr Wong Soong Kuan is a General Surgeon at The Colorectal Clinic, Mount Elizabeth Novena Specialist Centre.

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by Dr Ho Siew Hong

BEING A PARENT is hard enough without being bombarded with so many decisions to make for your newborn child. Perhaps one of the most important decisions you will face even before you take your baby boy home from the hospital is whether or not to have him circumcised.

For some parents, the decision is simple and non-arguable due to religious or cultural predispositions. For others, however, they need to heavily weigh the pros and cons. Circumcision is the removal of some of the excess foreskin (prepuce) from the penis. The reasons and benefits for circumcision include religious, medical and personal preferences.

Religious Practice
Male circumcision is religiously practiced by the followers of Judaism and Islam. The ceremony, with great rejoicing and festivities, usually takes place one week after birth for Jews and within the early few years of age among Muslims.

Medical Benefits
Phimosis or tight foreskin which prevents complete retraction and exposure of the glans (head) of the penis will benefit from circumcision. The tight foreskin harbour bacteria and become infected if not cleaned properly. This medical condition is called balanoposthitis, which is an infection and inflammation of the foreskin. Forcible retraction of the tight foreskin can be very uncomfortable and can lead to tears and infection of the foreskin. Tight foreskin may also cause discomfort during full erection of the penis and sexual intercourse.

The World Health Organization (WHO) recommends that circumcision is efficacious for HIV prevention, but it does not provide complete protection. Circumcision provides a 50% to 60% reduction in HIV transmission from female to male. However, this cannot be the recommended method to control the spread of AIDS. Circumcision at a very early age (within the first month of life) confers protection from penile cancer, but circumcision at any later age does not seem to confer such protection.

Personal Preference
Circumcision is not indicated if the foreskin can be completely retracted to expose the head of the penis. In some individuals, circumcision is perceived to provide better hygiene. The head (glans) of the penis can be exposed and cleaned. There is also less problems of urine accumulation around the foreskin. There is much data comparison for sexual pleasure before and after circumcision, but there is no clear evidence if circumcision will enhance or decrease sensation during sexual intercourse.

Circumcision Procedure
There is no age limit to circumcision. It can be done at birth and all the way until an elderly age. It may be uncommon to hear of an elderly gentlemen undergoing circumcision, but it is often done for repeated infection of the foreskin, especially in men with diabetes. Circumcision can be performed under local or general anaesthesia and can be completed within 15 to 20 minutes. There is minimum pain, and the procedure is done as day surgery. Patients are discharged with tablet painkillers and antibiotics for one to two days only. The excess foreskin is removed. A couple of stiches are placed to bring the edges of the skin together after removal of the excess skin. These stiches are self-absorbable and do not require removal in a later date. The stitches will dissolve within two weeks.

Risks and Complications
Generally, risk of complications in a competently-performed circumcision is very low. Minor bleeding and infections are the two most common complications.

Dr Ho Siew Hong is a Consultant Urologist at Urology Specialists Pte Ltd, Mount Elizabeth Novena Specialist Centre.

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by Fiona Walker

Empathy has been recognised as one of the most important qualities of a leader in any field and in any culture. It is a skill children learn, unlike intelligence and looks, which depend a great deal on genetics. More than any other skill, it leads to success in school, in social situations and in careers. Empathy is the ability to understand what another person is feeling, to understand how you would feel if you were in that situation, and the motivation to treat people kindly based on that understanding. It is an extension of self-concept, but it is far more complex and does require awareness that others have emotions and thoughts that are both similar and different from our own. The foundation of the ability to love, empathy is the core of good character. The very best teachers of empathy are parents.

Start Them Early

Children are aware of the emotions of those around them from birth and can become distressed if they hear crying, smile if they hear laughter, and can copy the emotions they see on their caregivers’ face from a few months of age. Although this isn’t necessarily empathy, it is the precursor in that the baby is aware of another’s emotions and reacts accordingly.

When a baby is around one, you will generally see the first signs of empathy emerging. After their first birthday, you may find your child will attempt to comfort a distressed or hurt child or parent with a pat, a cuddle or by handing them something to comfort them like a toy. So here you are seeing what is called ‘pro-social behaviour’. This is when the child not only responds to the emotion of the other person but they take some action to try to make that person feel better.

At around 18 months, children will often ask, “Are you okay?” and will be more consistent in offering comfort. This increases from then on.

As with adults, some children are naturally more empathetic than others at a younger age, and studies have shown that girls tend to demonstrate empathy earlier than boys. What we must remember is that in young children, empathy is not usually shown consistently, and while your child may seem like a little angel offering help and cuddles one day, the next day he may not be in the least bit bothered by someone’s misfortune. This is perfectly normal.
Praise your young child’s behaviour when she shows empathy. The more you praise the behaviour, the more likely your child is to repeat it.

Encourage Them to Express 
Feelings Openly

For your child to be comfortable expressing their own feelings and to be able to understand the feeling of others, it is helpful if you talk about feelings openly at home. Expressing how you are feeling or how you think someone else might be feeling will help your child be aware of the impact behaviour can have on someone’s mood. By communicating clearly about how your child’s behaviour is making you feel and asking about how they feel, you are helping your child develop an awareness of, and the vocabulary to, express their feelings and begin to understand the feelings of others.

This openness in communication develops emotional fluency. Someone who is emotionally fluent is also capable of picking up the cues in another person’s response to conversation. If more emphasis was put on developing this skill, we would see a lot less bullying, both cyber bullying and in the school yards.

Monitor Your Child’s Exposure to Internet/Other Media

The Internet has enabled us to explore different ways of life across the globe. Through the Internet we are able to reach out and help people or animals in far off places. Unfortunately, the increased access to computers and Internet means we are able to play games where the violence seems to have no consequence and we can communicate with people we are unlikely to ever meet. This can deaden the development of empathy.

There are many studies being done on the impact of these violent video games. The findings of these studies are generally that they promote:

• Acceptance of Violence – Frequent exposure to violent video games can impact a child’s perception that some types of violence are acceptable, even entertaining.
• Desensitisation – Children, especially boys, can become desensitised to violence because of frequent exposure to violent video games.
• Wrong Messages – The message of many of these games is that there are no consequences for this violence.
• An Imbalanced Perspective – Games rarely provide the perspective of the victim and can impede the development of empathy in children and teens.

As parents, it is an important part of our role to monitor what our children are being exposed to. Make sure your children do not watch too much violence, either on YouTube, in games or movies, as it really is damaging for their healthy development. As children get older, make sure you are able to monitor the relationships and communication they have with others on the Internet, whether it is Facebook or other social networks.

Be a good role model

If you are interested in different people and places and enjoy the diversity of this planet, your children are very likely too as well. Empathy enables us to connect with others, and the better we can do that, the more successfully we can communicate with others and the more trusting relationships we can have. So encourage your child to be in tune with the feelings and emotions of others and their own. Make sure that your child has the time and opportunity to talk to you about feelings; how they are feeling, how you are feeling and how others may be feeling. Think about it. That is likely to be far more valuable in the long run than any other structured activity or tuition lesson.

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ONE OF THE biggest challenges about being a parent is dealing with a sick child. It doesn’t matter whether it’s a slight fever, a simple cold, or a bad case of dengue, parents worry just the same.

With the impossible weather we have today, coughs and colds are common in adults and kids alike. And most often, parents find themselves worrying whether or not their kids’ cough is just due to a simple cold that can be remedied at home or something that needs a doctor’s attention. According to doctors, an occasional cough doesn’t always mean there is a problem. Cough protects your child’s body by removing mucus, irritating substances and infections from his or her respiratory tract.1 But if your child’s cough lasts more than two to three weeks, you should already pay your paediatrician a visit.

Causes and Symptoms of a Cough

There are many different causes of a cough in children, including both viral and bacterial infections, as well as irritations caused by pollution, smoke, or when your child inhaled foreign body. Sometimes the culprit are allergies, which cause a lingering cough, as well as an itchy throat, runny nose, sore throat, or rash. Although asthma can be difficult to diagnose due to varying symptoms, a wheezing cough, which may get worse at night, is one of its many symptoms. The cough caused by asthma is often worse at night or after a rigorous activity.

When your child’s cough is due to a cold, it is normally loose and sometimes produces mucus. It often gets worse at night, because when your child lies down, mucus drips from the back of her nose and mouth into her wind pipe.2

If your child has croup (laryngotracheobronchitis), his or her cough is hoarse and barking. And if your child suddenly starts wheezing while coughing, followed by a choking episode, it’s a probability that he/she could have inhaled foreign body. A whooping cough is when your child has had a very heavy cold, followed by bouts of heavy coughs for many weeks.

When to Call the Doctor3

Most coughs in kids are normal, and parents should have nothing to worry about. However, please call your doctor or bring your child to the clinic if:

• ⎭ Your child has trouble breathing or is working hard to breathe.
• ⎭ He/she is breathing more quickly than usual.
• ⎭ He/she has a blue or dusky colour to the lips, face, or tongue.
• ⎭ He/she has any fever and is less than three months old.
• ⎭ He/she is an infant (three months old or younger) who has been coughing for more than a few hours.
• ⎭ He/she makes a “whooping” sound when breathing in after coughing.
• ⎭ He/she is coughing up blood.
• ⎭ He/she has stridor (a noisy or musical sound) when breathing in.
• ⎭ He/she is weak, cranky, or irritable.
• ⎭ He/she is dehydrated.

Treatments at Home

Like any other illnesses, prevention is better than cure. So if your child has asthma, make sure to reduce his or her exposure to asthma triggers. Make sure your child has enough to drink to prevent dehydration.

If your child has blocked nose, ask your doctor for treatment or drops for nasal stuffiness. Vapour rubs are another treatment that some parents normally use for coughs and colds in children. They can be applied on the chest and back, as well as the feet. A new study also suggests that a spoonful of honey before bed may help little kids with a cough.4

If you think your child needs antihistamines, decongestants, or other cough and cold remedies, make sure you ask your doctor about it first before giving your child any over-the-counter cough medicines.

References:
1http://www.aaaai.org/conditions-and-treatments/library/at-a-glance/cough-in-children.aspx
2 http://raisingchildren.net.au/articles/cough.html
3kidshealth.org/parent/general/eyes/childs_cough.html#
4 http://www.reuters.com/article/2012/08/06/us-honey-coughing-idUSBRE87505G20120806

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What can be done about it?

by Dr Warren Lee

Severe growth hormone deficiency is said to be a rare condition, yet many of us have friends who are height challenged. Some of them cope very well, but others seem to lose out when it comes to job opportunities, sports activities, and choice of dates and life partners.

Some children are born small because of prematurity or because they had growth retardation in the womb. Small for gestational age is a term used to describe someone who was born small or lighter than expected for the gestational age (duration of pregnancy).

Average Height of a Singaporean Adult

The average height (50th centile) for adult Singapore men is about 170cm and that for Singapore women is about 158cm. The 3rd centile for Singapore girls is about 148.5cm and the 3rd centile for Singapore boys is about 160cm. In Caucasian populations, the average height of an adult male is about 175 to 178cm and that of an average woman is about 165 to 167cm. Some researchers in Japan have concluded that a functional definition of short stature is a height of 150cm or less for an adult woman and less than 160cm for an adult man because of practical difficulties with clothes, workplace requirements, and so on.

By definition, a person who is shorter than the 3rd centile (among the shortest 30 out of 1,000 individuals in a normal population) is considered to have short stature. However, in a class of 30 children, a person at or just above the 3rd centile is likely to be the shortest individual.

The Issue of Being Short

If a child is a late developer, and is only going to be short in childhood but has a reasonable hope to be of average height as an adult, we could talk about getting a child to accept his or her current height. However, some children are psychologically quite affected by being the shortest in class or among the group, and it may be necessary to address the problem without waiting for an uncertain future event.

It is also difficult to say who is going to be significantly affected by short stature. A child growing up in a family where all relatives are short (familial short stature) may have less difficulty accepting a short adult height than a person with the same final height who has relatives or close friends who are tall. Girls have the advantage of being able to wear high heels and they are not expected to be so tall. However, some occupations have minimum height requirements and employers (and potential life partners) may have unsaid but real prejudices against people below a certain height.

Conditions Affecting a Child’s Growth

A child may develop conditions which impair the release of growth hormone, such as a lack of thyroid hormone (hypothyroidism) or they may have a condition in which there is no pubertal growth spurt because of a chromosome abnormality (e.g. Turner’s Syndrome).

Less commonly, a child may have a genetic condition where the body does not respond well to the normal levels of hormonal signals for growth, such as people with skeletal dysplasia.

Rarely, a child may have severe growth hormone deficiency that was present since birth or may have growth hormone deficiency which occurred because of a brain tumour or following chemotherapy.

Nutrition and Growth Hormone Therapy

While good nutrition is, of course, an important factor in childhood growth, not every growth problem can be solved by nutritional treatments. In fact, children who put on too much weight in early childhood may develop early puberty, which may in turn lead to being short as an adult.

If a child who was born small has not caught up in height by the age of two years, growth hormone therapy may be an option. Growth hormone is a protein produced naturally by the body. It promotes growth in height, and muscle and bone development in children. It works on those who have growth hormone deficiency and in children who are born small for gestational age who are less sensitive to the effects of normal levels of growth hormone.

It has been in clinical use for over 50 years now and is quite safe if given carefully by a specialist experienced in the proper use of growth hormone. Because growth hormone is a protein hormone made nowadays by bacteria in the lab, it cannot be given orally, and has to be given as a daily injection over months to years. Fortunately, some human growth hormone preparations such as Saizen (Somatropin), have a delivery device which can give needle-less injections.

However, growth hormone can only work when the epiphyses, or the growing ends, of the bones are still not fused. The puberty sex hormones are the main driver for the fusion of the epiphyses. If a child is going to achieve a short final adult height because puberty has come too early or because the child is still short and the bones are going to fuse, doctors may use medications such as gonadotropin agonists to reduce the level of puberty sex hormones.

Reasons Why Some People Become Short Adults

There are many reasons why some children may end up as short adult. Some reasons include:

• Being born small – born premature or full term (full nine months) but small for gestational age and then failing to have good catch up growth in childhood and puberty

• Developing puberty prematurely (also called precocious puberty), and hence stopping growth too early

• Being born normal size, but having growth failure in childhood – sometimes due to chronic illness or ill health

• Being born normal size but growing slowly in childhood and developing puberty late (also known as constitutional delay of growth and puberty), but then failing to have a good growth spurt in puberty

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A student overcomes his medical odds to achieve academic excellence

SINGAPORE ESTIMATES THAT 3% to 5% of children have Attention Deficit Hyperactivity Disorder (ADHD). One such student – 17-year-old Shaun Sim from Victoria Junior College who attained a perfect score of eight A1s in the GCE O’ Levels – was among the stars who received the inaugural ACE Awards where it honoured outstanding children and youth who have excelled despite ADHD. The aim of the awards is to remove the stigma of ADHD and encourage children and youth with this condition to reach their full potential in Singapore’s inclusive society. Coaches and mentors who have made a significant impact to the lives of ADHD students were also honoured. Ezyhealth took time to find out how this ace student delivered the goods.

EH: How did your parents find help?
SS: My kindergarten principal noticed that I was different, as in hyper and less attentive, and recommended my parents to assess me. They then sent me to ‘child’s guidance clinic’ to seek help.

EH: Who is your doctor and what did he advise you to do?
SS: My doc is Dr Ong Say How, and he recommends me multiple methods to help. In a sense, he talks to me about living life, telling me how the normal kid goes through it and how I differ and any extra efforts required to keep up with the others.

EH: Has your family been supportive, how so?
SS: Yes they have been very supportive. My parents keep doing research and find new ways to accommodate my stranger study habits or hobbies. They keep me in check and provide strong moral support. My sister is also very interesting. She is normal, in the general context, but motivates me when things get too hard. She’s very close to me.

EH: How do you feel about getting such good grades despite your challenges?
SS: I am actually confused whenever I get superb results, often because I play down the efforts I put in studying. I appreciate the results, but am quite modest about it, preferring not to talk about them in front of others. As for my challenges, let’s say it goes to a day-by-day basis, some days I like myself being a little more hyper. Other days I need to sit down and concentrate, so then I need my medication.

EH: Did you go to the internet to find out more  about ADHD?
SS: Yes and no, depends. More often I prefer to think of myself as a normal teenager, no extra problems or miseries. So I do what a normal teen does, which also involves not going online to check about ADHD. However, there are times I wonder whether others feel like I do, and that is when the Internet is helpful.

EH: How do you think you can help other teen sufferers?
SS: Honestly, advice and mental conditioning. I have been working on a mode of thinking that allows me to see my condition a positive driving force that guides and shapes my life rather than a disability that would drag me down. This allows me to find peace within myself, allowing me to focus on other problems. I recommend this to other people with ADHD, and hope they can see themselves as gifted rather than cursed.

EH: What is the one thing you’d like to do but have never done so?
SS: I always wanted a sword, a traditional Japanese Katana to practice with. Short of that, I want to learn swordplay but never can find the right avenues to easily do so.

EH: Tell us what do you think life is all about?
SS: I have been philosophising about it actually, and it boils down do this – it is not about what cards you are dealt, it is how you play the ones you have well.

Rise Above Adversity – Attention Deficit Hyperactivity Disorder (ADHD)

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by A/Professor Anne Goh

CHICKENPOX IS AN infectious disease with most people coming down with it as a child or an adult if they have not been vaccinated. Many people fail to realise that other than the high fever, dehydration, diarrhea, skin infection and pox blisters, chickenpox can lead to serious complications such as inflammation of the brain membrane, pneumonia and even death, in rare cases. The chickenpox virus will also remain dormant in nerve cells, often causing a painful rash called shingles later in life. One in three people will get shingles in their lifetime; most often it will be elderly patients and sometimes children.
About one out of 500 unvaccinated children with chickenpox will need hospital care. In serious cases, the child will be hospitalised in an isolation ward.
Chickenpox being highly contagious, can be caught from an infected person who coughs, sneezes or shares their food and drink. It can also be caught from touching the fluid from a chickenpox blister. It spreads fast in crowded environments such as childcare, enrichment centres and nursing homes. An infected person can end up with 250 – 500 blisters all over the body, even inside the mouth! Other symptoms are fever, headache and a stomach ache. Housemum Krystal Cheong, and her son, Ki’en, recently suffered the trauma of his first chickenpox attack. He was just under a year old.
Although both mum and son did not miss work or school during the 10 days that he was sick with chickenpox, it was a trauma she wished that they had both been spared.
Krystal suspects Ki’en may have picked up the virus in their neighborhood playground. Her son was just three months short of the recommended age in Singapore for the vaccination.
The vaccination against the varicella zoster virus that causes chickenpox is not compulsory in Singapore. However, doctors recommend for children to be vaccinated between 12 to 18 months. Parents can choose a combined MMRV vaccine to protect against measles, mumps, rubella and chickenpox and should speak to their family doctor on this.
Krystal said she would have vaccinated Ki’en if he had been older. “It would have saved us all the 10 days of sleepless nights and anxiety when Ki’en had high fever and his skin flared up. I had to try to stop Ki’en from scratching his skin and I worried about his high fever and crying. He was just a baby.” Said Krystal, “No parent will want to go through what my husband and I went through. I limited myself to one shower a day to ensure round-the clock vigil for our sick son. I lost my appetite and suffered fatigue.”
Prevention is key
Professor Goh of the Singapore Paediatric Society advised parents to stop misperceiving chickenpox as a harmless rite of passage. Some parents are also known to expose their children to the infection at ‘chickenpox parties’, believing it is best to get over with the infection in childhood than wait for it to surface in adulthood. Professor Goh said, “Grandparents and many modern-day parents underestimate the potential severity of chickenpox. Many fail to realise that the infection can lead to more serious complications, including shingles later in life.”

Bust the Myths!
Myth: People with chickenpox cannot eat food such as chicken, prawns and crabs because these will aggravate the skin itch
Truth: No foods will make the
condition worse.
Myth: Parents should get their
children infected while they’re young.
Truth: It is impossible to predict who will have a mild case of chickenpox and who will have a serious or even deadly case of disease.

Tips for Mums!
 Try to keep your child from scratching the itchy areas as this will break the skin and lead to higher risk of infection
 Soak your child in a pinetarsol wash or bath to help relieve the itching
 Ensure your child’s pyjamas are cool
and light
 Avoid prolonged exposure to
excessive heat

References:
www.webmd.com/vaccines/features/shingles-chickenpox, WebMD. Accessed 19th Sep 2012
Nordqvist,Christian. “What Is Chickenpox (Varicella)? What Causes Chickenpox?”. Medical News Today.n.d. Web 1 July 2012
http://www.hpb.gov.sg/HOPPortal/article?id=6434 /
http://www.webmd.com/vaccines/tc/chickenpox-varicella-topic-overview /
US National Library of Medicine, PubMed Health, Diseases and Conditions – Chicken Pox
www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002559/

Article is contributed by Adjunct Associate Professor Anne Goh, President of Singapore Paediatric Society, MBBS, MMED (Paeds), FAMS, FRCPCH

More Than Meets The Eye – Stop perceiving chickenpox as a harmless rite of passage

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Control your child’s asthma with a plan

by Yvette Atienza

For most kids, breathing normally is taken for granted. However, for kids with asthma, breathing can be a lot more difficult because their airways are very sensitive. An asthma flare-up, which some people call an asthma attack or episode, happens when a kid’s airways get swollen and narrower and it becomes a lot harder for air to get in and out of the lungs. Sometimes the swollen airways produce extra mucus, which makes things pretty sticky, so understandably it becomes harder to breathe. In between flare-ups, a kid’s breathing can be totally normal or seem that way. But during a flare-up, it can feel like the person is breathing through a straw. A kid with asthma may wheeze (a whistling sound when he or she breathes), cough, and feel tightness in the chest. An asthma flare-up can get worse and worse if a kid doesn’t use asthma medicine. After an asthma flare-up, the airways almost always return to the way they were before, although it can take several days.

More Than You Know

Asthma is more common than you might think. Asthma affects about one or two kids out of 10. That means if you have 20 kids in your class, two to four of them might have asthma. Asthma can start at any age — even in a little baby or an adult — but it’s most common in school-age kids. No one really knows why one person’s airways are more sensitive than another person’s, but we do know that asthma runs in families. That means if a kid has asthma, he or she may also have a parent, sibling, uncle, or other relative who has asthma or had it as a child.

Asthma Triggers

People with asthma have what is called a chronic, or continuing, problem with their airways. The airways become swollen and full of mucus. This problem is made worse by asthma triggers. Triggers are things that don’t bother most people, but they can make people with asthma cough, wheeze, and have trouble breathing. Triggers don’t cause asthma (no one knows exactly what does) but they can lead to asthma flare-ups. Every person with asthma has different triggers. Some people have one or two while others have a dozen. Triggers may change from winter to summer and some kids even outgrow triggers as they get older. Common triggers for kids with asthma include dust mites (tiny bugs that live in dust); mold (if you’ve ever been in a damp basement and smelled something funny, it was probably mold); pollen (a kind of dust that comes from trees, grass, and weeds); stuff in the air such as smoke, cigarette smoke, chalk dust and pollution; colds or the flu; weather conditions; exercise; animal dander (skin flakes that are kind of like dandruff); animal saliva and urine; and feathers.

Managing Asthma

Medicines can help during an asthma flare-up, when the airways get swollen or become narrower and clogged with mucus, and it becomes really tough to breathe. There are two different kinds of medicines for treating asthma and these include rescue medications that can loosen the muscles around the airways. That opens up the airways and makes it easier to breathe. Rescue medicines are usually inhaled (breathed) right into the lungs, where they stop wheezing, coughing, and shortness of breath quickly. In other words, they rescue a person who’s having trouble breathing! The other method is controller medications that work over a long period of time by keeping the airways from getting swollen in the first place. They may be inhaled or taken as a pill or liquid. Rescue medications are important during a flare-up because they help someone breathe more easily right away. That means anyone who has asthma and has been prescribed rescue medications should always have them along — at school, on the basketball court, at the mall, and even on vacation. But rescue medications don’t do anything to help stop an asthma flare-up before it happens. That’s where controller medications come in. These medicines might not seem to be doing anything. In fact, a kid with asthma might not feel anything at all when taking them. But these medicines are quietly doing important work to control asthma every day. Some people with mild asthma use only rescue medications when they have flare-ups. Others who have more severe asthma must take rescue medication when they have breathing problems and they need to take controller medications every day. If you have asthma, your doctor will decide which type of medication you need and how often you need to take it.

Make a Plan!

Having a plan makes almost anything easier, even asthma. An asthma action plan is a set of instructions your doctor will write down for you and your family. It will tell you how to prevent asthma flare-ups and deal with flare-ups when they happen. Your doctor might give you a plan, or you can print out a sample plan and ask him or her to complete it with you. An asthma action plan helps you keep your asthma under control. And when your asthma is controlled, breathing problems won’t keep you from playing sports, having fun, and doing whatever you want to do. Following your plan can also mean fewer trips to your doctor or to the emergency department.

• Keep your room as clean and free of dust as possible. This means vacuuming and dusting weekly and getting rid of clutter. Your old stuffed animals might need to go into a box in the attic.

• Wash your sheets weekly in hot water. You can get covers for your mattress, box spring, and pillows that will help too.

• Get rid of carpets. Any kind of rug or carpeting can collect allergens that cause asthma symptoms.

• Keep any pets out of your room. Before you spend the night at a friend’s house, find out what kind of pets he or she has. If your asthma symptoms are triggered by allergies, you might also need to take allergy medication or have allergy shots. Your doctor will let you know.

References: www.kidshealth.org www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001196/ www.medicinenet.com/asthma/article.htm

Asthma in Children – Don’t Panic!

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Breastfeeding has been clinically proven to be the most comprehensive and safe diet for your baby. The benefits are many, and recommendations from experts are overwhelmingly in favour of it. It is also a natural, warm and caring way of bonding with your baby. Besides the positive effects it has on both you and your baby’s health, there are many other benefits too.
The general advice is to exclusively breastfeed for the first six months of your baby’s life and thereafter as long as mutually desired.

A Defence Against Infections
Breastmilk is uniquely superior as it consists of all the nutrients your baby needs. It is easy to digest; hence breastfed infants experience fewer feeding problems during the weeks after birth.
Breastmilk contains antibodies from you. It therefore protects your baby against infections. The antibodies also stimulate the development of your baby’s own defence system.

Feeding Choices
If you are unable to breastfeed, it is important to ensure that you choose an age-appropriate infant formula for your baby. Consult your doctor for the best option.

Tips on Breastfeeding
• Start breastfeeding as soon as possible after birth. Your baby’s suckling reflexes are strongest immediately after birth. This is also the perfect opportunity for bonding.
• Stimulate your baby’s natural urge to suck by tapping his cheek. Your baby will turn his head in your direction and open his mouth. Then introduce your nipple into the mouth making sure that at least part of the areola is grasped as well. The areola is the brown-pigmented skin surrounding your nipple. Once your baby ‘latches on’, move him closer so that his mouth covers a large part of your areola.
• Empty your breast during feeds as milk production is most effective in this manner. The opportunity to feed often will stimulate more milk production as well as prevent breast engorgement.
• Feed your baby from both breasts at one sitting or alternately at successive feedings.
• Avoid feeding from a bottle or using a pacifier in the first few weeks, as that will discourage the learning process of breastfeeding for the baby.
• Rest as much as you can. Stress and interrupted sleep can lead to fatigue. This can result in a decrease in milk supply.
• Avoid smoking and alcohol, as nicotine and alcohol can pass into your breast milk and may affect your baby. Also, be aware that some medication can
be passed to your baby in the breast milk. Although most medications are safe, your doctor should be aware that you are breastfeeding if you require any medication.
• Treat any breast engorgement by applying hot compresses or take warm showers before feeding and applying cold compresses between feedings to reduce your discomfort.
• Treat sore or cracked nipples as they can lead to breast infections such as mastitis (an inflammation caused by bacterial infection) or breast abscess. Sore nipples should be “air-dried”. Avoid feeding from the affected breast. See your doctor if you develop red blotches on your breast or have a fever.
Quote:
A new study, published in BioMed Central’s open access journal Genome Biology, suggests that human milk promotes the beneficial crosstalk between the immune system and microbe population in the gut, and maintains intestinal stability.

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by Fiona Walker

The different learning styles between boys and girls have been well-documented over the past decade, with brain-based research and behavioural case studies from leading educationists invariably reaching similar conclusions. Whilst gender differentiation may be only a starting point for understanding how to provide the best learning environment for children (from birth onwards), it is important that we are aware of these differences, understanding how and why they occur, in order to manage our expectations of children’s development and behaviour.
Research reveals that there are significant structural and functional distinctions in the brains of boys and girls. What are the main differences and what does this mean in terms of learning and behaviour?

Physical Development
How do these differences in the brains of boys and girls affect their development?
Boys engage in rough and tumble play in the school playground because their sense of spatial awareness requires them to move as they learn. This assists the development of their gross motor skills. The urge to explore physically is what pushes boys to want to rush off and explore; to run, cycle, jump, roll and leap as much as they can. Conversely, during early childhood, girls tend to be ahead with fine motor development. Happy to sit for longer periods of time, girls develop strong skills in drawing, colouring, threading, painting and writing.

Social Development
If you watch a class of boys and girls rush outside for free-play, you’ll notice that girls often spend most of the session discussing what they will do beforehand: who will be the Mummy, the Daddy, and other social aspects of the dramatic play, often leaving little or no time for the actual game itself! Boys on the other hand will tear around the playground immediately, as if the aim of their play is to cover as much ground as possible, as fast as possible.

Cognitive Development
Although boys may have an advantage over girls in terms of spatial-mechanical learning and girls may excel in language rich situations, this does not relate to any difference in intelligence. However, because traditionally we treat boys and girls differently from birth and often fail to provide them with the most suitable learning environment for their gender needs, this can lead to a disparity in academic results.

Ideal Learning Environment
The ideal learning environment for young children is one which recognises the different learning styles of boys and girls, ideally considering the spatial, emotional, social and cognitive needs of each gender. Ensuring equal opportunities for both sexes does not necessarily mean providing the same opportunities. For example, a young boy who finds himself in a crowded social setting may behave aggressively compared to a young girl, who will adapt more easily. Often, during the first few months of Nursery One, it is not uncommon for a little boy to hit, push or even bite as he struggles to feel comfortable in an unfamiliar setting.
Boys benefit from the opportunity to learn through outdoor projects, constructing, field trips and games. Because of this leaning towards hands-on-learning, boys more easily verbalise what they are doing than what they are feeling. When talking to boys while they are actively engaged in an activity, their language will be richer and more expansive.

How to Motivate Boys and Girls
From birth, babies are born with a huge amount of intrinsic motivation. When they see the results of their actions they are motivated to continue. This starts with understanding that crying will bring Mummy and milk. There are a number of ways that parents can help their children remain motivated:

• Provide an environment which allows them to explore freely.
• Do not jump in to help the child too soon. Provide ample time to allow for persistence to develop, vital to enable children to remain motivated.
• Set clearly defined limits that allow your child to be as independent as possible.
• Provide opportunities for you and your child to play to together. By exploring and interacting together, you provide a model for your child to learn from and you will get to know your child’s current interests and strengths.
• Praise and rewards should always be based on the child’s efforts rather than accomplishments. This can encourage the child to take on greater challenges rather than stick to a comfort zone.

It is important to understand that each child has individual interests and strengths and to get to know what these are. We all tend to be more involved with an activity if we enjoy it. This is especially true for young children. By understanding the differences between boys and girls we can plan activities which are more likely to appeal to them and lead to success. However, don’t forget that regardless of whether they are boys or girls, all children are best motivated by feelings of success, empowerment and by your encouragement, nurturing and love.

Girls’ Brains:
• Strong neural connectors in the temporal lobes make girls good listeners, with a sensually detailed memory.
• The hippocampus (storage area) is larger than that in boys, leading to an advantage in the language arts.
• Higher levels of serotonin in the bloodstream and hence the brain, mean girls are biochemically less impulsive than boys. Girls can sit calmly for long periods; take time to gather facts before reaching conclusions; happy to sit and chat.
• Large expanses of the brain used for verbal and emotive functioning. Girls are better able to multitask, with fewer attention span problems.

Boys’ Brains:
• Large areas dedicated to spatial and mechanical functioning. Boys, on average, use only half the space that girls use for verbal and emotive functioning. Boys adopt whole body approach to learning; can switch off if too much verbal explanation or when upset.
• Lower levels of serotonin and oxytocin (the chemical which promotes human bonding) leads to physical impulsiveness.
• Male brain is structured for compartmentalised learning.
• Male brain analyses symbols, abstractions, diagrams and objects moving through space. Hence boys tend to be good at maths, reading maps and logical thinking.

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