Childhood Obesity – Our Experience

Our daughter E was born at the 50th centiles for both weight and height.  Around 12-18 months old, she started rapidly falling down both curves, and eventually around age 2-3 she was diagnosed with food allergies (dairy, egg, and soy proteins).  She actually turned out to have FPIES (food protein induced enterocolitis syndrome).  Regardless, the only treatment is strict avoidance of the offending foods.  Even minute quantities of these cause her to have horrible abdominal cramping, nausea, vomiting, and sometimes diarrhea. She became a very picky eater because food often made her feel sick.

Finding foods E likes and doesn’t react to has been challenging.  She was able to hold her own, though, and started tracking along the growth curves around 0-1% for height and 5-10% for weight for about 3 years.  She is followed by an endocrinologist for her growth and has been diagnosed with idopathic short stature (initially it was felt she had constitutional growth delay).  [I suspect her stunted growth has to do with the several years it took to diagnose her allergies, when she wasn’t digesting much of the protein in her diet.]

Anyways, about two years ago now, E started to increase in weight proportionately more than height.  This could be because she started enjoying foods more (getting less picky; she had recently outgrown the egg allergy so more foods were now an option as well), so we didn’t worry about it at first. We were actually encouraged that she was eating better.  We thought maybe she was getting ready to have a growth spurt…

Then suddenly we realized that she had gained a lot of weight and never did have a corresponding growth spurt.  She had rolls of extra skin, double chins, and no longer fit any of her clothes (and not because they were too short).  I also noticed that exercise became more difficult for her – she would become winded more frequently and was more resistant to running and active play.  Gross motor skills have always been challenging for her with her hemiplegia and she has always preferred to be sedentary, but this was a noticeable change.  She had also started complaining about her knees hurting.

Since E is followed quite frequently by various health care professionals (including pediatrician, endocrinologist, and others), I was surprised that no one had expressed any concern about this to us.  I did a BMI calculator for children (BMI is calculated differently for kids than adults) online and E was in the 98th centile.  (CDC BMI Percentile Calculator for Child and Teen)

Less than the 5th percentile is considered underweight; between 5-85% is a healthy weight; 85-95% is considered overweight; 95% and higher is obese.

I already was aware that being overweight/obese as a child can have significant health consequences.  These include cardiovascular disease (including increased stroke risk), continued obesity (over 80% likelihood), type 2 diabetes, asthma, sleep apnea, increased cancer risks, and psychological stress.

It is important to discuss this issue with your child’s health care providers so they can provide advice and monitor progress.  Testing for contributing factors is often indicated.  Several health issues can cause rapid or unexplained weight gain, including (but not limited to) thyroid disease.  Because I have a thyroid condition, we had E’s thyroid levels checked (free T4 and TSH).  She also had a CBC and blood glucose screen.  These came back normal.

Dieting in children can have very negative effects on growth and development.  The goal with overweight/obese children is to try to slow or stop the weight gain while height catches up.  (This of course varies with the age and developmental stage of the child).

Instead of “dieting”, we made some long term dietary changes.  We decided to control E’s portions for pasta and grains (which she loves) and allow her unlimited fruits and vegetables (which she doesn’t love).  She doesn’t tend to overeat meat/protein or dairy (almond/coconut) so we kept that the same.  We implemented these changes immediately.  The first few weeks were difficult as E struggled with feeling hungry.  Somehow she had lost that ability to sense when she was full, even though she had been very good at that when younger.  (We had done Baby Led Weaning, which I highly recommend).  However, we explained to her the importance of being healthy so that she feels good and so that her body can develop properly.

After several months, she became quite good at stopping eating when she was full, and wouldn’t feel compelled clear her plate even of things she loves.  I also have to remind myself not to give her so much food – it is better to give too little and have her request seconds, than to give her too much and have her overeat.  So this is a job on my part, to not let my eyes be too big for her stomach!  I do require her to finish her fruit sometimes, as she struggles with constipation.  If she is still hungry after her fruit, I let her have seconds.  But more often than not, she decides she is truly full.

We also deliberately increased her physical activity.  We enrolled her in swimming lessons, Taekwon-do, and dance.  We also started more deliberately walking around the neighborhood and to parks.  I try to incorporate some form of physical activity into every day.

It has been a full year now and although E hasn’t lost any weight, she hasn’t gained any either.  Because she grew, she has gone down from 98% to 95% in her BMI.  Our goal is to get her BMI down under that 85% into the healthy range.

Here are some resources on childhood obesity from the American Heart Association:

  • Understanding Childhood Obesity is an American Heart Association sourcebook on child nutrition and physical activity. Both the full and condensed downloadable PDF versions are an update of the 2005 version.
  • AHA Recommendation – Overweight Children – Obese children are more likely to be obese adults. Successfully preventing or treating overweight in childhood may help reduce the risk of heart disease, adult obesity and other complications.
  • AHA Scientific Position – Physical Activity and Children – Physical inactivity is a major risk factor for developing heart disease, stroke, high blood pressure, overweight/obesity, and diabetes. The American Heart Association recommends that children and adolescents participate in at least 60 minutes of moderate to vigorous physical activity every day.
  • AHA Scientific Position – Dietary Recommendations for Healthy Children – The American Heart Association has specific healthy dietary guideline recommendations for all adults and children over the age of 2 years. more.

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Maybe all your life has been leading to this one moment: The Bridge to God.

Adult Braces Journey

This week I added braces to my list of mid-life activities checked off…  I know it’s not part of E’s journey, but since she will have braces in her future (we have seen Panorex’s of her permanent dentition!), I am able to get a sense of what it will be like for her!

I have a class II bite, some overbite and overjet, with a few slightly rotated and crowded teeth.  Nothing too major, but no perfect smile.  In fact, I have been somewhat ashamed of my smile most of my life.  Braces had been suggested to me as a child, of course, but this was back in the day where they pulled lots of teeth…which frightened me.  As an adult I had gone for several orthodontist consultations over the years, but each time was told I would need orthognathic surgery (break my jaws and wire them in different positions).  I found some online videos of the procedure, which is quite intense.

Fast forward to this year.

I’ve had some major clenching and grinding issues (bruxism) over the last decade and was clenching so hard on my night guard that I was dislocating my jaw.  I didn’t know this, of course, but knew my jaw hurt just as bad whether I wore the guard or not.  I had some panoramic x-rays done, and they showed that the little hook parts that hold your TMJs stable are just….missing.  Did I grind them off?  I don’t know.  They aren’t there now.  Also, my bite changed from all my teeth touching to only two of my teeth kind of touching at the very back.  All from the night guard chomping.

Enter a new dentist, who told me that bruxism is highly associated with sleep apnea in petite women particularly.  I was sent for some sleep studies and low and behold, have been diagnosed with mild to moderate sleep apnea.  I knew I had insomnia, but the apnea was a surprise…

I also went for an orthodontic consultation, to see if braces could help with the bruxism.  The orthodontist told me he actually didn’t think that braces would help with the clenching at all, and perhaps would only improve the TMJ issues slightly by stabilizing my bite.  He recommended that I pursue treating the sleep apnea instead.  I was intrigued.  He didn’t push braces at all.  When I asked, he said that yes they could fix my bite, and that it would involve no extractions or surgery, but would only take 15-18 months with conventional braces.  Orthodontics has come a long way!

I am fairly excited at the prospect of having straight, aligned teeth after all these years!   I also hope it will help my TMJ issues, joint stability, and reduce my bruxism.

_______________________________

BRACES – DAY 0

I can’t say I was nervous to get braces on, they seem commonplace enough that I was pretty sure I knew what to expect.  It took about an hour and a half to go over the financial arrangements, the mouth care instructions (electric toothbrush, flossing apparatus, scary photographs of what your teeth will look like if you don’t brush and rinse a billion times a day), and the actual braces placement.  The placement itself took about 30 minutes.

First, they polish your teeth just like at the dentist.  Then they pull your cheeks out with retractors to keep your teeth nice and dry and prep your teeth for the glue.  I read the bottle.  It said enamel etcher, which disturbed me… It tastes like they are painting realemon on your teeth (very citric acid-ish).  They then paint a sealant on, let that dry, then the orthodontist glues each bracket on the outside of the teeth.  I didn’t have to get any metal rings around my molars.  Each bracket with glue is cured with blue light for about 20 seconds.  Once the brackets are all in place a wire is threaded through.

My braces are the Damon low torque.  My roots don’t have to do a ton of moving so I am fortunate I guess!  The wires are self ligating, which means no elastics around each bracket to hold it in place, the teeth will freely move along the archwire as treatment progresses.  This, they say, will make the treatment faster (Damon braces are about 6 months faster) and hurt less.  The archwires are memory wires, and exhibit low pressure as they try to return to perfect arch position.

Day 1 – My mouth felt weird and the brackets felt enormous!  My teeth didn’t hurt at all…slight discomfort maybe…until I tried to chew.  Wowza.  I guess teeth start changing almost immediately, as biting anything (even pasta or the middles of bread) was quite painful!!  Tried the electric toothbrush and almost hit the ceiling.  Will stick with gently brushing conventionally for a few days until my teeth settle down.  Tried to floss between two teeth and almost cried.  Abandoning flossing for now as well.

img_20161008_094217

Day 2-3 – oatmeal, mashed potatoes, and rice.  Getting tired of white mushy food….  Can now brush a few teeth with the electric toothbrush.  No flossing.

Day 4-6 – I can now chew on my right back teeth fairly well, soft foods like pasta, scrambled eggs, and even cooked veggies.  I’ve done some guacamole and hummus scooped up by a soft wrap.  I still can’t bite with my front teeth, and it hurts to chew on the left.  My teeth are more sensitive to cold now, which I wasn’t expecting.  I have to rinse with warm water and cut back on the ice in my drinks!  Weird.

I may end up with scurvy…  Miss eating whole fruits.

Brushing about half my teeth with the electric toothbrush.  (The very back ones).  The front half of my mouth can’t take the vibrating!   Able to floss my top teeth now with dental tape.  The fancy flossers they sent are thicker and hurt too much.  It takes seriously 10-15 min to floss half my teeth!  My bottom teeth seem more crowded and it is painful (sharp shooting pain) to try to get the floss through.

Day 7 – I swear my most tipped tooth has rotated slightly!  I never really noticed how angled forward it was until I saw how the archwire did a 30 degree angle to get through its bracket.  This morning when I looked in the mirror I noticed right away that this tooth looks different!  Still has a ways to go but I am so excited that I can start seeing small changes at only 1 week!

_________________________________________________________

BRACES – DAY 14 – Two weeks done!

Perhaps my weight loss would be going better if I hadn’t moved into the fall drinks – eggnog and pumpkin spice lattes🙂

img_20161016_135916

Eating still hurts.  I am so surprised!  I can still only chew on my right side, and nothing too substantial.  Although I have been gumming up the restricted list items – even popcorn…. With no ill effects🙂. I am being very careful to avoid sticky things (caramel) and things I have to bite (chips, cheezies, popcorn kernels), but it seems perfectly fine to suck on chocolate!

I found out I am in the “leveling and aligning” phase of treatment.  This usually lasts about 3.5 months with the Damon braces, or about 6 months with conventional.  I can tell at least one of my teeth is rotating to be closer to the archwire alignment.  I am glad that there is some very minor movement noticeable already (end of week 2), but it is hard not to be impatient!  I read on an adult message board for braces (archwired.com) that some people noticed a lot of movement around week 3 so hoping for some good stuff this next week or two.

I can tell from the archwire that my bottom incisors are supposed to move down, like into my chin.  As I already have a gummy smile I am hoping my top teeth have to move up a bit but the wire doesn’t look like it.  Perhaps that could only be fixed surgically by shaving down my maxillae, in which case I will pass🙂

So far, braces – kind of annoying to eat, but otherwise perfectly fine!

I have a few product recommendations:

  1. X-Pur OPTI-Rinse fluoride rinse.  I have been using the 0.05% daily and the 0.2% once a week.
  2.  97d6921bf5aadeef284463f05be1c26f_ra,w380,h380_pa,w380,h380
  3. MI Paste – topical available calcium.  I have only remembered to use this a few times, but would use it regularly if I remembered.  I’m not sure the best frequency, but probably alternating with fluoride as they both work to strengthen the enamel.  I believe they attach at the same spots chemically.MI_Paste_Image-258x258
  4. Interdental brush – in the smallest mini size you can find.  I have been using these little buddies instead of flossing… I *should* do both, but these are SO MUCH FASTER!  I reuse them, and clean them with either mouthwash or soap and water in between.a89e91e606d367d5b94370a1a3c5d6d1
  5. WaterPik – This is awesome if you want to cheat and try to carefully eat popcorn.  (I’m not advocating this, but admit to doing it – the kernels can pop your wires out of place so I carefully and gently munch the puffy bits and spit out the kernels). This little buddy squirts out all the popcorn residue which ends up EVERYWHERE stuck in your teeth and braces.
  6. waterpik-ultra-water-flosser

I’ve been reading about the treatment sequencing for Damon braces.  The different archwires are used in different phases of treatment.  Here is the link for anyone interested!  I got my wires changed about a month ago for the first time, and have now completed 3 months of treatment.

Phase 1: Initial Light Round Wires – align teeth and bracket slots just enough to move to the second phase of archwire progression.  This wire was super thin and bendy (0.014 Damon Copper Ni-Ti) to start tooth movement, leveling, and begin arch form development.  They applied cement on the biting surfaces of both my back molars to prevent my bite from hitting the brackets; however, the left side fell off the first day and they didn’t replace it.  I was in this wire for 8 weeks.  Not much movement occurred – a few rotations and a few teeth slightly moved.  I was using thin, light elastics only at night as directed like this, both sides:

Components-of-Braces-2-300x198

________________________________________________

BRACES – DAY 56 – Two months done!

Phase 2: High-Technology Edgewise Wires – starts working on torque, root angulations and levels, completes rotation control, continues arch form development, consolidates space in the anterior segments, and prepares for the third phase.  This wire was WAY thicker and firmer than the first (0.018 x 0.025 Damon Copper Ni-Ti).  Movement started right away and my teeth really hurt again for a good week or two (only used Tylenol Day 0 and 1).  4 weeks in and I have new gaps, my midlines are aligned, my bite is totally wonky.  This wire is a powerhouse.  I continued with light, thin elastics on both sides as above, only at night.  I was in this wire for 9 weeks.

I asked about wearing the elastics only at night, as everywhere online I have read suggests that movement that occurs during elastic wear is stalled and even reversed in the time spent out of elastics.  I was tempted to wear the elastics all day long because of this, but they advised against it at the office as I didn’t have much movement necessary (1-2mm).  It could in fact move my teeth TOO much if I wore them all the time.

___________________________________________

BRACES – DAY 121 – Four months done!

I completed Phase 2, and started Phase 3.

Phase 3: Major Mechanics – posterior space closure, anteroposterior dental correction and adjusting buccolingual discrepancies.  (0.019 x 0.025 SS Preposted)  This wire wasn’t so much thicker, but FIRMER than the previous wire (being stainless steel).  It again hurt to chew for a good week or two!  At this point I had an open bite on my right side from the cement bite block on my back molars.  They drilled this off and gave me a different elastic configuration to close the open bite on my right, similar to this but on my right eyetooth and first premolar:

class-3-triangle-elastic

On the left they gave me a heavier duty elastic to go from top eyetooth to bottom molar.  The stronger elastics made me clench my teeth really hard and aggravated my TMJ so much I couldn’t sleep, so I phoned the office and asked for lighter elastics which they mailed out to me.  These still hurt more than the previous configurations I had been using, but were bearable (and I still had to only wear them at night).

__________________________________________

BRACES – DAY 179 – 6 months done

After 8 weeks I again got my wire changed, this time to a (0.018 x 0.025 SS Preposted).  Still stainless steel, but a bit thicker.  I had sensitivity for a week after for chewing again.  By this point the open bite on my right is probably about half resolved.  My midlines are aligned quite well, although my bottom teeth are perhaps overcorrected.  I no longer have an overbite or an overjet.  I have several gaps on the bottom that had opened up in the last two months.  They placed a powerchain along all my bottom teeth to close these gaps (mine is on the bottom, but a powerchain is just a long connected rubber band around each bracket):

power-chain-braces

I have noticed the gaps on my bottom teeth start to close within 2-3 days.  By my next appointment I am anticipating that all my gaps will be closed (they were less than 1mm), and that my midlines will be aligned again.  My open bite will likely be closed completely on the Rt.

What remains is that it looks like several of my bottom teeth near the front have had brackets not placed quite right.  One tooth sticks up a little too high, one a little too low and is slightly angulated.  This still needs to be addressed.  My bite also isn’t completely comfortable; as in, my teeth don’t feel like they are quite lining up perfectly when I bite.  I hope at the next appointment I can move to the finishing and detailing phase.

______________________________________

Phase 4: Finishing – finishing and detailing phase.  Will update as I get to this phase.  (0.019 x 0.025 SS Preposted)

Overflow Incontinence, Neurogenic Bladder, and PostPartum Woes

I can relate to E’s decreased bladder sensation and tone, and can understand how it can be difficult for her to tell when she needs to urinate.  My understanding comes not from a stroke, but from mismanagement in my post-partum care.

After approximately 63 hours of labor and 2 hours of pushing, E was delivered via vacuum extraction.  I had an epidural for the last 8 hours of labor, and was unable to urinate at that time so they had done “in-and-out” catheterization.  After E was born I had a significant amount of perineal swelling, and was unable to void after her delivery even though it had been about 3-4 hours since they had last emptied my bladder.  I had no urinary sensation whatsoever.  The nurses did not seem concerned in any way, so we just carried on with getting up to our room and figuring out the newborn thing.  I was still hooked up to IV fluids and pitocin due to some uterine bleeding I was having.  At this time I was also having horrible pelvic pain, which I attributed to the pitocin or uterine cramping.  It was so bad that I asked for narcotic pain meds.  I thought this was normal following delivery; it was similar to transitional contractions.  (After having a second child, I know this is NOT normal.  Uterine pain is basically gone after birth.  It was my bladder overdistending and dying causing the pain – which was misdiagnosed.  An attending resident saw me and gave me narcotics without pausing to figure out why I was having pain.)

About 6 hours later, when I stood up, I had a flood of what I thought was blood.  I rang the nurse and she got housekeeping to clean it up, and she didn’t seem concerned at all, so I thought that much bleeding must be normal.

The next morning when I got up, I again had a flood of what I thought was blood.  The nurse said, “Oh, it looks like there’s some urine as well”.  Again, she didn’t seem concerned, and I was super embarrassed since I had no idea I had to pee at all.

I continued to flood urine whenever I stood up, so I tried to stay in bed as much as possible.  It was about 36 hours before it occurred to me that I hadn’t peed since delivery willingly (on the toilet), and I asked the nurse if that was normal.  She told me that having incontinence was normal after delivery.  I was horrified that no one had warned me that every time I stood up I would completely wet myself, and have no urge to pee at all.  (Of course, this is entirely ABnormal.  A SMALL amount of dribbling, when sneezing or laughing, or having difficulty making it to the toilet on time is normal.  Flooding is ABNORMAL and indicative of urinary dysfunction).  I had no idea if this was going to continue my whole life long, and along with the influence of post-partum hormone and a severe lack of sleep, had suicidal ideations.

Meanwhile, the nurses were roughly manhandling me trying to teach me nursing (after breastfeeding for a total of 5 years, I now know that they were not giving me accurate or complete information), and poor E (post-stroke, but undiagnosed) gave up on the whole thing.  It had been 36 hours and she hadn’t eaten/drank at all and wailed any time we attempted to nurse.

The doctor eventually ordered the nurses to catheterize me to see what was remaining in my bladder after I attempted to pee (when I did, nothing would come out – no sensation at all).  Two nurses tried, and called in a third, but the swelling was so profound they couldn’t get the catheter in.  They abandoned trying until the next day.

The next morning (approx 64 hours after delivery) my doctor came in, irritated, and used some freezing and Ativan and catheterized me right after I had had a “flood” episode.  She drained 2.5 LITRES of urine out of my bladder. Normal bladder capacity is somewhere around 500-700 mL max, and 800-900 is considered overdistension.  My bladder was well over 3x that after it had already overflowed.

Wikipedia defines Overflow Incontinence as:

Overflow incontinence is a form of urinary incontinence, characterized by the involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate.

Source

Risk factors for post-partum urinary difficulties include:

  • Nulliparous women (first babies)
  • Prolonged labour, especially a prolonged second stage
  • Assisted/instrumental delivery
  • Perineal injury
  • Caesarean section
  • Regional analgesia

bladder overdistensionObsGynae&Midwifery News has an excellent summary article about post-partum urinary dysfunction.  In it, they estimate:

It would be reasonable to quote that 10-15% of women have voiding dysfunction to some degree and for some time following delivery.  Up to 5% of these women may have significant and longer lasting dysfunction, which if not recognised in the early peripartum period, may lead to bladder distension and overflow incontinence with significant long-term bladder dysfunction.

Symptoms of acute retention are obvious as women are not able to void and suffer an associated painful bladder.

However, the pain should not be misdiagnosed as caesarean wound (or other abdominal) pain.

Symptoms of incomplete emptying/ chronic retention of the bladder in post partum period include:

  • Difficulty in initiating a void after birth
  • The feeling of bladder fullness after voiding
  • Dribbling of urine post micturition
  • Frequency with small void volumes
  • Poor flow rate with straining to void
  • Nocturia >2 times which is not related to baby feeding

It needs to be emphasised that symptoms may be masked or a patient may be asymptomatic, especially if they have had an epidural. In some cases they may have overflow incontinence due to bladder over distension, displaying symptoms of stress incontinence.

I remained in hospital for another couple days with an indwelling catheter.  I had to keep the indwelling catheter in place for several weeks, due to my perineal swelling.  Unfortunately, I had some tears that the catheter rubbed right in, and these did not start to heal until the catheter was removed.

I felt like I was being treated like a nuisance the entire time, and no one could give me answers.  The truth was, they had no idea if my bladder would ever improve, no one wanted to tell me so directly, and no one wanted to admit fault.  It was a series of negligent actions that led to my condition – the “swiss cheese effect”.

Once the indwelling catheter was removed, I still had no bladder sensation and was not able to void.  I had to catheterize myself to pee every 4-6 hours for 7 months.  Catheterization, even when done “cleanly”, carries risk of infection, and I had a kidney infection at one point.  It may have started out as a bladder infection, but because I had no sensation in my bladder region, I didn’t notice until I got horrible flank pain and a raging fever.

I was referred to a urologist, who again had no idea if I would recover bladder function or not.  I remained very emotional and borderline suicidal, having dreams of killing myself and my baby.  I was referred to a psychiatrist, and saw her several times but was being watched by a “team in training” behind mirrored glass, and was very uncomfortable with the whole situation so I just lied about the extent of my emotional state.  I went on anti-depressants, but these decreased my milk supply so I went off them, as breastfeeding was critically important to me.

I did eventually regain some bladder sensation, a little bit at a time, around the 5 month mark.  Around 5-6 months, I could dribble a little bit of pee.  At 7 months I could somewhat empty my bladder and did have a residual of around 50mL which the urologist said was just fine and I could stop catheterizing.  7 years later, I still have limited bladder and urinary sensation, but can function almost normally.  I do have some occasional episodes of minor incontinence.

For anyone reading this, I can only suppose it is because you are having post-partum bladder issues.  One day at a time, my friend, one day at a time.  Out of the deepest, darkest tunnels, eventually glimmers of light can be seen.  I have records of my catheterizations and how my function improved over time that I am willing to share if you comment with an email address below.  Please indicate if you want your comment to remain unpublished.

For more information you can google:

  • Detrusor dysfuntion
  • Neurogenic bladder
  • Overflow incontinence post-partum
  • Detrusor stimulation (if I didn’t get bladder function back, I looked into bladder transplants – which aren’t successful, as well as bladder muscle stimulation – which is what they were doing in Germany at the time and showed promise).

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

download

“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)

ECC – Early Childhood Caries

One of the other medical issues we have dealt with – which came seemingly out of the blue – is ECC, or Early Childhood Caries (cavities).

When N was 2, I had noticed some orange-ish brown spots on several of his teeth and took him to the dentist.  The dentist had a look and felt that they were stains from his iron drops (which can turn the teeth temporarily greyish black and spotty if on plaque).  Here’s a great chart I found showing the appearance of various stages of tooth decay:

cavities

The next year, the spots were still there, and there was a part on the back of one of his top front teeth that felt jagged and had an orangey brown spot as well.  I knew it didn’t look good, and so we went back to the dentist.  She thought it was a “superficial cavity”, and that he had 3 of them (the front tooth, as well as two back molars).  She told me she could just buff them out with the polisher, no freezing, so I told her to go ahead.  N was brave, confident, and did just fine.  At first.  Until she got out the drill, and without freezing, proceeded to drill and fill the first cavity.  While N was screaming and screaming and they were holding him down.

I was horribly traumatized.  N was horribly traumatized.  E, who was also there, was traumatized.

We didn’t fill the other 2 that day.  We went home, talked about it, played dentist, and talked about how she did the wrong thing.  She should have stopped.  She should have used freezing.  She didn’t listen to him, and that was wrong.  (It is important to affirm the child’s experience and feelings, for resilience)

We went to a different dentist for a consultation.  He also felt that N had 2 small cavities remaining in his molars, but that we could watch and wait for a few months to give him time to settle down about dentists.  In the meantime, we researched remineralization for teeth and discovered an awful lot about dental decay that your dentist won’t tell you:

  • Dental decay and gum disease are basically infections – they are caused by an overgrowth of pathogenic bacteria (Streptococcus mutans, or S. mutans).  Your mouth has a normal flora which can keep S. mutans in check, but you can “catch” S. mutans by sharing utensils, straws, cups etc with someone who has an overgrowth of it.
  • Dental decay and gum disease can be prevented by selectively killing off S. mutans and allowing other normal flora to repopulate your mouth
  • S. mutans is killed with hydrogen peroxide, baking soda, alcohol (think mouthwashes), and alcohol sugars (xylitol and erythritol).  The best choice to use in children is alcohol sugars (as ingesting hydrogen peroxide, baking soda, or alcohol is not a good idea!)  Bonus: xylitol and erythritol are lower calorie than regular sugar, have a lower glycemic index, as well as selectively inhibiting S. mutans (that bacteria can’t feed on it like regular sugar).  At higher doses they can increase bowel motility (a good side effect for kids who struggle with constipation).  Aim for xylitol or erythritol to bathe your teeth and mouth 5+ times per day (Strive for Five).  It is available in candies, gum, and toothpastes, but the cheapest way is to buy a bag of the sugar and either eat the sugar or dissolve it in water and rinse with it.
  • Plaque is a biofilm of bacteria and their waste products.  It takes about 8 hours for the biofilm to form and the acid to start etching your teeth (the earliest start of a cavity).  Hence, if you brush your teeth more frequently than every 8 hours, you disrupt this biofilm process.
  • Remineralization can be promoted with fluoride (pastes, polishes), but fluoride can cause upset stomach or spots on teeth if too much is ingested.  A better option is called MI paste, which contains bioavailable calcium and phosphorus.  MI Paste Plus also contains fluoride and is great for adults.  MI paste can be found at many dentist offices, without a prescription.  It is about $20 per tube (CDN).   To use, apply a pea-sized amount to the border between the gums and teeth, and smear right on any orange-brown spots right before sleeping (you want it to sit there as long as possible).  I did it after my son had fallen asleep, and just rubbed along his gumlines.  Apply nightly for at least 4-6 weeks.

MI_Paste_Image-258x258

  • We have also found a great mouthwash which includes both xylitol and fluoride, if your child knows how to spit it out – X-Pur Opti-Rinse.  It comes in 0.2% fluoride (mint) and 0.05% fluoride (berry) flavors.
  • 97d6921bf5aadeef284463f05be1c26f_ra,w380,h380_pa,w380,h380
  • Early stage cavities, in the enamel layer, can be healed in this way (remineralization pastes, fluoride pastes, xylitol or erythritol 5x a day – “Strive for Five”).  It is more difficult to heal cavities in the grooves of molars, as bacteria can hide out there easier.
  • Here’s a link to some great preventative mouth care:  Dr. Ellie’s Mouth Care System

We went back in about 5 months, and the dentist said we should try to fill the spots (this time on his back molars).  Unfortunately, the spots on his molars were past the enamel layer into the dentin.  However, the orangey spots that had been on several other teeth had disappeared or turned dark brown/black and shiny (inactive/healed).

We booked an appointment with sedation (Versed (midazolam) drink).  The sedation went OK, but he never did get sleepy.  The dentist started to drill, and N started getting anxious as he recalled the last drilling fiasco.  I asked for the nitrous oxide.  The hygienist fiddled around with the machine for 45 minutes before admitting that the machine hadn’t been tested and was malfunctioning.

Meanwhile, the dentist was behind schedule, and started getting mad at N.  He quickly placed a filling in the hole he had drilled, and N was very upset.

It took about 6 hours for the Versed to wear off, and N was a crazy person.  Peed his pants (it makes your muscles relax), freaked out, wouldn’t sleep, and basically acted like he was way overdosed on caffeine.  He yelled, raged, threw himself on the floor, flopped around.  Luckily, I don’t think he remembered it, as that is one of Versed’s side effects.  I didn’t get any Versed, so I remember the whole thing!!!

N still had one filling to go, and his new filling didn’t look like it was done very well (I could see dark spots beside and through it), so we ended up going to a third dentist.  This dentist specializes in “sleep” dentistry.  We had a 5-minute consultation, in which he grandiosely suggested that N had a mouthful of cavities.  N had general anesthesia dentistry and got a thorough cleaning, fluoride treatment and SEVEN fillings.  Silver amalgam ones, as they apparently are more durable, and we didn’t want to go through this again (even though I am on the fence about silver amalgam and replaced my own with porcelain).

In several months I am taking him to a fourth dentist, whom I will get to review the x-rays to see if he agrees that there were actually 7 cavities.  I am a little suspicious that the drill and fill dentist was a little overzealous with fillings, but – we really had no other choice at that point.

UPDATE 1:  Fourth dentist reviewed N’s x-rays and showed me there were one, possibly two, cavities between his molars.  He also needed two surface molar fillings.  So in total, he needed 3-4 fillings, not 7.  It’s so frustrating to get sub-optimal treatment and to be so helpless in your own child’s care, even when you’re trying to be an advocate. I’m glad that N was asleep for the fillings, and I am *super* glad that they are his baby teeth, but it does make me wary of dentists.

Case in point, this fourth dentist was going to give ME 7 fillings (replacing some of my old ones, claiming they were leaking).  I didn’t feel comfortable for some reason and went for a second opinion (Fifth dentist).  The Fifth dentist took bitewings and informed me that NO fillings were necessary – that they would just be cosmetic to remove staining from food, coffee, tea.  He explained that intact teeth are always stronger than any filling material and it is best to leave them intact as much as possible.  I am wondering how many of MY many fillings were in fact, actually necessary!  This is something to advocate for your children and for yourselves going ahead!  Get second opinions, try the xylitol and MI paste, and watch and wait if it’s not obvious!

UPDATE 2:  N’s front teeth with the front orange pre-cavity discoloration have mostly remineralized following the above protocol off and on for a year and a half now.  No further cavities.

____________________________________________

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

download

“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)

 

Constitutional Growth Delay / Idiopathic Short Stature – Our Experience

E was born at the 50% centile and followed the 50% growth curve for her first year.  At that point, she started slowly dropping in her growth velocity.  By 18-24 months she had dropped to the 5th percentile; she continued dropping until she fell below the 1% line.  Since age 3, E has tracked steadily under the 1% for height.  Her weight has varied from about 5-20%.

When your child drops more than 2 curve lines on the growth charts, they are flagged for “failure to thrive”.  At this point, we were referred to feeding clinics and nutritionist consultations.

At the feeding clinic, an occupational therapist, physical therapist, nutritionist, and psychologist evaluated E while she ate a typical meal.  She was eating independently (since 6 months old – we followed Baby Led Weaning), and they were happy with her interest in food and physical ability to feed herself, chew, and swallow.  At that point the nutritionist gave us suggestions to increase her caloric intake.

From our post on allergies, you will see how that didn’t go so well for us.

At this point, E had some bloodwork done to rule out nutritional deficiencies.  She also had a left hand x-ray to determine bone age.  Both came back within normal limits.

E’s genetic height potential (which you can calculate for your child here) is 5’1″, but her growth curves lead her to being approximately 4’7″.  Concerned about this, I asked for a referral to a pediatric endocrinologist.

In the meantime, E’s x-ray for bone age was repeated, along with bloodwork to rule out celiac disease / gluten intolerance (which, if untreated, can cause growth delay).   Both came back as normal.

We had our consultation with the endocrinologist, who was very helpful.  She suggested that reading bone age is a bit of an “art form”, and that she reads E’s x-rays as being delayed by about 1-1.5 years (1 step on the bone age scale).  The term for this is Constitutional Growth Delay.  The logical explanation for this would be from her malnutrition when we were feeding her excessive dairy calories, which she wasn’t able to digest.  It had taken a good 1.5-2 years to diagnose her dairy, and subsequent soy and egg, allergies.

The endocrinologist explained that if E’s growth was plotted as if she was 1.5 years younger than she is, it neatly follows the 50% curve again.  She is following E yearly, and we will be able to know more the closer she approaches puberty.  Apparently, if this is what she has, she will eventually reach her growth potential (and just be a “late bloomer”).  Otherwise, she may need daily Growth Hormone injections.  So for now, we are just waiting and watching.

UPDATE 2016:  E had another x-ray for bone age, which came back as normal.  This indicates that she does not, in fact, have constitutional growth delay.  She may be on the borderline normal (which is +/- 5″ of calculated genetic potential) or could have idiopathic short stature.  I did ask for her to be tested for Turner Syndrome, as that can also cause short stature and be undetected if it is a mild case.  Her karyotype came back normal.  The endocrinologist is willing to treat her with growth hormone anyways, but estimates that she would only gain 1-2″ total.  It would also be unfunded, so we would have to pay out of pocket approximately $25,000 per year until puberty ended.  For cost/benefit we just can’t justify this!  I did discuss trying it for only one year, as most catch-up growth occurs in the first year.  However, if growth hormone is discontinued before growth potential ends, often what happens is “catch-down growth” – meaning, growth will slow until she is back on the curve her body was trying to grow on.  We will continue to watch and wait for now, and consider 1 year of growth hormone near the end of puberty (when she is 13-14) depending how things are looking at that time.

Wikipedia describes constitutional growth delay as:

Constitutional growth delay (CGD) is a term describing a temporary delay in the skeletal growth and thus height of a child with no other physical abnormalities causing the delay. Short stature may be the result of a growth pattern inherited from a parent (familial) or occur for no apparent reason (idiopathic). Typically at some point during childhood, growth slows down, eventually resuming at a normal rate. CGD is the most common cause of short stature and delayed puberty.

Children with constitutional growth delay (CGD), the most common cause of short stature and pubertal delay in males, typically have slowed linear growth within the first 3 years of life. In this variant of normal growth, linear growth velocity and weight gain slows beginning as young as age 3–6 months, resulting in downward crossing of growth percentiles, which often continues until age 2–3 years. At that time, growth resumes at a normal rate, and these children grow either along the lower growth percentiles or beneath the curve but parallel to it for the remainder of the prepubertal years.

At the expected time of puberty, the height of children with CGD begins to drift further from the growth curve because of delay in the onset of the pubertal growth spurt. Catch-up growth, onset of puberty, and pubertal growth spurt occur later than average, resulting in normal adult stature and sexual development. Although CGD is a variant of normal growth rather than a disorder, delays in growth and sexual development may contribute to psychological difficulties, warranting treatment for some individuals. Recent studies have suggested that referral bias is largely responsible for the impression that normal short stature per se is a cause of psychosocial problems; nonreferred children with short stature do not differ from those with more normal stature in school performance or socialization.

Individuals with constitutional growth delay (CGD) are usually of normal size at birth. Deceleration in both height and weight velocity typically occurs within the first 3–6 months of life. This shift downward is similar to that observed in infants experiencing normal lag-down growth but tends to be more severe and prolonged. Individual variation is substantial; however, most children resume a normal growth velocity by age 2–3 years. During childhood, these individuals grow along or parallel to the lower percentiles of the growth curve.

Skeletal age, which is estimated from radiographic studies of the left hand and wrist, is usually delayed (typically 2-4 y by late childhood) and is most consistent with the child’s height age (age for which a child’s height is at the 50th percentile) rather than the child’s chronologic age. Because the timing of the onset of puberty, pubertal growth spurt, and epiphyseal fusion are determined by a child’s skeletal age (biologic age), children with CGD are often referred to as “late bloomers.”

At the usual age for puberty, these children continue to grow at a prepubertal rate appropriate for their biologic stage of development. Natural slowing of linear growth just before onset of puberty may be exaggerated, emphasizing the difference in size from peers who are accelerating in growth. The timing of the pubertal growth spurt is delayed, and the spurt may be prolonged with a lower peak height velocity. In patients with both CGD and familial short stature, the degree of growth retardation may appear more severe, but the adult height is appropriate for the genetic background.

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

download

“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)

 

Blood Tests in Children – How to Prepare

As part of E’s stroke workup, and for her allergies and growth, she has needed to have blood draws done.  Here are some suggestions that have worked for us to minimize her discomfort and fear:

BEFORE the Procedure:

  • Talk about it beforehand, but not TOO far ahead.  One or two days before the procedure, let your child know what to expect –
    • Before the needle, a big rubber band that feels like a balloon will be wrapped around your child’s arm. Tell her that the band will feel tight like someone is squeezing her arm.
    • The lab technician will clean a small patch of skin on your child’s arm and this will feel cold.
    • The needle will be put into the arm and blood will go into the needle. Your child will feel a pinch or prick that can sting or hurt a little, or she may feel nothing at all.
    • Once the blood is taken, the needle comes out and a small bandage is put on the spot where the needle was.
  • Let your child practice taking blood from you and from her stuffies – guide her in the steps to follow.  A medical kit is a great tool to have!  If you go to a lab beforehand and explain, they may be willing to give you a syringe and arm elastic.
  • Tell your child why she is having blood taken
  • Let your child know that it is okay not to like what is going to happen.  Let her know that most people don’t like to have blood taken, but that it is necessary to check for ______.
  • Give your child some control where possible – ask her if she would like to bring a special toy, or what she would like to do afterwards to celebrate being done.
  • Let her know that it is very important to stay still so that it will hurt the least and won’t have to be redone.

The DAY OF the Procedure:

  • Hydrate!  Water, juice, soup, popsicles – anything!  The more liquids in your child, the plumper the veins; the plumper the veins, the easier they are to access.  We forgot this one time and it took them a lot of digging to get my daughter’s blood, which hurt her.
  • Apply an Emla patch or cream to the inner elbow 1 hour prior, following package directions.  This will numb the area, and she will only feel the needle if they have to dig for the vein – if you don’t follow the HYDRATE suggestion above….  Note that we tried Emla when E was 9 months old, and then they couldn’t find her veins.  So I would only recommend it for older children, on whom you can see their inner elbow veins quite nicely. Emla makes the veins go deeper, or some such thing.  Emla can be found at most pharmacies, and doesn’t require an Rx in Canada.  HIGHLY recommend the Emla for toddler+.

blood-draw-hospital

RIGHT BEFORE the Procedure:

  • Give her some sugar.  Something fast acting, like orange juice or chewy candies.  Studies have shown that elevated blood sugar can dull pain somewhat.  When E was a baby, I dipped her soother in water and then powdered sugar before her immunizations.  When she was older, I used skittles.
  • Remove the EMLA patch, and wipe clean with a wet washcloth.
  • Gently heat the area; this brings the veins up to the surface and enlarges them.  I heated a warm bag in the microwave at home, and brought it along wrapped in tea towels.  After washing off the Emla, I put the warm bag on her inner elbow for a few minutes.  Test it on your inner wrist first, remember that her arm is numb and you don’t want to burn her!!!
  • Butterfly IV lines (as shown above) hurt much less than a needle as they have a smaller diameter, and you don’t feel it move during changing of tubes; ask your technician to use one of these if possible.

DURING the Procedure:

Blood Test

  • Hold your child firmly, but not tightly, cooperating with the positioning the technician needs.  Block your child’s eyes from watching, either with your hand or head.
  • Distract your child if possible – a toddler may be distracted by a light-up or noisemaker; an older child may be distracted by an iPad or your phone.
  • Celebrate afterwards, even if it was unsuccessful, letting your child know how brave she was and how proud she must be of herself!  (This allows her to internalize her bravery, instead of you being proud of her which is external)

Many of these suggestions can also be used for routine childhood immunizations!  Although, the EMLA patches will be much more difficult to place accurately!  (We tried Emla for their 5 yr vaccinations and it didn’t seem to help at all)

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

download

“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)

Sleep Challenges – Delayed Sleep Onset, Frequent Night Wakings, Insomnia…

There are a few basic human needs – food, water, air, clothing/shelter, and sleep.  Why sleep seems to elude so many…from the young to the old…is puzzling!  Difficulty falling asleep, difficulty staying asleep, and irregular sleep patterns are common in children with developmental disabilities.

Sleep patterns are affected by:

  • Nature (circadian rhythms, hormonal influences)
  • Environment (sleep associations and habits)

E struggled with falling asleep and staying asleep ever since she was born.  She took 2-3 hours to fall asleep.  And once asleep, she never slept more than 1-2 hours at a time; in the daytime her naps were 20 minutes long 1-3x a day (until she gave up napping at 2 yrs old).  She would waken and call me 6-10x a night until she was 2, then 4-8x a night until about age 3, and continues at 1-2x a night age 6+ (she has slept through the night only a handful of times).

I realize this is not an uncommon complaint with babies and toddlers, hence the plethora of sleep training methods and books.  My second child (no developmental delays) isn’t a much better sleeper.  And after years of being woken repeatedly throughout the night, I have difficulty falling – and staying – asleep.

So, here are my thoughts based on our experience:

  • Rule out any underlying medical condition.  Get a check-up, including bloodwork if necessary.  (see my post on bloodwork for little ones)
  • Follow a Sleep Hygiene schedule and stick to it religiously
    • Maintain a regular wake and sleep pattern seven days a week – get up and go to bed at the same time each day
    • Avoid daytime naps (adults), or make sure there is at least 4 hours between the end of a nap and bedtime for babies/toddlers/kids.  This might involve waking them up (unless they are sick).  Good luck with that…
    • Get exposure to light first thing in the morning – open the blinds, turn on the lights.  This helps your brain establish the wake part of your sleep-wake cycle.
    • Dim the lights for the hour before bed if possible.  This includes NO SCREEN (TV, tablet, phone) unless it is a specific reading screen.  This alerts your brain to release melatonin – the sleep hormone.
    • Avoid caffeine after lunch (adults); don’t give caffeine to kids (pop, dark chocolate)
    • Avoid nicotine and alcohol after supper (adults)(alcohol disrupts second stage sleep)
    • Exercise during the day anytime before supper; regular exercise can promote healthy sleep patterns
    • Don’t eat too much before bedtime
    • Establish a relaxing bedtime routine.  Bath (a warm bath followed by a drop in body temperature when you get out helps your body think it is time to sleep), stories, one last drink and potty trip.  Don’t rush this routine – relaxing takes time.  Allow your child to talk about his/her day.  We love Cloud B’s Tranquil Turtle to ease the transition between story time and sleep time.
    • Ensure the sleep environment is relaxing.  It should be very dark (blackout blinds); if you use a nightlight, it should be very very dim (try putting a sock or electrical tape over it).
    • Consider something for white noise (we use a cheap fan pointed at the wall on lowest setting). Cloud B makes a Sleep Sheep; there are other baby white noise machines available.
    • Essential oils might be a part of your routine to signal sleep – lavender and roman chamomile are safe to use with babies and toddlers.

The book I recommend for baby/toddler sleep issues is Elizabeth Pantley’s No Cry Sleep Solution.  She has one for older children as well.  Note that I don’t recommend letting babies or children of any age “cry-it-out” for a number of reasons that are supported by the scientific literature (see here, here, here).

sleep_rest

After trying all this, you still may struggle with sleep.  We gave E a low dose of melatonin (like the liquid one found here) for a year.  Give the lowest dose possible that is effective.  Note that melatonin will only help with initial falling asleep, and not staying asleep.  There are extended release formulas, but your child has to be able to swallow a pill whole to take them.  Talk to your child’s doctor before trying melatonin, as it is a hormone and may cause problems down the road (such as puberty issues, hormonal dependency, sleep cycle issues).

I had read at the time that melatonin will only work if there is a melatonin deficiency.  I know that it worked very well for E, and didn’t do anything for me.  Following sleep hygiene as above will stimulate your brain to produce more melatonin.

For very infrequent nights when we *had* to get sleep…note that Benadryl and Gravol are approved to give to children age 2+ and both have drowsiness as a side effect.

E’s sleep cycles did regulate at around age 4, even though she continues to have night wakings.

For myself, zopiclone does the trick as long as I don’t take it regularly (my body habituates to it VERY quickly).   There are several anti-depressants that can cause drowsiness, but they have side effects.

Sleep continues to be an issue at our house, but consistent, good sleep hygiene has helped a lot.

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

download

“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)