Enuresis is more commonly known as bed-wetting. Nocturnal enuresis, or bed-wetting at night, is the most common type of elimination disorder. Daytime wetting is called diurnal enuresis. Some children experience either or a combination of both.
This behaviour may or may not be purposeful. The condition is not diagnosed unless the child is 5 years or older.
The main symptoms of enuresis include
Repeated bed-wetting, Day time wetting in the clothes and Urgency and increased Frequency.
Dr Tewary is a specialist in this field and has many years’ experience treating the root cause of Enuresis. For further information please contact us today to arrange your consultation.
Fabrile Convulsion (seizures) in young Children & Babies
Febrile convulsion is a condition for younger children, most commonly presenting in between 6 months to 6 years of age.
Some children in this age group are more vulnerable to disturbance in electrical activity of brain with high fever, and get a generalised shaking of body often followed by stiffness. It usually last for less than 3 minutes, and child is often tired after the convulsion but recovers fully within 24 hours with no deficit in his neurological condition. This usually is a clinical diagnosis based on presentation and findings on examination, and does not need any specific treatment apart from antipyretics.
Very rarely it can present in an atypical manner such as a focal convulsion, such as involving on one side of body or one limb, or a weakness of one side of body after persisting for more than 24 hours, or convulsion lasting for more than 10-15 minutes.
A typical febrile convulsion is not dangerous, and does not cause any long term damage to brain.
There is often also a family history found for febrile convulsion in one or more of family members.
It is important to make sure that child is in a safe condition. There are videos and education provided for putting the child in recovery posture, and basic life support procedures –
NHS Information Link:
Once the child is put in recovery position, it is important to make sure that there is no vomit/forth in the mouth to obstruct the breathing. The body should be tried to cool down by ventilating the room, and sometimes a fan can be helpful.
Any extra clothing should be removed as possible. If the convulsion persists for more than 5 minutes, parents should ring ‘999’ for ambulance services with paramedics, and child may need to be taken to the nearby hospital/doctor for further management. If the fit stops within 3-5 minutes, child should still be examined by a doctor at earliest possible opportunity to make sure about further management of fever, and treat the cause such as any infection if necessary.
There is no measure to predict the onset of convulsions and prevent it. However it is useful to look after your child to prevent the rise of temperature if he/she is unwell for any reasons. Once convulsion starts, you should make sure putting the child in recovery position, and take necessary actions as above mentioned.
Usually there is no need of any investigations for a typical febrile convulsion. Children may need a brain wave testing called as EEG ( Electro –Encephalogram), in atypical presentations, and sometimes even a brain scan to make sure that the convulsion is not due to any changes in brain.
Majority of children presenting with Typical Febrile convulsion recover fully by age 5 years. A very small number of children may need further investigation and may have likelihood of Epilepsy in later life if they got atypical presentations, or a family history of Epilepsy. It very much depends on children’s’ and family history and the presentation.
Asthma in young children - chronic illness
Summer should be a time for outdoor fun in the sun – but for parents of youngsters suffering from asthma or hay fever it can also be a time for concern.
The symptoms of hay fever can be unpleasant enough but can hay fever actually trigger an asthma attack and what can parents do to protect their children without restricting their time in the open air.
What is the difference between hay fever and asthma?
Both conditions are on the ‘Atopic’ spectrum and are usually caused by release of intrinsic enzymes/factors such as histamine or cytokines.
Asthma symptoms occur due to inflammation of upper airways causing a partial obstruction during exhalation and presents with a typical musical sound called as ‘wheeze’ and/or in difficulty in breathing.
Hay fever symptoms are produced due to inflammation of nasal mucosa and usually present with nasal stuffiness, sneezing, runny nose and blocked nose. The eyes can also be affected causing itchiness with occasional redness, watery discharge and swelling around eyes. Symptoms normally occur after the person is exposed to a trigger such as pollen.
Someone suffering with hay fever may have predisposition to asthma but this is not always the case. People can suffer with one or the other.
Once diagnosed of asthma it is important to continue with inhalers as prescribed. There are usually two types of inhalers prescribed- blue and brown. Blue is a reliever and used ‘as and when’ child feels wheezy or breathless, the brown inhaler is a preventer and once started should be continued every day as per prescription unless doctor has reviewed the condition and decided to stop it.
It is quite common for people suffering with asthma to have a worsening of their symptoms as seasonal triggers such as pollens and grass come into play so doctors can provide an ‘Asthma Treatment Plan’ to address such symptom fluctuations and this could mean a change of inhaler dosage.
However if after being given a ‘Plan’ if the symptoms are not settling or even getting worse then the patient should revisit their GP to discuss the possibility of further changes.
Avoidance of triggering factors such as exposure to grass and pollen can help but it can be extremely difficult and damaging to a child’s day to day life to implement this.
The general precautions recommended are:
- Avoid high pollen count areas
- Shake or even wash clothes after coming in from outdoors
- Keep windows closed
- Dry the clothes inside or in a dryer, rather than hanging them on the line where they may be exposed to various ‘triggers’
- Take regular showers and keep the child’s hair clean and free from pollen that may have been picked up while outdoors
- Try not to rub itchy eye, instead wash the entire face with a clean cloth and a gentle cleanser
- People are often advised to avoid histamine-producing food such as smoked and cooked meat, fish, cheese and nuts and take more of Omega 3 fatty acid though green vegetables, carrots, beans, and fish oil. However, the evidence around this is variable and I would only consider taking this option in very severe cases.
- Parents take note! If you smoke around your children you will be at risk of adversely affecting your children.
Hay fever typically present with localised symptoms such as nasal congestion, stuffiness, eye irritation in combinations, and has very seasonal occurrence at certain specific times of the year.
Other localised conditions such as an allergic conjunctivitis (eyes go red and sore), or perennial rhinitis (nasal symptoms round the year) can often be confused with hay fever. They are usually isolated and need some specific treatment. Children should be seen by a doctor if symptoms are not settling with normal day to day remedies.
Anti-histamine tablets and syrup are available as well as non-medicated nasal sprays. However one should not use it without discussing with your pharmacist.
A good and active lifestyle often boosts the immunity. Avoidance of Histamine releasing food and taking more of Carotene and Omega 3 fatty acid has been shown to provide some relief, although, as said earlier, the evidence is variable.
Although asthma is most commonly precipitated by viral infections a proportion of children may have onset with exposure to environmental factors. While avoidance of these factors often helps in alleviation of symptoms, it is not recommended to restrict a child’s activity from playing out to the extent of affecting their development and socialisation. A balance should be achieved with precautions as above mentioned.
Asthma is mostly a diagnosis made on basis of history and clinical findings. In clinical settings, children often get other tests with their breathing such as Peak Flow measurement, and sometimes Lung Function tests.
X-ray I of chest any sometimes be requested in severe cases however it is s not a recommended test to make the diagnosis.
There are usually 2 types of medications:
- Reliever: an inhaler to dilate the airways
- Preventer: a storied inhaler to suppress the hyper-reactivity process and inflammation.
There are several steps to the escalate the treatment phase and it can vary from a simple blue inhaler to dilated the air ways to adding steroids by inhalation, or sometimes by intravenous or oral route in moderate to severe cases. It is always advised to give the inhalers through a Volumatic/ chamber (a wide funnel shape portable chamber) to increase the efficacy of medicine in children < 5 years of age, and also to add a mask in very young children.
There are other medications known as ‘Immuno-modulators ’to target the process and stabilise the calls which react causing the symptoms of Asthma.
Children with sever presentation often need other supporting measures such as Oxygen, or in a minority of cases a respiratory support.
Constipation in young children - childhood illness
Constipation is a very common condition and usually considered if child is having hard/painful and large stool at infrequent intervals. The normal frequency of bowel movement can vary from once or twice every day to 3-4 times every week.
Constipation is usually precipitated due to lack of liquid intake, having less fibre in diet or irregular bowel habit.
It is mostly physiological, however rarely a chronic constipation can be secondary to reduced peristaltic movement of bowels due to conditions such as underactive Thyroid, or very rarely due to a megacolon which usually presents in first few days of life, and usually delays the first passage of stool for more than 48 hours.
In young children it may be precipitated after having an episode of very hard stool causing severe pain and bleeding from the back passage, and the child starts holding the bowel movement due to the sore bottom.
It is usually diagnosed through a good history and examination. In certain cases with chronic constipation, blood tests may be required the rule out underactive Thyroid.
Constipation usually resolves through improving the liquid intake and increasing fibre in diet. Children may need a short or long course of Laxative (a medicine to soften stool and stimulate bowel movement). There is no defined duration of this medicine and it can be prescribed for a few days to many months depending on needs.
If constipation is not improving despite improving the liquid and fibre intake, and persisting, it is advisable to discuss this with your doctor, and he may need to refer to a paediatrician if further advice is needed.
Heart murmur are an additional sounds to the heart beat, and not uncommon to have in early childhood, and usually picked up by doctor during a routine examination of children.
Heart murmurs are usually caused by either by a noise in the blood vessels due to turbulence of flow, or sometimes may be caused due to some changes in the structure of heart.
It is often benign and harmless, however this needs to be checked by the doctor at first instance.
In certain cases there may be difficulties in the blood flow causing mixing of clean and used blood, and children usually present with blue spells in very early childhood, or during the new born period.
Heart murmur is usually picked up during routine examination. Doctor may decide to go for few more investigation such as Electrocardiogram (an investigation to read the electrical activity of heart), and/or Echocardiogram (an ultrasound of heart).
Very rarely a child may need more investigations and depending on needs it is only advised by a heart specialist.
Heart murmurs are often benign and harmless. Many of heart murmurs are caused by a simple turbulence of blood, often listened when a child is unwell, and disappear at other times. This is called ‘Innocent murmur’ and does not require any treatment.
Sometimes the child may have a small structural defect in the wall between 2 big chambers of heart, and it usually closes itself by 5 years of age in about half of the cases requiring no treatment.
However it is always advised to be seen by a specialist/paediatrician if you suspect or have been told that the child has heart murmur.
Bed Wetting in Children and Infants is not just a traumatic and upsetting thing to cope with for the child, it can also put a strain on the parents and other members of the family.
Up to the age of 5, wetting the bed is normal. It usually stops happening as your child gets older without the need for any treatment. Up to 1 in 5 5-year-olds wet the bed, 1 in 20 10-year-olds wet the bed and about 1 in 50 teenagers wet the bed.
Bedwetting can happen when your child makes more urine at night than their bladder can hold, and/or the feeling of having a full bladder doesn’t wake them up. Children don’t wet the bed on purpose – it happens while they’re sleeping. Most children only learn to stay dry through the night after they’re potty trained and dry most days, give or take the odd accident.
Young children often don’t wake to the feeling of a full bladder like older children do. This is a skill they learn gradually. Bedwetting can run in families, and boys are more likely to wet the bed than girls. The medical name for bedwetting is nocturnal enuresis.
It can be messy and frustrating for both you and your child. Try to deal with bedwetting in a positive and calm way, just as you would with problems you face during the day.
Dr Kishor Tewary is a private specialist consultant in the area of Bed Wetting and Enuresis and has been running special clinics for this for patients of all ages for nearly 2 decades. Serving as a ‘Lead for Incontinence’ in Sandwell, Mid-Stafford, and South Staffordshire areas till recent past, he has helped a vast majority of children dealing with the issue of Bed Wetting/day time wetting.
For more information contact us today to arrange your appointment.
Urinary Tract Infections
A Urinary Tract Infection is an infection of any part of your urinary system such as Kidneys, Ureters, Bladder and Urethra. Most infection involve the lower urinary tract.
Urinary tract infections in children are a marker of possible urinary tract abnormalities (eg, obstruction, neurogenic bladder, ureteral duplication); these abnormalities are particularly likely to result in recurrent infection if vesicoureteral reflux (VUR) is present. About 20% to 30% of infants and children age 12 to 36 mo with UTI have VUR. The younger the child at the first UTI, the higher the likelihood of VUR. VUR is classified by grade.
Recurrent UTI can be associated with VUR, especially VUR of higher grades. This association is likely due to two factors—that VUR predisposes to infection and recurrent infections can worsen VUR. The relative contribution of each factor in children with recurrent UTI is unclear. Children with more severe reflux may have a higher risk of developing hypertension (high blood pressure) and renal failure (caused by repeated infection, chronic pyelonephritis and kidney scarring), the evidence is variable.
- Malformations and obstructions of the urinary tract
- Indwelling urinary catheters
- Neurological conditions affecting bladder/bowel
- Other predisposing factors in younger children include constipation and Hirschsprung disease.
- Poor hygiene
- Poor bladder habit
- In females, sexual intercourse.
If you believe your child has a UTI and you would like a second opinion or specialist help and advice then Dr Tewary who is a specialist consultant paediatrician is on hand to help. Contact us today for more information or to book an appointment.
Useful Tips for UTI
Author: Dr Kishor Tewary
MBBS, MD, MRCP, FRCPCH, PGCME, PGC Health Sciences
Consultant Paediatrician, special interest in kidney/bladder disorders
It’s always advisable to take between 6-8 glasses of plain liquid at least every day. A good liquid intake replenishes the circulation and flushes the kidneys and bladder to prevent collection of waste and toxic products/germs
A regular bladder habit ie voiding every 2-4 hours is recommended to prevent growth of unfriendly germs. Yung children often have a tendency to hold urine, especially at school. This not only affects the bladder tonicity, but also promotes growth of unhealthy germs in the bladder in the stagnant urine hold in bladder, and hence infection. UTI being an ascending infection can often migrate to upper tract ie kidneys.
A constipated bowel (Rectum/colon) can affect the emptying of bladder and also irritate the bladder musculature. This causes incomplete emptying and residual urine in bladder and also irritability of bladder muscles. Residual urine can promote growth of unfriendly germs and infection.
It is recommended to have a regular bowel habit, ie opening bowels every day as possible, and the stool consistency should be soft. A regular liquid intake, good intake of fruits and fibre, and regular exercise/physical activity helps to keep the bowel movements regulated, sometimes a laxative may be needed on doctor’s advice.
A regular cleaning of genital area is very important to keep the area germ free. The urinary passage is quite close to anal area in girls and an improper cleaning can promote the growth of germs from gut to migrate to bladder and cause urinary infection. A front to back wiping and daily/regular shower/bath helps in keeping the area clean.
There is a variable evidence. However often a use of live yogurt or lactobacillus/probiotic drinks may help prevention of infection by prompting growth of friendly bacteria in gut and colon. There are other agents tried such as Cranberry juice, and again the response is very variable.
Children can often present with being unwell, mostly with a fever, pain in passing urine, loin pain, feeling sick /nauseated, and generally unwell. However the symptoms may vary, and often younger children cannot verbalise their symptoms. The symptoms in babies can often be non-specific such as presenting with vomiting, being unwell,diarrhoea and/or loss of weight or even prolonged new-born jaundice.
It is important to seek doctors’ advice whenever child seems to be unwell, with no obvious source of infection such as cold, cough etc. A delay in diagnoses and management may sometimes affect kidneys and hence a prompt action is required if suspicious.
Method of collecting a clean catch sample-
Boys Retract the prepuce (as possible) and wash the glans with lukewarm water, either directly or through cotton balls soaked in water..
Girls Spread the labia in frog leg position and wash with lukewarm water, directly or through cotton balls.
For the very young child a sterile container with provided funnel (often available in hospital children’s ward/GP Surgery) can be used to collect the sample into the container.
If toilet trained it may be easy to place a sterile bowl into a pot and collect the urine in this. Urine can then be poured from the bowl into the sterile container.
An older child may be able to urinate directly into the container.
A “mid-stream” sample of urine is best for the sample collection, as the initial stream may be contaminated with the bacteria from skin.
Only a small amount of urine is required for the test.
- Avoid the container touching the child’s skin while collecting urine as it may contaminate the sample from bugs normally found on skin..
- Also be careful not to touch the rim of the bottle with your fingers for the same reasons.
- Always try to collect urine sample before starting antibiotics ( However this may be overridden if child extremely sick needing urgent antibiotics, and urine collection is delayed)
- Try collecting urine a non-sterile pot such as cleaned potty or jugs, they can give rise to contamination despite thorough cleaning.
- Collect urine and submit for test after 4 hours of collection and kept outside fridge.
- Touch the sterile pot inside, and avoid urine flow touching any part of skin before going in the pot.
- Clean the genital area with wipes; they are not ideal substitute for cleaning with water.
Links for Parents
Urinary Tract Infection