Monthly Archives: June 2017

Help my Son Who is not Growing Well

Poor weight gain isn’t an uncommon problem among children, and it’s a very prevalent problem that prompts a visit to a pediatric gastroenterologist. Poor weight gain is typically noticed by the parents (usually the mother) or primary physician, who notice that the child isn’t growing well – or their weight gain deviates from a normal growth pattern. When that weight trend is poor, doctors may describe the child as “failing to thrive” or “malnourished.”

When Does a Drop in Weight Become Concerning?

Often, the trend in weight over time is more important than a single drop in weight measurement. It’s important for weight to be compared to height to ensure that the child is gaining weight well in comparison to his or her height. This height and weight correlation is plotted using a weight for length chart or Body Mass Index chart.

Sometimes, toddlers will lose weight as they become more active. In this circumstance, their weight may drop in relation to their height, but the child will still continue to progress at a normal rate for their age. When there is a significant drop in weight with a single measurement, that may be concerning. In this situation, the child will have to be seen by a doctor and re-measured in order to see if the drop in weight is significant enough to warrant further action.

What Are the Reasons a Child May Not Grow?

The most common reason that accounts for over 90 percent of these cases is a lack of adequate caloric intake. This can occur when a child is not interested in eating due to variety of reasons, or when there is a lack of understanding by the parents regarding the caloric needs of the child. This happens with toddlers who are active and otherwise well, but who are less interested in eating. For even younger children in their first few months of life, this may be due to an inadequate supply of breast milk or to the improper mixing of formula in a formula-fed baby. Occasionally, a caregiver with emotional problems may not adequately feed the child. In the case of an older child or teenager, they may limit calories secondary to body image issues, which is considered nutritional insufficiency (previously called anorexia nervosa).

A child may also not feed well if he or she has heightened oral sensitivity or neurological issues. Such problems may affect their ability to swallow and may be caused by conditions such as cerebral palsy or a cleft palate. Sometimes, a child cannot keep their formula or food down due to excessive vomiting. This may be due to severe acid reflux; in a child with neurological issues, this causes low muscle tone and a variety of other disorders. Most infants with acid reflux will improve, and their growth will continue without issue. Less frequently, a younger infant with excessive vomiting may have a narrowing of the outlet of the stomach called pyloric stenosis and may need a special evaluation that would include an ultrasound of the abdomen.

A child with the inability to digest food due to poor capacity of the pancreas may not gain weight well. In this scenario, parents report their children as having bulky, frothy, loose, foul smelling and greasy stools. Disorders affecting lining of the bowel, including celiac disease or Crohn’s disease can also cause children to have poor weight gain. In celiac disease, symptoms start when foods that contain gluten are introduced into the diet.

In some situations, a child may burn too many calories if he or she has an over-active thyroid gland. A child with a heart disorder that leads to heart failure may also not feed well if they’re working too hard to breathe. Rarely, kidney failure or other kidney disorders will affect weight gain (as well as height) by affecting certain mechanisms of growth. Additionally, some children may have genetic disorders that affect weight gain and require evaluations by specialists.

How Should Poor Weight Gain Be Evaluated and Managed?

If you’re concerned that your child is not gaining weight well, you should seek the help of your child’s primary care provider. The child would need a good physical exam, and his or her doctor should be looking for signs of medical disorders other than simply inadequate caloric intake. The BMI chart may need to be closely monitored, and your child may need frequent follow-ups and weight checks during this time. Negative signs from the exam would be fatigue, paleness, thin extremities, loose folds of skin on the arms and thighs, and loss of fat over the cheeks. The provider may run tests to evaluate for anemia, nutritional status and kidney function. Based on the clinical assessment, further tests may be ordered to check for possibilities of celiac disease, Crohn’s disease or a pancreatic enzyme deficiency. For these, the provider may seek the help of a specialist like a pediatric gastroenterologist or pediatric dietitian.

Most children require subtle increases in their caloric intake to improve weight gain. This may require some imagination on the part of parent, and extra calories could be in the form of additional oil, sugar or special formulas in the diet. Interestingly, growth only requires 5 to 10 percent of the total caloric intake after six months of life.

A child with persistent poor weight gain despite increase in caloric intake may require admission to the hospital to observe weight and feeding trends and for testing and evaluation by a pediatric dietitian. Children with persistent poor weight gain may need be started on supplementary feeding though tubes placed into the stomach through the nose called naso-gastric feeding. Certain medications that stimulate appetite may be beneficial in some children. Diet modification in the form of a gluten-free diet will be required for celiac disease, digestive enzyme supplementations will needed to aid pancreatic enzyme and the help of specialists should be sought to treat heart problems, Crohn’s disease, thyroid problems or pyloric stenosis.

Ways to Sleep Better With Diabetes

Sad but true: If you have diabetes, quality sleep may be hard to get.

However, you should work with your doctor to try and pinpoint just what’s causing your sleep problems.

“While a good night’s sleep and maintenance of a healthy weight are good for everyone, those good habits promise special health benefits for people with diabetes,” says Dr. Paris Roach, an endocrinologist with Indiana University Health in Indianapolis.

There are a few reasons why you may not get the restful sleep you need when you have diabetes.

First, major swings in your blood sugar at night can disrupt your sleep. “Very high blood glucose levels can lead to excessive urination, and sleep may be interrupted by frequent visits to the bathroom if blood sugar is poorly controlled,” Roach says. If your blood sugar gets too low at night, symptoms like restless sleep, excessive sweating and a pounding heart can occur.

A common condition called sleep apnea is more common when you have diabetes. “Apnea literally means ‘not breathing,’ and sleep apnea refers to brief periods of a minute or two when breathing is extremely shallow or absent during sleep,” Roach says. Usually, it’s a partner who spots this problem because you’re snoring or breathing shallowly at night. However, you also may feel fatigue or sleepiness during the day or have trouble concentrating.

Sleep apnea increases your chance of a heart attack and stroke, and the more severe the sleep apnea, the more severe the risk for diabetes, says Dr. Christopher Winter, medical director of Sentara Martha Jefferson Hospital Sleep Medicine Center in Charlottesville, Virginia, and author of “The Sleep Solution: Why Your Sleep Is Broken and How to Fix It.”

Another common problem in some people with diabetes is diabetic neuropathy. That can cause painful sensations in the feet like burning or stinging that can disrupt sleep. Another sleep disorder called restless legs syndrome can cause an urge to move your legs when you fall asleep. “Diabetic neuropathy and restless legs syndrome can be present in the same person, making the two sometimes difficult to separate diagnostically,” Roach says.

Because of these problems, insomnia is often more common in people with diabetes, says Dr. Rajkumar Dasgupta, an assistant professor of clinical medicine at Keck Medicine of USC in Los Angeles. Insomnia also can occur as a side effect of certain medications such as antidepressants – and depression can be more common in people with chronic diseases such as diabetes.

That lack of sleep can cause an increase in stress hormones, which then make it harder to control your weight. It can start a tricky cycle that connects to diabetes, obesity and sleep deprivation, Dasgupta explains.

To find out what’s causing your sleep issues, your doctor will likely recommend a sleepstudy. During a sleep study, your heart rate, body movements and brain activity are monitored to see how well you sleep and to determine what may cause your sleepproblems. Although these tests are often done in a lab, they can also now be done at home, Dasgupta says. This makes these tests more common and less of a hassle.

It’s important that you get treatment for any sleep disorders so you can have deeper rest at night and better function during the day. For example, if your doctor says you have sleep apnea, one common treatment is a CPAP mask, short for continuous positive airway pressure. You wear the mask over your mouth and/or nose, and it helps provide pressure to the upper airway so it stays open during sleep. “Most people can be fitted with a mask they can sleep with comfortably and are often surprised how much better they feel during waking hours when their sleep apnea is effectively treated,” Roach says.

Sleep apnea treatment may help with blood sugar control, insulin resistance and other signs associated with heart disease, Winters says. Also, losing weight can help improve and possibly eliminate sleep apnea.

For less-severe sleep apnea, doctors may recommend a dental device that moves your jawbone slightly forward while you sleep.

For blood sugar swings, some people will use a continuous glucose monitoring device, Roach says. Another solution is waking up once or twice at the night for a week to check your blood sugar and track trends. Usually, adjustments in medication or diet can help address this problem.

For RLS, your doctor may prescribe medications. You may also have to get your iron level checked, as that can contribute to the problem, especially in premenopausal females, Dasgupta says. If you smoke and you have RLS, there’s yet one more reason to quit: Smoking cessation can help alleviate the problem, Roach says.

There are some things you can do on your own to help improve your sleep:

Make sleep a priority. Sleep at consistent times and in adequate amounts, advises says Susan M. De Abate, a nurse and certified diabetes educator and team coordinator of the diabetes education program at Sentara Virginia Beach General Hospital. Many Americans are not getting the recommended seven to eight hours. Make a commitment to better sleep.

Sleep in a dark, quiet cool room, De Abate recommends. And put the technology away, as it can work against going to sleep.

Avoid sleep medications. They can make sleep apnea worse and have other side effects.

Use your bed for sleep only. If you have trouble going to sleep after 15 to 20 minutes, leave the bed and go read a book (preferably not on a tablet or electronic device, Dasgupta cautions). Do something that’s not stimulating for your brain.

Make exercise a habit. It will help you sleep better at night.

Talk about sleep problems with your doctor. Dasgupta sees a lot of focus on what’s happening in patients’ lives during the day and how that relates to health problems, but he’d like more talk about sleep issues. By diagnosing and treating sleep issues, you can improve your quality of life and your health, he says.

What is Lymphedema

Among the many side effects you’ll potentially deal with during the course of treatment for breast cancer, one of the most unpredictable, intractable and difficult to address is lymphedema, a chronic condition that can result after surgery and radiation treatment for breast cancer. As The Memorial Sloan Kettering Cancer Center explains, “Lymphedema develops when the lymph vessels in an area are no longer able to carry all the fluid away from the area. If this happens, the fluid can build up and cause swelling.”

In breast cancer patients, lymphedema usually occurs along the arm that’s on the same side where the cancer is located. It can develop any time after surgery or treatment, so it’s something to look out for no matter how long ago you completed treatment. Dr. Roman Skoracki, division chief for oncologic reconstructive surgery at the Ohio State University Wexner Medical Center, says the first symptom is often a feeling of heaviness in the limb. Some patients may also have rings or watch bands that start to feel too tight. Lymphedema is a staged, chronic condition, and over time, it can progress to a noticeable swelling of the hand and fingers and/or the arm and armpit area. As swelling increases, the skin becomes tight, and the site can become inflamed and painful. In later stages, some patients may lose function in the affected limb.

Although it sounds like a relatively simple problem, lymphedema is related to the vastly complex human immune system, and it’s not completely understood why some people develop lymphedema after lymph nodes have been removed or damaged while others don’t. According to the MSKCC, 15 to 25 percent of patients who undergo an axillary lymph node dissection to treat breast cancer will develop lymphedema after surgery. This is a relatively high risk of a troubling and chronic side effect that has no cure, so some doctors are trying to avoid this more invasive treatment in favor of sentinel node biopsy. Patients who undergo sentinel node biopsy have a reduced risk of developing lymphedema, which MSKCC estimates at about 7 percent, but a 2011 review article in the International Journal of Radiation Oncology Biology Physics reports that “published incidence rates for [breast cancer-related lymphedema] vary substantially with a range of 2 to 65 percent based on surgical technique, axillary sampling method, radiation therapy fields treated and the use of chemotherapy.”

Skoracki explains that the lymph fluid that can build up and cause lymphedema is like “liquid mortar” that flows between the cells or “bricks” that make up our organs, bones, and other tissues. “This fluid is generated during the process of bringing nutrients to each one of the cells,” and it’s critical for exchanging oxygen, nutrients and waste from inside the cells.

He says this lymph fluid moves across the cell membrane and then through channels that route through the body. The problem is, these channels only flow in one direction, so if there’s a blockage or the fluid arrives at an area where a cluster of lymph nodes used to be but are now missing, it can get backed up and pool there. “If there’s a dysfunction either because of genetic reasons, underdeveloped lymph nodes or more commonly because of an insult to the lymph nodes from a dissection, radiation or chemotherapy… anything that’s downstream encounters a blockage where the intervention took place. The fluid continues to get produced and collected and moves up the extremities and hits a dead end. That’s where it starts to swell like a traffic jam.”

In most people, Skoracki says, there’s redundancy in the lymph system that enables it to continue functioning despite the loss of some lymph nodes, which is likely why patientswho have only one to three sentinel lymph nodes removed tend to have lower rates of lymphedema than patients who have all of the axillary lymph nodes removed during dissection or radical mastectomy. Even so, “in some people [the lymph system] gets overwhelmed or there’s not enough collateral channels,” so the fluid backs up and the area swells.

Although there’s currently no way to prevent lymphedema, there are ways to treat and manage the condition after it develops. Kate Howell, a doctor of physical therapy and certified lymphedema therapist with Peltz and Associates Physical Therapy in Santa Rosa, California, says that when lymphedema develops, it’s best to address it as soon as possible and stay vigilant for flare ups and other signs of worsening prognosis. The sooner you can address the issue, the better your chances are of reducing the severity of the condition.

“The standard of care is called complete decongestion therapy,” an intensive program of physical therapy that helps move pooled lymph fluid, Howell says. “This is initiated after someone has presented with lymphedema. We start with manual lymphatic drainage,” which Howell says is a specific type of “geographical massage that moves the lymph in the regions where there’s lymphatic vessels that can take it up and moves it to nodes that are not compromised.”

In addition to this hands-on approach that Howell says should only be executed by a certified lymphatic therapist, compressive bandages that look something like an ACE bandage but have compressive properties also help. These fitted garments apply pressure to the affected area to restrict how swollen it can get, but it’s a cumbersome, ongoing process to keep the swelling in check. “It’s really complicated. You have to come back to PT almost every day to get it rewrapped and you can’t shower with it, so it’s really a hassle. But the idea is that your limb has returned to normal or almost normal size and then you wear a garment for the rest of your life to keep that limb decongested to a size that’s palatable for you.”

These garments can be uncomfortable and expensive if your insurance company doesn’t cover them. Medicaid and, consequently, many other insurers do not cover lymphedema garments, which is why the Lymphedema Treatment Act has recently been introduced to Congress. If enacted, the bill will change Medicare law to cover the cost of lymphedema garments and set a precedent for other insurers to follow.

Beyond decongestion and compression, the National Lymphedema Network notes that exercise is an important aspect of treating lymphedema. The action of flexing and stretching the muscles during exercise helps move lymph fluid along. Skoracki says some newer surgical procedures are also helpful. These can involve creating a bypass channel to shunt fluid off or transplanting lymph nodes from other parts of the body. Skorecki says these procedures “are by no means a cure, but they usually help the majority of patients and they’ll reduce the volume [of fluid] significantly.”

Howell also says that whether you’ve experienced any symptoms of lymphedema or not, if you’ve had lymph nodes removed, you’re at risk for developing lymphedema. Therefore, it’s critical to avoid any kind of injury to the limb, as that can trigger additional swelling as the body tries to fight the damage or subsequent infection by sending more lymph fluid to the area. “You need to take extra good care of that limb. You don’t want manicures. You don’t want to garden without gloves. Technically, you shouldn’t even shave. Try not to get sunburned.” A small infection resulting from any of these sources can trigger swelling. “You can have survived cancer, had a mastectomy and dealt with all of that, and then you get a mosquito bite and the limb puffs up. So take really good care of it even if you don’t have symptoms,” she says. Howell also advises patients to regularly take and keep a log of measurements of the arm so you’ll be able to tell right away if something changes.

How To Provide Social Support To Overcome Depression

Humans are social animals by nature. But modern life has disrupted many of the traditional social norms that people have relied on for millennia, to the detriment of our overall health. The American Psychological Association reports that loneliness has been linked to health problems including “high blood pressure, diminished immunity, cardiovascular disease and cognitive decline” and that “low levels of social support have even been linked to increased risk of death from cardiovascular disease, infectious diseases and cancer.” Social support plays a big role in depression, as well.

Individuals with poor social support have a higher probability of developing depression, according to a study in the Journal of Clinical Nursing. And many Americans today don’t feel like they have a social network they can count on. The APA reports that 55 percent of survey respondents said they could use “at least a little more emotional support” when talking about problems or making difficult decisions. Strong social support can help people cope with problems and improve self-esteem and a sense of autonomy, the APA says. But not everyone has the skills to be socially connected, while many others find that maintaining those connections are harder these days.

“At its worst, depression is a disease of isolation,” says Dr. Drew Ramsey, assistant clinical professor of psychiatry at Columbia University and chair of the American Psychiatric Association’s Council on Communications. “People generally tend to be social creatures. We feel best when we are connected to others and to our community. That is a huge part of the human identity.” It also provides us with important psychological benefits. “It’s like the keel on the ship,” Ramsey says. “You can have an awful day, but if you can lean on social support, be that your regular Tuesday basketball game, your church choir or whatever you use, the bumps in life are digested much better.”

Breaking Out of the Cycle

While social support is one of the most powerful protections against depression, it’s also one of its most challenging treatments. “In the depths of depression, someone’s self-esteem is awful,” Ramsey says. “They know they are not their best selves, and so they don’t want other people to see them that way. They are alone in the darkness, which perpetuates the depression and is also dangerous. Our biggest fear is that they end up isolated and disconnected, which leads to the worst outcome, which is suicide.”

Carl Tishler, a psychologist and adjunct associate professor of psychiatry and psychology at The Ohio State University, adds that trying to help depressed people back into the world when they don’t want to go can be difficult for those trying to help them. “The ‘alone’ feeling is something they don’t know what to do about. The friend or relative or significant other who is trying to help the person gets frustrated and throws her hands up and walks away,” he says. “That causes frustration for support-givers, who can feel overburdened, and then the depressed person feels increased guilt and becomes more withdrawn. It’s a viscous circle.”

How can depressed individuals escape this circle? Psychotherapy can help patients reframe their view of the world, making it less scary for them to re-enter. “Depression is a distortion in the mirror we evaluate ourselves in,” Ramsey says. “When we see or more importantly feel our role in others’ lives, that is very protective from the worst of depression.” Mental health professionals screen suicide risk by asking patients what keeps them alive. “We are reassured when people look you in the eye and say, ‘I know I need to be here for my children’ or ‘I need to show up to work because my employees depend on me,’” Ramsey says.

He also reminds patients that, even in the depths of depression, “their light can still shine and people can enjoy them. I spend a lot of time with people who are depressed, and I often find them making me laugh. I remind them that, in the midst of feeling horrible, they are still themselves.”

Start Small

Someone who is depressed isn’t likely to go to a big party. But he may be convinced to make baby steps back into society. That may be a small community function without much social interaction, or going to a movie instead of dinner with a friend to limit conversation, or simply taking a walk in a park, Ramsey says. “I want to chip away at their isolation,” he says. “One of the tips I learned from patients is that it is easier to socialize if there is something other than yourself to focus on.”

He also tries to add structure to their lives by creating commitments they need to meet. “It’s hard to go work out when you’re depressed, but it’s easier if you have a commitment of a class to go to.” He might also suggest less stressful ways to revisit activities patients usually enjoy. “If they used to like dinner parties, they might take a cooking class or go to a tasting menu, or simply go to a farmers’ market,” he says. “The goal is to get them out of the home and with other individuals. What makes you feel good is being with other people mutually enjoying an activity. Getting out of your head and into your life is one of the things I try to engage people in.”

Tishler adds that taking care of another living thing is also helpful. “[Caring] for plants or animals makes them feel they have some responsibility for another life, not just their own,” he says. “I have had a number of patients who, were it not for their dog, wouldn’t get out of the house. The dog forces them to meet the neighbors, say hello, go to the vet or to buy dog food. It forces interaction.”

Ramsey provides one more caution. “The word ‘social’ has changed because of social media,” he says. “Socializing online doesn’t count.” Indeed, data suggest that social media networks lead to more depression, he says. “Social media provides the potential for connecting us, but is real human connection really happening? When we spend hours online comparing ourselves to others, counting ‘likes,’ that is horrible for the human psyche. Make sure social media is actually social in that it is making you feel good and connecting you with friend outside the house. That is what feels best as humans, and I don’t need any research to support that.”