Easy bruising needs to be evaluated carefully as some cases may have serious underlying problems.

A BRUISE or ecchymosis is caused by bleeding underneath the skin and leakage of red blood cells out of injured blood vessels. This is a common complaint and a good majority of them turn out to have nothing sinister or serious.

Nevertheless, easy bruising needs to be evaluated carefully because a few of these cases may have serious underlying disorders.

Some of the important factors for doctors to sort out whether this is something trivial or a serious problem include the duration of the symptom, local or generalised bruising (if there is bleeding from other sites) and accompanying symptoms such as fever, weight loss, joint pain and so on.

All patients with easy bruising need careful history and thorough physical examination followed by laboratory tests, which are guided by clinical impression.

Anatomy of a stable clot

The fear of patients presenting with easy bruising is the likelihood of a defect or defects in the clotting mechanism causing “excessive bleeding”. The formation of a stable clot would need:

1. An intact coagulation system with adequate coagulation factors.

2. Adequate platelet count with normal platelet function.

3. Normal blood vessels which constrict locally to decrease blood flow in time of injury.

Patients with low coagulation factors such as in liver dysfunctions can bruise/bleed excessively.

Patients with low platelet count (thrombocytopenia) can develop spontaneous bruising and similarly those with impaired platelet function can have bleeding problems.

Vascular or blood vessel abnormalities rarely cause significant bleeding.

Some patients can have multiple clotting or haemostatic failures such as in disseminated intravascular coagulation (DIC) where there is consumption of both clotting factors and platelets due to activation by procoagulants or substances that promote clotting.

History is essential

Easy bruising at different age groups can have some unique causes. For instance, the commonest cause of easy bruising in childhood in tropical countries like Malaysia is a condition called acquired platelet dysfunction with eosinophilia (APDE).

This is an interesting disorder (poorly documented by Western authors!) resulting from the overactive or hyperimmune response to parasitic infestations and the resultant immune complexes “coat” the platelets, causing defective platelet function and hence the bleeding tendency.

Amongst the elderly, easy bruising is fairly common. The so-called senile purpura is likely due to capillary fragility and weakened collagen tissue with ageing and is entirely innocuous.

Easy bruising is a far commoner complaint amongst females. If the bruises occur for the first time excessively over a short period, she needs to be evaluated urgently.

Patients who have bruises for years generally do not have blood clotting or serious blood disorders. A common problem is the “easy bruising syndrome”, which typically occurs in females of reproductive age. The underlying cause is unknown and has been linked to fragile blood vessels, antibody problems or hormonal disturbance. The laboratory tests on coagulation studies are typically normal. The bottom line is that there is no bleeding tendency even when they are challenged with surgical procedures/operations or when they sustain injuries.

Family history is important because some bleeding disorders are inherited, with the well known examples being haemophilia A (Factor VIII deficiency) and B (Factor IX deficiency) and Von Willebrand’s disease.

Drug history is crucial in clinical practice. Aspirin, non-steroidal anti-inflammatory drugs (NSAID), steroids and warfarin are capable of causing bleeding problems.

Some “health foods” such as ginseng, spirulina and gingko can result i

n bleeding due to their anti-platelet actions.

Unexplained bruises in unusual locations such as around the eye or face should raise the possibility of domestic violence or abuse.

Past medical history of bleeding episodes are illuminating to the underlying cause. Patients who could go through surgical procedures such as dental extractions without bleeding problems are unlikely to have serious congenital bleeding disorders. Patients with liver disease, renal failure and bone marrow failure (e.g. aplasia or leukaemia) can have bleeding tendency.

Some of the more definitive symptoms indicative of serious disorder include bleeding from multiple sites, for instance nose bleed, gum bleed, gastrointestinal bleed with black stool or melaena, bleeding in the urine (haematuria) , menorrhagia (excessive menstrual bleed) or prolonged bleeding during or after surgery/tooth extraction.

Other symptoms such as persistent fever, painful joints and bone pain would need further evaluation.

Physical findings such as bleeding in the eyes and wet purpura in the mucous membranes are indicators of serious haemostatic or clotting failure. Severe pallor would indicate anaemia and hence the severity of the bleed.

Wet purpura in the buccal mucosa (mouth) is likely to be associated with severe thrombocytopenia.

Thrombocytopenia or platelet dysfunctions are associated with petechiel haemorrhage (small little bleeding spots) and mucosal bleeds such as gum or nose bleed.

Bleeding into joints and muscles are indicative of coagulation problems such as haemophilia or liver diseases. Acute leukaemic patients can present with pallor, enlarged lymph nodes, swollen gum and spleen. They would need immediate laboratory assessment.

Blood tests for easy bruising

Basically, we want to make sure that the blood cells, especially platelet counts, are in the normal range, and also whether the clotting mechanisms (dependent on platelet number and function, clotting factors and vessel wall interactions) are intact.

The screening blood tests ordered consist of full blood picture and coagulation profile. It is important that the tests are done in good time and abnormal results are acted promptly as delay in diagnosis and treatment impact adversely on the immediate outlook of the disease.

Preliminary diagnosis of acute leukaemia can be made in the blood film if there are circulating leukaemic cells €“ this is especially important in acute leukaemia to avoid onset of life threatening bleeding and associated infective complications.

More specialised tests such as bone marrow examination or detailed coagulation tests e.g. factor assay, need to be performed quickly in those with abnormal screening tests. These tests may only be available at tertiary medical centres and urgent referral needs to be organised.

In dealing with cases of suspected of leukaemia, the patients should be assessed quickly by the attending specialist within a day or two. Circulating inhibitors/antibodies, especially to factor VIII, can cause almost intractable serious haemorrhage and needs urgent specialist care.

What are the treatment options?

Treatment depends solely on the underlying cause. Some patients just need reassurance while others need immediate supportive treatment as well as definitive treatment, for instance blood component transfusions and induction chemotherapy for acute leukaemia.

The supportive care for bleeding complications has improved with the used of blood component therapy. For instance, haemophilia patients are given factor concentrates while thrombocytopenic patients are given platelet transfusion, while patients with coagulopathy or multiple factors deficiency are given fresh frozen plasma (FFP) to replace the missing/deficient component.

Component therapy is certainly more effective than traditional whole blood transfusion and carries less risk of overloading patients.

The definitive treatment depends on the diagnosis. Acute leukaemia patients would need chemotherapy, and later, in some cases, bone marrow transplant to achieve the possibility of cure.

Aplastic anaemia patients would need anti-thymocyte globulin or bone marrow transplant if they have severe disease.

Immune thrombocytopenic patients are treated with steroids, immunosuppressive drugs such as azathioprine, or splenectomy in some cases.

Patients with congenital factor deficiency such as haemophilia need life-long supportive care.

Those with disseminated intravascular coagulation (DIC) need treatment of their triggering cause quickly (for instance, severe infection, shock, hypoxia) to have any chance of survival.

n This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public.

The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my.

The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care.

The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.

This is the first of a two-part series on how to space your pregnancies.

NEWLY-wed couples have a lot to think about after the blissful glow of the honeymoon has faded. One very important aspect of married life to consider is family planning.

Careful family planning helps you to space your pregnancies so that your body can recover and heal from the previous pregnancy. It also helps you to plan your family’s financial resources so that you can comfortably welcome the new addition to your family.

You can practise family planning by using contraceptive methods. There are two kinds of contraceptives: non-hormonal and hormonal methods.

Non-hormonal methods

Family planning with non-hormonal methods include the use of natural methods, or devices and procedures that do not involve hormones.

Natural family planning method €“ This is a contraceptive method that relies on Mother Nature. With this method, a woman has to keep track of her fertile period through her menstrual cycle.

A woman usually ovulates about two weeks before her cycle begins. This will be the start of her fertile period and when she should avoid sexual intercourse.

The method of counting days is not very reliable, because not all women are as regular as a clock. A more effective method of charting ovulation is the basal body temperature (BBT) method, which involves charting the temperature of the vagina every day. Just as a woman is about to begin ovulating, her body temperature will rise and her cervical mucous will increase, and become clear in colour and “stretchy”. You can check this with a basal body thermometer - different from a normal thermometer - every day.

A new development in this method is the ovulation predictor, which tests the urine for oestrogen metabolites (which marks the start of the fertile phase) and the LH surge that takes place 36 hours before the end of the fertile phase.

While this method is entirely natural and does not use any chemicals or devices, it is not always suitable for every woman, especially those who have irregular cycles, are often ill, work irregular hours or are unable to keep records. It requires so much constant monitoring and abstinence from sex for more than one week every month that it may cause stress and tension between a couple.

If you are not confident in using this method correctly, it could have a high failure rate.

Barrier methods - These are probably the most common contraceptive methods. They include latex condoms, diaphragms and caps, as well as spermicides.

They work by putting up a physical barrier that prevents the sperm from being able to reach the egg inside the woman’s body. An added benefit is that they also protect against sexually transmitted infections, while other contraceptive methods don’t.

While barrier methods are easy to use and relatively cheap, they should always be used in combination with another contraceptive method. After all, condoms have been known to break, or one may forget to put in the diaphragm in the “heat of the moment”.

Lactational amenorrhoea method (LAM) - LAM is really just a fancy name for a form of contraceptive that occurs when you are breastfeeding. When you are breastfeeding, your body undergoes hormonal changes that suppress ovulation and menstruation. This method offers 98% protection from pregnancy.

However, your breastfeeding routine must follow strict guidelines. You must practise exclusive breastfeeding (only giving baby breast milk) on demand. If you do give supplemental foods, such as other liquids or solid foods, they must not exceed 5-10% of the baby’s total daily diet.

The intervals between feeding must not exceed four hours (in the daytime) or six hours (in the night).

The contraceptive effects of breastfeeding are an added benefit of breastfeeding, but they are not foolproof. When your baby reaches the age of six months, or if you begin menstruating, you should use another family planning method.

Intrauterine devices (IUDs) - Intrauterine devices are suitable for monogamous women in stable relationships who want a reliable, long-term, non-hormonal method of contraception.

An IUD is a T-shaped copper device inserted in the uterus to inhibit fertilisation of the egg by the sperm. It is highly effective (94-99% success rates), lasts for five to 10 years, can be reversed easily, and best of all, allows for sexual spontaneity without having to worry about taking a pill or putting on a condom.

While IUDs have few side-effects, they can cause heavy menstrual bleeding, or spotting between periods. In rare cases, the IUD may be pushed out of the uterus into the vagina, or perforate the wall of the uterus.

There is also a type of IUD that works by releasing hormones into the body. Ask your doctor about the benefits and drawbacks of each type, and whether it is suitable for you.

Sterilisation - Finally, there are couples who may want a permanent method of birth control - meaning they are not planning to have any more children.

There are sterilisation methods for both men and women. For women, the procedure is called “tubal ligation”, which involves cutting, sealing or blocking the fallopian tubes (the tubes between the ovaries and the uterus, through which eggs travel). This prevents the eggs from reaching the sperm and becoming fertilised.

For men, sterilisation involves a vasectomy. This is a small operation to cut the vas deferens (the tube that takes sperm from the testes to the penis). Once the vas deferens is cut, sperm can no longer get into the semen that is ejaculated during sex.

You and your partner have to be absolutely sure that you no longer want children before you agree to undergo either of these procedures. Although they are reversible, you will have much lower chances of being fertile after that.

Ultimately, the family planning method you choose is a decision best left up to you and your partner. In my next article, I will describe the hormonal methods of contraception and the considerations that should guide your choice.

Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician & gynaecologist (FRCOG, UK). For further information, visit www.primanora.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

There are many conditions that can affect our eyes. It’s wise to get eye problems checked early, just in case.

ACCORDING to the International Agency for the Prevention of Blindness (IAPB), approximately 45 million people worldwide live with blindness, of which 80% or 36 million are over the age of 50.

With the world’s ageing population growing as a result of improved life expectancy, this represents a significant problem as the prevalence of eye diseases such as cataract, glaucoma and age-related macular disorder rise significantly with age.

In a time and age where our older generation should be enjoying the fruits of their labour, they are instead at risk of losing their sight.

World Sight Day

World Sight Day, commemorated annually on the second Thursday of October, is championed by VISION 2020, a global initiative supported by the World Health Organisation (WHO) and the International Agency for the Prevention of Blindness (IAPB). Its objectives are:

·Raise public awareness of blindness & vision impairment as major international public health issues.

·Influence governments/Ministers of Health to participate in and designate funds for national blindness prevention programmes.

·Educate target audiences about blindness prevention, about VISION 2020 and its activities, and to generate support for VISION 2020 programme activities.

In Malaysia

The National Eye Survey conducted in 1996 recorded the prevalence of blindness in Malaysia at 0.29%, with cataract and retinal diseases forming the majority of cases.

Prof Dr Muhaya Hj Mohamad, Chairperson of the Malaysian Medical Association (MMA) Ophthalmological Society, says: “Among those afflicted by blindness, the majority are above 50 years of age because the eye diseases that cause blindness take many years to develop. This is both a blessing and a tragedy €“ a blessing because it can be detected early enough for treatment, and a tragedy for those who never knew that blindness can often be avoided.

“Preserving our sight for as long we possibly can is not as straightforward as it might seem,” she adds.

“Although some cases can be protected and preserved through interventions like corrective glasses, some chronic conditions, such as diabetes, can contribute to blindness as well. So there is no one-stop solution of just seeing an ophthalmologist and getting the problem solved.”

Avoidable blindness

Avoidable blindness is defined as blindness which could be either treated or prevented by known, cost-effective means. Although there are many causes of vision impairment, VISION 2020 is targeting the main causes of avoidable blindness, in order to have the greatest possible impact on vision loss worldwide. These target disease areas are:

Age-related macular degeneration €“ Age-related macular degeneration (AMD) is the most common cause of blindness in industrialised countries, and mainly affects those over 50 years of age. Its prevalence is likely to increase as a consequence of population ageing.

AMD presents in two forms, “wet” and “dry”. In most populations, the dry form is the more frequent, but it is less likely to lead to severe bilateral visual loss.

The wet form is characterised by the development of abnormal new blood vessels deep to the sensory retina, which can leak or bleed, leading to marked loss of central vision; if bilateral, this can be very disabling.

Each year, after the onset of wet age-related macular degeneration in one eye, 15% of persons develop the wet form in their second eye. Current options for prevention are limited, but new treatments are being developed to preserve or restore vision in some patients with the wet form.

Cataract €“ Cataract is defined as the clouding of the lens of the eye, which impedes the passage of light. Although most cases of cataract are related to the ageing process, occasionally children can be born with the condition, or a cataract may develop after eye injuries, inflammation, and some other eye diseases.

Childhood blindness - In low-income countries, high proportions of children are blind from preventable causes, which require community-based interventions. In all regions, children with treatable diseases, principally cataract, can have their sight restored.

Childrens’ eyes cannot, however, be considered smaller versions of adults’ eyes, and specific expertise and equipment are required. Unlike adults, children require long-term follow-up after surgery to manage complications and to prevent amblyopia (“lazy eyes”). The understanding and involvement of parents is critical.

Diabetic retinopathy €“ Diabetic retinopathy is a complication of diabetes mellitus. Well-conducted clinical trials have shown that good control of diabetes and hypertension significantly reduces the risk for diabetic retinopathy, and there is evidence from studies spanning more than 30 years that treatment of established retinopathy can reduce the risk for visual loss by more than 90%.

Screening programmes for detecting diabetic retinopathy at an early stage at which treatment can prevent visual loss and health education programmes are the main means of prevention of blindness due to this condition.

Glaucoma - Glaucoma is a group of conditions characterised by damage to the optic nerve and loss of the field of vision. The two main types are primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

POAG is more frequent in whites and Afro-Caribbeans, while PACG is more common in South-East Asia. Glaucoma is uncommon among persons under the age of 40, but the prevalence increases with age.

Other risk factors include raised pressure inside the eye (intraocular pressure), a positive family history and belonging to a susceptible ethnic group.

As the early stages of both types of glaucoma are often asymptomatic, patients often present late, particularly in developing countries. Once vision has been lost, regardless of the type of glaucoma, it cannot be restored.

Low vision - Low vision is currently defined as “visual acuity of less than 6/18 down to and including 3/60 in the better eye”, from all causes. Many such persons require cataract extraction or refraction services. Low-vision services are aimed at people who have residual vision that can be used and enhanced by specific aids.

Onchocerciasis - Onchocerciasis is caused by an infection which is transmitted by the blackfly species. The vast majority of the 37 million infected people live in West, Central and East Africa.

This infection also causes a range of skin diseases and other systemic conditions. The WHO Onchocerciasis Control Programme, which operated between 1974 and 2002, covered 11 countries in West Africa and was highly successful, and it is no longer a public health concern in most of the affected areas.

Refractive errors - Refractive errors (myopia, hypermetropia, astigmatism, presbyopia) result in an unfocused image falling on the retina. The resulting vision impairment often result in lost education and employment opportunities, lower productivity and impaired quality of life.

Assessment of individuals who have refractive errors, particularly those aged 50 years or above, provides an opportunity for identifying other potentially “blinding” conditions before they cause visual loss (such as glaucoma and diabetic retinopathy).

Trachoma - Trachoma, which is the most common infectious cause of blindness, is caused by Chlamydia trachomatis. Children who have the active stages of the disease are the reservoir of infection, while blindness, which occurs after repeated episodes of infection, usually affects adults. Boys and girls are equally affected by active infection, while blindness is more common in women.

Trachoma affects communities that have poor water supplies, sanitation and/or poor health services.

The organism is transmitted from person to person through direct and indirect contact and by flies. Blindness can be prevented by surgery while the infection and its transmission can be reduced with surgery, antibiotics, facial cleanliness and environmental change.

Preserving sight for the future

According to global statistics, as much as 75% of blindness is avoidable through early prevention and diagnosis.

“One of the worst mistakes to make, especially in an ageing person, is to assume that loss of vision is supposed to happen as we grow older,” asserts Prof Dr Muhaya. “This is absolutely untrue. Any change or loss of vision should be investigated because this is our eyesight that we are trying to preserve. Ignoring vision loss is like ignoring chest pain. Just because loss of vision is not fatal doesn’t mean that it’s less important.”

Suggestions for good eye health include the following:

·Visit an ophthalmologist every other year for an eye screening if you are below 40 years old. An annual check-up is recommended for people above 40 years old, have a family history of eye conditions like glaucoma, cataracts or diabetic.

·See a doctor immediately if you have any acute or prolonged episodes like blurred vision, flashes of light, blind spots or any other symptom that affects your vision.

Contact lens users

For those who use contact lenses, there are steps to take to reduce the risk of infections. These include:

• Wash your hands before handling contact lenses
• Follow directions for cleaning and storing contact lenses
• Clean the lens case after each use
• Follow the recommended lens replacement schedule
• Avoid sleeping and swimming in lenses or wearing them longer than recommended
• Maintain better control of blood sugar levels to slow the onset and progression of diabetic retinopathy.

Spotlight on AREDS

The Age-Related Eye Disease Study (AREDS) was conducted by the US National Eye Institute to determine the role, if any, of antioxidant supplements in reducing the rate of progression from intermediate age-related macular degeneration (AMD) to advanced AMD.

This is based on the assumption that the antioxidants can prevent cellular damage in the retina by eliminating free radicals and harmful oxidants that are generated by the eye’s absorption of light and other normal metabolic processes.

The composition of antioxidants and minerals used in AREDS were:

• Vitamin C, 500mg
• Vitamin E, 400 IU
• Beta carotene, 15mg (equivalent to Vitamin A, 25,000 IU)
• Zinc (as zinc oxide), 80mg
• Copper (as cupric oxide), 2mg

This combination, taken daily, was effective in reducing the risk of developing advanced AMD by 25% in patients with intermediate AMD in one or both eyes, and in patients with advanced AMD in one eye only, or vision loss due to AMD in one eye.

AREDS was conducted among 4,757 men and women aged 50 to 80 years, with five years of follow-up. Researchers also cited no significant adverse effects, although individuals who smoke or are exposed to asbestos are not advised to consume high levels of betacarotene.

References:

1. American Academy of Ophthalmology, www.aao.org

2. National Eye Institute, US National Institutes of Health, www.nei.nih.gov

3. National Eye Survey 1996

4. WebMD Eye Health Centre, www.webMD.com

5. Vision 2020, www.v2020.org

Toddlers’ negative habits should be managed positively.

MY son is two and a half years old. He likes to bite his lips when he is sleepy. He picked up this habit when I stopped breastfeeding him at about one year old.

He does it often now – when he is alone, sleepy, watching TV or on long car rides.

Can I put some chilli or minyak angin on his lips to discourage him from biting them? – Concerned Mother

WHEN toddlers develop habits such as nail-biting, hair-pulling, thumb-sucking or lip-biting, parents should find out the cause. To change a habit, parents need to know what triggers the behaviour and use only positive management.

Your son started biting his lips at the time when he was weaned and became more self-aware.

Whenever he feels anxious, worried or lonely, he will bite his lips to channel off negative feelings. According to Dr Alicia F. Lieberman, author of The Emotional Life of the Toddler, as toddlers become more competent and aware of things around them, they will develop fears and insecurities.

Their security base is no longer the same. For example, your son used to find comfort in breastfeeding, but now he is no longer able to do so. At two years of age, your son is becoming more competent and independent but still needs to feel reassured.

He worries about a lot of things such as being left alone or travelling for long periods of time in a car.

You may want to help your child deal with the underlying reason for biting his lips, rather than working at stopping the habit. If you nag him about his lip-biting, he may do it more often to comfort himself.

Before you do anything to get rid of your son’s habit, you must recognise his feelings. Acknowledge them whenever possible so that he knows you are aware of how he feels.

When he is afraid, you can tell him: “You don’t like to be left alone. You are afraid that you cannot see Mummy.”

He may get anxious when he is watching something that is scary on television. Say to him: “You don’t like watching that man on television.” Be watchful to ensure that your child is not exposed to violent acts or display of behaviours that are confusing to a toddler. Keep him occupied with songs and simple games during long car journeys.

Your child needs to be occupied so that he does not bite his lips unknowingly. If he is feeling uncomfortable, try to help him relax by making more frequent pit-stops.

Toddlers fare better when they get a chance to run around to relax. They need to be active after sitting passively for a long time in the car.

Dr Lieberman also cautioned parents that toddlers are affected by the intuitive reactions to their behaviour and responses. If you perceive your toddler positively, and love and accept him unconditionally, he will respond in a like manner.

Keep your expectations reasonable and be attuned to your child’s development. Toddlers do better when they are given an alternative that is pleasing. Instead of telling him to stop biting his lips, try giving him a healthy and tempting snack.

If you try to stop his habit with unpleasant solutions such as ointment or hot peppers, it may make matters worse.

• The Malaysian Child Resource Institute is organising a series of Sunrise workshops and seminars for parents in Cheras, Kuala Lumpur, every Friday at 7.30am. For more information, call 03-9132 1748 or e-mail mcri@streamyx.com.

No human is perfect but, with few exceptions, each one is born with the gift of a mother’s perfect, unconditional love.

I COULD never understand before the parents who decide to have a child already diagnosed with Down Syndrome or other defects while still in the mother’s womb.

I especially couldn’t understand how a victim of rape would want to keep her baby, and how parents with physically and mentally challenged children fuss over them with such love and compassion.

With modern technology, defects can be detected in unborn foetuses so why would anyone bother to give birth to an imperfect child?

It wasn’t until God blessed my husband and me with a little one in my womb that I could comprehend the bond between a mother and her unborn child.

By the end of the first trimester, I had undergone so many tests, including screening for Down Syndrome and other defects. As my doctor announced the good news, I was relieved.

Yet, would it really have made a difference if the results had been otherwise? Would I really have terminated the pregnancy just because the child would have been different?

After seeing him via ultrasound, with all his wriggly toes and fingers, would I really want to abort him just because some test results told me he would not be normal?

Not long after that, I had a chance to experience the fear and anguish from the prospect of losing him.

In my 23rd week, shortly after hubby and I enjoyed a short “baby-moon” in Singapore, I noticed some blood stains one Tuesday night but ignored it as it stopped the following day.

I went to work as usual the next two days. I had a fantastic work-out at my step aerobics class on Thursday evening, and then noticed blood clots that night. I was worried but convinced myself that it was just my panicky self overreacting so I slept on it.

The next morning I went to see my doctor. He did an ultrasound and confirmed that baby was fine, facial features already formed. Yup, definitely the father’s nose.

Then he checked me physically and horror flashed across his eyes.

“Girl, you are dilating!”

My doctor’s countenance said it all €“ something was wrong.

I was diagnosed with cervical incompetence. My cervix was dilating prematurely. I was already in labour. Had I came in later, I might have lost the baby.

He needed to perform a cerclage, a cervical stitch right away. If we were to wait until the following Monday, we wouldn’t know what might happen during the weekend.

But there was a risk of losing the baby. During the operation, even after surgery, the procedure might irritate the womb and there might be contractions anyway. And, at just 23 weeks, the baby was not viable.

I was just looking at baby’s face a few minutes ago! I was terrified, not of the operation but of losing the baby.

I called my husband. Our doctor explained everything to him. After the longest 30 minute deliberation, hubby and I decided that the operation had to be done that day.

When we told our doctor of our decision. I remember telling him over and over again to take care of the baby.

Over the next few hours, hubby made numerous phone calls to friends and family.

A lot went through my mind. It was my fault, all my step aerobics classes, my strength training and body combat classes.

I had been warned many times by my doctor and my in-laws, my family, even hubby but I had chosen to worry more about how I would look after pregnancy than my baby’s well-being.

Yes, it was nice having people commenting on how toned and good I looked at 6 months but what’s the point if I were to lose baby?

And then it was time for me to go into the surgery room. It was cold. I was shivering. I was given a spinal anaesthetic that paralysed me from the waist down for two hours. In the operating theatre, I didn’t know where my legs were. I could hear my doctor giving instructions to his nurses, and the sound of scissors snipping away. It must have been the longest 20 minutes of my life.

When it was all over, I was still shivering, probably from the cold of the operating theatre, or maybe it was from fear.

The first thing I asked doctor was whether baby was all right. The news was good €“ baby’s heartbeat was normal, no contractions.

As I was wheeled out of the OT, I saw my husband. He had stayed outside all along, with no lunch yet. He was obviously worried as well, but him being him he wasn’t about to show any emotions. But he was with me the whole time.

My in-laws had been lighting candles and saying prayers and so was I. Never had I been so “prayerful” in my entire life.

I was soon discharged. I have to go back for weekly check-ups, and I was put on strict bed rest over the next few weeks.

I encountered many sleepless nights as I didn’t know how contractions would feel like. I worried about the stitch tearing, about my waterbag leaking.

At the same time, it was difficult to stay in bed all day, and I was not supposed to step out of the house.

I’ve always been a hyperactive person. If I wasn’t at the gym, I would be singing in the choir, or I would be cleaning the house and preparing baby’s nursery, or shopping for baby’s stuff. Unable to do all these, I spent a lot time crying instead.

I am hitting 30 weeks now, but I have been advised not to go back to work until baby is delivered. It hasn’t been easy as I miss work, I miss human interaction, and I definitely miss my daily activities.

But perhaps this is a blessing in disguise. Now, I know what mother’s love is.

Today, I cannot understand those mothers who dump their babies. Or those unmarried (and married) mothers who carelessly get themselves pregnant and then terminate their healthy pregnancies, time and again. I definitely cannot understand mothers who abuse their own children.

For me, a mother’s love for her unborn child is so sacred and pure that it transcends all things, seen and unseen.

This page is for stories that are heart-warming or thought-provoking. If you have an original one to share, write, in not more than 900 words, and e-mail it to starmag-heart@thestar.com.my. Include your full name, IC number, address, and contact phone number. Stories without these details will not be entertained.

Never be too busy to build bonds with your children.

I WAS aghast when I came across a recent newspaper report that parents spent an average of just eight minutes a day with their children.

What were the parents doing the rest of the 23 hours and 52 minutes? No wonder we read in the papers about children who have gone astray and parents lamenting that they are not able to control their children.

Parents should take full responsibility for taking care of their children. Parenting is a huge on-going task and if one cannot come to terms with that, then one should never embark on being parents.

Below are some guidelines for parents.

Know your child. Who is his best friend in school? Who does he hang around with after school? Better still, meet his friends and have them come over to your place.

Make your home a place where they can hang out and if possible, cook a meal or two for your children’s friends. Also, know who their parents are and more importantly, the contact number and addresses of their buddies so that if anything goes awry you can contact them.

Their friends will think twice if they want to do anything out of the ordinary, after having being acquainted with you.

When was the last time you visited the school? Some parents make it a point to go when they have to collect the report card. Others turn up during the annual Parent Teacher Association meeting. Some never make an appearance in school.

Being an ex-teacher myself, I find that it is imperative for parents to come and meet the teachers, and not only when they are summoned to. When the parents take the trouble to meet the teachers, the teachers will take extra care over the student. Also, the pupil will be wary now that the teacher has met his parents and will think twice before he does mischief or play truant in school.

Aside from that, what about the tuition teachers? Many parents faithfully send their children for tuition and feel they have done their duty. Make it a point to see the tuition teacher to check on your child’s progress. These can be topics of conversation with your children.

One way to make sure that you spend time with your offspring is to have at least one meal with them. Dinner would be good but if you cannot fit it in during weekdays, then try the weekends.

Better still, prepare your children’s favourite dishes, if you know what they are. Sit and chat with them. A joke or two would be good. If you can do that with your friends, why can’t you do that with your family members?

I also advocate visiting the grandparents during the weekends; family bonds are ever so important.

Take the initiative to organise family dos, for example, a picnic with cousins or a barbecue with uncles and aunts. Or there might be enough cousins to have a football game, with fathers and uncles included.

Finally, parents nowadays tend to indulge their children. When both parents are working, they shed their guilt of not spending time with their children by giving them more money than they need. There are expensive toys for the younger ones and PlayStations for the older kids. Many youngsters today are armed with the latest handphones.

Parents should keep a check on their children’s expenditure; perhaps then there will be fewer youths who smoke or while away their time at Internet cafes. We could even eradicate the problem of Mat Rempit if parents keep an eye on their children’s whereabouts.

And so I urge all parents to spend more time with their children. Do not live to regret that you did not have time for them in their formative years.

Marcelen Cox sums it up when she says: “Parents are so busy with the physical rearing of children that they miss the glory of parenthood, just as the grandeur of the trees is lost when raking leaves.”

The best inheritance parents can give their children is to spend time with them.

Osteoarthritis may seem to be just a symptom of ageing, but like any medical condition, it needs medical attention.

IF you have known or lived with men and women nearing their retirement age or beyond, you will find many who have experienced the agony of muscle and joint pain.

Their complaints are strikingly similar. Common grouses include pain in their elbows after lifting heavy objects, pain in their knees after a day on their feet and inability to bend down or squat. Some even have difficulty in bending their fingers or reaching for things on higher shelves.

Unlike chest pain, pain in the muscle and joints is often accepted as part and parcel of ageing. It does not create the urgency for those who experience them to consult a doctor immediately – at least not until the pain becomes unbearable and their daily lives are affected.

However, if you are above 50 and have joint pains, the bad news is that you may have some form of arthritis (arthro: joint; itis: inflammation). The good news is, you don’t have to worry about joint replacements yet if you get appropriate treatment early.

“Osteoarthritis (OA) is one of the major causes of disability around the globe that is affecting mankind physically, mentally, socially and financially,” said consultant orthopaedic surgeon Dr Saket Jati.

While rheumatoid arthritis are mostly seen in people about 12 to 40 years of age, people who have osteoarthritis are mostly above 35, said Dr Jati.

In Malaysia, an estimated 60% of the population will have some form of arthritis by the age of 60, particularly osteoarthritis (more than 20%). Rheumatoid arthritis (RA), on the other hand, affects 1% of our population and can affect all age groups.

As there is no cure for osteoarthritis yet, conventional treatments are aimed at giving patients the means to achieve pain-control, increase mobility and maintain a good quality of life. Early diagnosis is the first step in ensuring appropriate treatment.

Osteoarthritis

The joints are essentially two bones with cartilage and fluid in between held together by connective tissue to allow movement and provide support to our body.

Cartilage at the ends of bones and (synovial) fluids in between them act as shock absorbers and lubricants to ensure the bones move in tandem smoothly.

When you have OA, you are experiencing a gradual loss of cartilage from your joints as your cartilage loses its ability to repair itself normally. The smooth surface of cartilage becomes rough and causes irritation to your joint. And with less “cushion” in between, bones eventually rub against each other when you move or carry weight, causing pain and difficulty.

There are two types of OA – primary or idiopathic OA and secondary OA. Idiopathic OA has no identifiable cause while secondary OA can be caused by specific underlying conditions – including previous joint injuries, joint conditions that are present at birth and joint conditions that occur during growth.

Regardless of type, OA is a chronic condition that can gradually worsen over time. Common symptoms of OA are:

• Pain in a joint during or after use, or after a period of inactivity
• Tenderness in the joint when you apply light pressure
• Stiffness in a joint that may be most noticeable when you wake up in the morning or after a period of inactivity
• Loss of flexibility may make it difficult to use the joint
• Grating sensation (crepitus) when you use the joint
• Bone spurs, which appear as hard lumps, may form around the affected joint
• Swelling (effusion) in the affected joints in some cases

Any joint can be affected by OA, but the most commonly affected ones are joints in the hands,

hips, knees and spine.

The pattern of joint involvement varies between individuals, but unlike rheumatoid arthritis (RA), it often affects joints on one side of the body differently than the other side. There may also be enlargement of finger joints in some OA patients.

Not just an old people’s disease

According to a review paper published by the American Academy of Family Physicians, the exact etiology (cause) of osteoarthritis is unknown. Although OA is strongly associated with the wear and tear of joints through the course of life, it is no longer considered a normal part of ageing, wrote Dr Kenneth C. Kalunian in his osteoarthritis patient information sheet found at clinical information resource website, UpToDate. “Studies suggest that the risk of OA is also influenced by other factors, including heredity, obesity and occupation,” Dr Kalunian explained.

In the same write-up, Dr Kalunian noted that most people with OA have one or more of the following risk factors.

Age. While statistics show that at least 80% of people over age 55 have some x-ray evidence of OA, advancing age remains one of the strongest risk factors of the disorder. Nevertheless, despite an abnormal x-ray, many people have no joint pain or impaired function.

Gender. For unknown reasons, the chances of women developing OA are between two and three times more than men. However, according to the Arthritis Foundation of Malaysia, more than half of men over 65 also developed osteoarthritis.

Obesity. Although the association between obesity and the risk of OA varies for different joints, studies have found that the risk of developing OA is decreased in women who lost weight. Obesity also appears to increase the risk of pain and disabilities to those with OA.

Other risk factors include previous joint injury, higher bone mass, muscle weakness, occupations that require frequent squatting or kneeling and other activities that require heavy lifting, prolonged standing or walking several miles a day.

Sports could also predispose some to the risk of developing OA. According to Dr Kalunian, the risk of developing OA in people involved in certain sports such as wrestling, boxing, cycling, gymnastics and ballet dancing is increased.

But you do not need to hang up your ballet shoes just yet. The risk of developing OA in these sports depend on the initial health of your knee joints and the type of activity (low-impact or high impact).

Repetitive low-impact activity (activities that do not impose high-impact forces on the joints) like cycling is associated with an increased risk of OA in people who have pre-existing knee abnormalities, but not in those who have healthy knees [2].

In contrast, repetitive high-impact activities like wrestling and boxing is associated with an increased risk in both people with or without pre-existing knee abnormalities.

Diagnosing osteoarthritis

It is difficult to identify a definitive diagnostic test because the signs and symptoms could be caused by various kinds of diseases.

Therefore, the diagnosis of OA is based on a consideration of several factors, which include the evaluation of signs and symptoms, results of laboratory tests and x-rays.

Laboratory tests indirectly aid the diagnosis of OA by helping to rule out conditions with similar symptoms. Common tests are the erythrocyte sedimentation rate (ESR) test, rheumatoid factor, and synovial fluid analysis (examination of the fluid in the joints).

Blood tests like the ESR and rheumatoid factor can help doctors distinguish whether your arthritis is a case of OA or RA.

“OA usually do not show blood abnormality,” said President of the Arthritis Foundation of Malaysia and consultant rheumatologist Dr Chow Sook Khuan.

She also added that a synovial fluid analysis will only be performed to exclude other associated conditions like septic arthritis and co-existing inflammatory arthritis. X-rays are helpful for determining the severity of OA in advanced cases, but it is not routinely done for people without symptoms because changes may not be present on x-rays in the early stages of OA.

Treatment and practical solutions

To find out the nature and extent of muskuloskeletal (muscle and bone) pain in Malaysia, consultant rheumatologist Dr Kiran Veerapan, along with Richard Wigley and Hans Valkenburg embarked on a COPCORD (Community Oriented Programme for the Control of Rheumatic Diseases) survey in year 1988.

The survey results, published in the Journal of Rheumatology in the year 2007, showed that 58.8% of those who have rheumatic pain in the study self-medicate with over-the-counter analgesics or other medications that they acquired without prescription.

But is self-medication advisable? According to Dr Chow, although mild analgesics like paracetamol is allowed to relieve pain, if a person has persistent joint pain, especially with signs such as joint swelling, significant morning joint stiffness (more than 30 -60 minutes from awake in morning), loss of joint function (regardless of one or more joints affected), this person must seek medical advice as all those signs and symptoms imply more serious arthritis.

“Early treatment of a serious arthritis can prevent structural damage of the affected joint,” Dr Chow said.

If you are diagnosed with OA, make sure you are well informed about the natural course of osteoarthritis. You can learn about ways to manage your condition and have realistic expectations of the treatments your doctors can offer.

For mild OA pain that is bothersome, but not enough to affect your daily activities, your doctor may prescribe rest, exercise, losing weight, using heat and cold to manage the pain, physiotherapy, over-the-counter pain creams and braces or shoe inserts [1].

While applying heat is often the common method used for pain relief in our community, cold packs can also do the trick. However, if you have poor circulation or numbness, do not use cold treatments. Heat treatment should also be warm, not hot [1].

If the pain persists despite initial treatment, you may require medications for pain-control or to slow down cartilage degradation. “Medicines are used to provide a pain-free, more mobile, efficient and effective lifestyle,” said Dr Jati, adding that analgesics (painkillers) and anti-inflammatory agents should be used with caution as they have possible side-effects.

While there are no proven disease modifying agents for OA, glucosamine, chondroitin sulfate, diacerin and esterified fatty acids may ease pain in some individuals and slow down cartilage degradation in some early cases if they combine the use of medication with non-drug measures, says Dr Chow.

According to Dr Chow, intra-articular steroid injections (injecting small amounts of steroid to the affected joint) can also be used to treat the inflammatory flare-ups associated with knee OA, but it must be done by a trained doctor in accordance to certain guidelines.

However, studies show that the injections are effective only for the short term.

“Early treatment in the form of knee strengthening through exercises is useful. Drug therapy does not halt OA, but since exacerbation prevent people from exercising, pain relief is important,” says Dr Kiran, who is a consultant rheumatologist now based in Canada.

Surgery may be an option for severe OA that is not relieved by other treatments. Joint replacement and debridement (removing loose pieces of cartilage and bone from around your joint) are among the surgical options available [1].

Although medical advances have provided physicians means to help you relieve or lessen the pain caused by OA, a major component of OA treatment lies in your attitude towards the condition.

A positive attitude will go a long way to help you cope with OA. More importantly, it determines how much impact OA will have on your everyday life, despite the pain and disability.

For more information about osteoarthritis, you can visit the Arthritis Foundation of Malaysia website www.afm.org.my.

References:

1. Osteoarthritis, by Mayoclinic.com; http://www.mayoclinic.com/health/osteoarthritis/DS00019

2. Patient information: Features and diagnosis of osteoarthritis, by Kenneth C Kalunian, M.D.; http://www.uptodate.com/patients/content/topic.do?topicKey=arth_rhe/2266

3. Osteoarthritis: Diagnosis and therapeutic considerations, by Ralph Hinton et al., American Academy of Family Physicians; http://www.aafp.org/afp/20020301/841.html

4. Musculoskeletal Pain in Malaysia: A COPCORD Survey, by Dr Kiran Veerapen, Richard D Wigley, and Hans Valkenburg, The Journal of Rheumatology. http://www.jrheum.com/abstracts/abstracts07/207.html

Where do parents’ rights end and children’s rights begin?

WE LIVE in a world filled with different ways of expressing life. Every parent has his or her own way of raising children.

There are parents who believe that children should be told what to do and set right by strict disciplinary rules.

Other parents prefer to raise their children by offering them guidance in making their own choices.

We would like to think that every child is safe under the protection and guidance of his or her parents. But sadly, with the rising number of child abuse and neglect cases in our society, we must view with seriousness how parents deal with their children.

There have been too many incidents where the rights of children were violated. We cannot condone any form of violence against children.

The United Nations Declaration of the Rights of the Child states that “children have the right to special protection, and facilities to enable them to develop in a healthy and normal manner, in freedom and dignity” and “love and understanding and an atmosphere of affection and security, in the care and under the responsibility of their parents whenever possible.”

One parent I talked to was of the opinion that children will become spoilt brats if the cane is not used to discipline them.

She said she was a responsible adult whose parents used physical punishment on her. Her young boys know how to behave because they fear the cane.

Another parent said she chose to raise her children without the cane because she did not want them to fear her, the way she feared her own father.

She wanted a different kind of relationship with her children, one that stems from respect and not fear.

Her father used to hit her to manage her misbehaviour. As an adult, she still finds it hard to communicate her feelings and opinions to him.

Parents are caretakers of their children’s rights. Joan E. Durrant, a child-clinical psychologist who authored a parents’ manual on positive discipline (Save the Children, Sweden, 2007), stated that parents need help with parenting.

She wrote that many parents still rely on instincts or their childhood experiences. They have not given much thought to their reactions to their young children. Sometimes parents may have childhood experiences that are negative and violent.

Parents who have little knowledge of what discipline is all about, end up thinking that scolding and hitting are the only ways to manage their children.

No parent does all the right things and none of the wrong things. We all want to do what is best for our children and ourselves.

To do the job right, parents need information on child development and know-how to set the right goals for their children.

Parents have the right to make choices for their children. It is up to them to ensure their children have a reasonable opportunity to develop in a healthy and normal manner.

These include the right to adequate nutrition, housing, recreation and medical services, as well as love, security, education and protection against abuse and discrimination.

Research studies find that children are sensitive to the way parents deal with their challenging behaviour.

They imitate parental behaviour in using force and anger to solve problems. Many behavioural problems in children are the result of how their parents disciplined them.

Parents can explain things to children and provide them with the resources and knowledge to make informed decisions. They should then respect their children’s choices. As they guide their children based on their own values and beliefs, they should also respect their children’s choices in developing their own values and beliefs.

Do parents have the right to decide the values and traditions by which their children are to be raised, or do children have a right to choose these for themselves?

I believe parents who have positive self-awareness and are confident that they are doing right by their children, can strike a balance between the rights of children and those of parents.

Parents are not only teachers; they are also learners. As we embark on this parenting journey, we will learn many lessons about ourselves and our children.

Excessive self-touching should be viewed seriously.

MY three-and-a-half-year-old son is quite active and adorable. Of late, I caught him playing with his penis. It surprised me and I tried hard to be discreet in handling the situation.

I asked him what he was doing and he replied that he was just playing. He then asked me to turn away or watch TV or carry on with what I was doing and leave him alone to play.

The third time, I caught him off-guard. I asked him why he was playing with his penis, and whether it was itchy. I also enquired whether anyone had touched him there.

He quickly changed topic and ignored me. When I probed further, he said his dad taught him. I asked my hubby and he said he never taught him that.

I then told my son that he lied to me and that it was not right to lie. Then he named his cousin brother. He kept on changing his answers each time I asked him.

Just yesterday, he locked himself in the bedroom. I couldn’t get in and he finally opened the door after one or two minutes.

I asked him what he was doing and if he was playing with his penis again. He said no.

I pulled down his pants and his penis was erect. I then asked him if he enjoyed doing it. He said it was itchy down there.

Is this something unusual or part of growing up? I’m worried that he will continue to do this elsewhere, or when he is on his own.

Both my husband and I never behave badly and we hardly get intimate with him around. I wonder what caused him to react in this manner.

A babysitter is looking after my son. She is also looking after two girls, aged two and four. – Worried Mother

First, start by taking your child to see a medical professional to rule out a medical issue, such as infection or even possible exposure to sexual abuse.

When a preschooler shows excessive self-touching, you have to look into the matter seriously. Barring all medical issues, it is normal for a preschooler to touch himself as he explores and develops body awareness.

Often, young boys will touch, scratch or tug in that area. In the course of doing this, many toddlers and preschoolers discover that they get a pleasant sensation from touching themselves.

Dr Gwen Smith, retired paediatrician, mother of five and grandmother of seven, says that children at this age are discovering their own bodies.

Your son has probably found that this is an interesting part of him. It is not necessary to attribute his behaviour to someone else having taught him to do so.

He has no knowledge of sexual function. His behaviour is not immoral although socially unacceptable to people who are not used to dealing with small children.

Dr Smith added that it is better not to reinforce his interest by paying a lot of attention to his behaviour. Distraction is the best approach. Don’t make him feel guilty. This is often a self-comforting behaviour.

You may also want to consider whether there is any reason for him to need to use a comfort habit at this time. Is there a new sibling or a new teacher in school? Are you moving house?

Find out if your child is upset over certain changes in his daily routines. Don’t call attention to this by discussing it with other adults while he is there and listening. Any sort of attention will reinforce the behaviour.

Avoid confronting your son with questions that may worry or frighten him. You may want to take some time to explain about his body and his private parts. You can also talk about privacy like when he goes to the bathroom.

If you feel uncomfortable with his self-touching, keep him occupied with “hands-on” activities such as playdough, building blocks, craft play and simple cooking activities.

It is also advisable to do spot-checks at his babysitter’s house. Make observations of your son at play with other children as well as his interactions with other adults.

It is important to know what is going on at different times of his life. This will help you deal with the developmental changes in your son.

• There is a parent and child learning together session at Children’s World Kindergarten in Subang Jaya this Saturday, 10am to 12pm. For more information, call Anne (012-653 4975/ 03-8025 9910). This is a community programme.

Lutein’s role in protecting the eyes from age-related macular degeneration begins at birth.

WHEN the macula, the central area of vision found on the retina of the eye, loses its light-sensing cells, this can result in an inability to read, drive, see fine details or recognise faces. This is known as age-related macular degeneration (AMD) and affects those aged 60 and above.

The principle cause of AMD is exposure to blue light which is present in all kinds of lights – from fluorescent light to candle light – and predominantly found in sunlight.

Fruits such as mangoes are rich in lutein.

Unlike ultraviolet (UV) light, blue light is visible. Blue light waves are what make an object appear blue and even in yellow light, you can still find blue light. You don’t need to look directly into a source of light to be affected by its glare because blue light waves are very short and scatter easily.

In the eyes, UV light and infrared light are generally absorbed by the corneas and lens. But blue light or high-energy wavelengths of light which fall in the range of 400-500 nanometers (nm) on the visible light spectrum can pass through the cornea and lens and reach the retina directly.

Melanin, which gives eyes their colour, helps to trap high-energy light rays so that they don’t reach the macula and cause damage. This is why people with fair skin or light-coloured eyes are more susceptible to macular degeneration caused by blue light, as they have less melanin in their irises to protect the macula.

One way to cut down on the exposure to blue light is to wear sunglasses.

Dr Choong Yee Fong, Head of Cataract Service and Paediatric Ophthalmology Service in Selayang Hospital, Kuala Lumpur, says: “Everybody should wear sunglasses, even babies.”

But not all types of sunglasses protect the eyes from blue light. Golfers wear yellow-tinted sunglasses as the colour blue has been shown to block yellow. They are known as blue blockers and come in a variety of tints, including light yellow, dark yellow, amber and plum.

As we age, the lenses in our eyes naturally turn yellow, helping to filter out blue light and protect the retina from damage. But children don’t have the same protection as their lenses are clear and allow blue light to reach the retina.

As the eyes do not stop forming until the age of 18 to 20, any damage to the eyes can affect the quality of vision.

“Children’s eyes are particularly vulnerable to exposure and subsequent damage from blue light as they are born with relatively clear lenses. The amount of blue light reaching the retina at the back of the eye is greater in infants and young children than in adults,” says Dr Choong.

Studies have show that 60% to 70% of blue light reaches the back of the eye in children between the ages of two and 10, compared to only 20% in adults between the ages of 60 and 90. Hence, there is a need to protect children from the damaging effects of blue light as it affects their eyes the most during their early years of childhood.

Looking into lutein

Lutein, (pronounced “loo-teen”) from the Latin lutea meaning “yellow,” is one of 600 naturally-occurring carotenoids (a natural colorant or pigment) found in dark green, leafy vegetables and fruits that are yellow, red or orange in colour.

“It protects the retina and reduces the chances of macular degeneration, therefore providing the eyes with a window of protection,” says Dr Choong.

The benefits of lutein are different from that of vitamin A (beta-carotene) as the former protects the macula by absorbing and filtering blue light, while the latter is responsible for a person’s ability to see.

Lutein is concentrated in the outer plexiform layer of the retina, the layer before the light hits the photoreceptors.

The best source of lutein is mother’s breast milk.

Prof Dr Eric Louis Lien, of the Department of Food Sciences and Human Nutrition, University of Illinois, Urbana, says: “I would advise mothers to feed their babies exclusively with breast milk for the first six months. That will give them the protection they need. Of course, the mother also needs to eat more fruits and vegetables, which is another source of lutein, to increase the level of lutein in her breast milk.”

Lutein cannot be manufactured by the body and must be obtained from foods that are rich in lutein such as kale, spinach, bok choy, mangoes, tomatoes and carrots. As most children are averse to eating their greens, parents have to find creative ways to disguise vegetables in their children’s meals.

Although lutein has an accumulative effect in the retina, the eye’s built-in defence mechanism can weaken with age, neglect, injury and disease. A fresh supply of lutein daily will help top up your lutein “bank account” and ensure your retina is constantly shielded from the damaging effects of blue light.

Study shows angst-ridden teens have different brain structures.

IT TURNS out your mother was right: angst-ridden teens really do have something wrong with their heads.

A study found that teens who regularly get into fights with their parents have significantly different brain structures than their more laid-back peers.

Australian researchers mapped the brains of some 137 early teens and then videotaped them during “problem-solving” conversations with their parents about disagreements over issues like homework, bedtimes, or Internet and cell phone use.

“What we found was there was actually a relationship between the size and the structure of the various parts of the brain and the way the kids behave in these interactions,” said lead researcher Nicholas Allen of the University of Melbourne.

The parts of the brain which are involved in emotional responses were much more developed in the teens who got into fights with their parents, Allen said.

“Their emotions are developing much faster than are the parts of the brain that help them to manage those emotions,” he said.

“That’s the kind of thing that hopefully catches up later on, but in between you’ve got this mismatch between the two.”

The findings should offer some comfort to parents trying to understand why their once-cheerful children are suddenly transformed into sulky, over-sensitive strangers, especially since this mismatch is usually resolved by the time the brain finishes developing in the mid-20s.

“Many parents do find it a comforting thought to be told that it’s not necessarily abnormal or a reflection of the child’s character that they’re being grumpy and surly because they are going through a biological change which is a fairly significant one,” he said.

“(But) there are all sorts of things that can influence grumpiness.

“It might be that the family has developed a poor pattern of interaction, it might be that the kid is lazy, or the kid needs to be taught more responsibility or to respect others more.”

It’s also possible that these biological changes are in response to the home environment, Allen said of the study published by the Proceedings of the National Academy of Sciences.

Other studies have found that extreme neglect and sexual and physical abuse can impact brain development. A stressful home environment has also been linked to the early onset of puberty in girls, he said.

“What we don’t know anything about is, is there an affect about the more normal variations in the family environment on the way the brain develops,” he said.

“We’re not sure if the environment is affecting the biology or the biology is affecting the environment. Probably the most likely truth is they both affect each other.”

Allen hopes to find some answers to these questions as his team delves deeper into a long-term study of these youth and their families.

They will be closely analysing the family interactions to see if there is a link between parenting skills or styles, and the emotional and biological development of the teens. – AFP

Getting your toddler to eat need not be a war of wills.

PETER made a face when he detected something green in his fried rice. No, it was not a worm, just a harmless shred of spinach. Peter is becoming extremely fussy with food. Welcome to the world of toddlers!

As a baby grows into a toddler, you will see dramatic changes in his eating habits. Easy spoon-feeding becomes history as your toddler starts self-feeding.

He begins to express his preference for a certain food to the extent of wanting it everyday while waging war against others, usually vegetables.

Sometimes he licks his plate clean but generally you find him eating less now. He kicks up a fuss when he sees his chicken “touching” the carrot on his plate.

Or a tantrum erupts when gravy is drizzled over his rice. And he drives you to boiling point by playing with food that you have painstakingly prepared. Is your little one becoming a monster? No, he is just maturing.

For a smoother ride through this picky eating phase, let’s look at it from Mum’s angle and from junior’s perspective.

Mum has junior’s nutritional interests at heart. She believes that junior needs good nutrition for optimum growth and development. So when junior refuses food, Mum resorts to coaxing, cajoling, bribing, threatening and lastly forcing him to eat.

This sets off mealtime battles. Moreover, up till now, junior has depended fully on Mum for food and everything else. So Mum feels unprepared and challenged by junior’s sudden urge for independence. She finds it hard to relinquish her control over him.

On the other hand, junior is suddenly aware of the many things around him that are begging to be explored. Sure, he feels hungry at times but discovery, fun and new experiences are top priorities now.

Through them, he makes remarkable progress mentally, physically, emotionally and socially. So food takes a back seat. In fact, his declining appetite is normal and in tandem with his slower growth rate at this stage.

To be precise, junior experiences growth spurts, during which he grows very rapidly over several weeks, and that accounts for his good appetite then, before lapsing into slow growth mode again.

But for sure, junior will never starve himself. If only Mum knows this, she will have more peace of mind and nag less.

Once you understand that junior’s changing attitude towards food is a part of his development, you will be able to manage his quirky eating habits better.

Mealtimes should be happy times. You should impart positive attitudes towards food and create pleasant eating experiences for your child so that he grows up healthy and with high self-esteem.

For example, a child who is not force-fed but instead is allowed to use his own discretion on how much to eat, will feel more confident and in control.

By heeding his natural fullness and hunger signals, he will less likely become obese. In contrast, a child who has to fight constantly at the dining table would tend to become stubborn or defiant because if we look deeper, mealtime battles are not only about food but are actually wars of wills between mother and child.

So how do we fill a fussy toddler’s tummy and make his mealtime happy?

Here are some tips to help you.

· Accept your changing role, from spoon-feeding a baby to supervising a self-feeding toddler. This will reduce force-feeding and fights.

· Keep mealtimes regular and have variety to stimulate appetite.

· Introduce new foods alongside familiar ones and make foods easy to eat.

· A tired toddler has no interest in food. Let him rest well before serving him food.

· Food refusal may be a gimmick to get attention. If so, hug or play more with the little one to solve the problem.

· If junior boycotts vegetables, grate, chop or mash them. Then sneak the vegetables into soups, porridge, sandwiches or pies.

· Shapes and colours appeal to kids. Employ them in your choice of foods and crockery.

· Use interesting, child-friendly crockery. A melamine plate with different compartments will prevent foods from “touching” each other. Junior will also get to appreciate the unique taste of each food.

· Serve child-sized portions of food. Do not worry that your child is not eating enough. By nature, babies and young children eat when hungry, stop when full.

Lastly, set a good example yourself. Little junior is watching closely. – Article courtesy of Nestle Nutrition

How to ensure a complete and balanced nutrition plan for children.

PARENTING these days is no longer as straightforward as it seems. Our lifestyles have changed so much with the arrival of fast food restaurants, satellite TV and computer games that it is often quite a challenge for parents to practise or even remember the golden rules of nutrition for their children.

As a reminder of how we can help our children receive the daily vitality they need for a good head-start in life, it is important that we keep up with our parental lessons in nutrition. This article, as the last in the series on nutrition, reprises some of the points that have been discussed so far.

The balancing act

The Food Guide Pyramid is still the best reference for planning balanced meals. It depicts four basic food groups along with how much to eat from each group.

Always top up on fruits and vegetables to ensure proper intake of dietary fibre and essential vitamins and minerals, and cut back on empty sugars and starches and hydrogenated fats (from deep fried foods).

Remember to fortify your healthy food intake by incorporating healthy eating habits through practising balance, moderation and variety for ample nutrient availability, a healthy weight maintenance and proper digestion. And follow that up with regular exercise as it is the all-important other component to optimal health.

Power up with breakfast

There is good reason why breakfast is called “break fast”. It is because your child has been “fasting” for the last eight hours or more the night before. Eating food in the morning breaks that fast, pumping in the fuel his body needs to power him on for tackling the day’s activities, whether they be school work or exams or sports and other play activities.

Well-nourished children go into class alert and better focused and they seldom fall sick due to immune system problems triggered by lifestyle stressors and of course, poor nutrition.

However, what is preached must also be practised. Children are influenced by role models. When they see their own parents eating breakfast, they are more likely to eat breakfast themselves and carry on the habit for life.

Happiness equals health

Mental stressors do cause immunodeficiency. Unhappy homes filled with fighting and quarrelling, an autocratic parent, constant criticisms and loneliness can bring on headaches, indigestion, diarrhoea, depression and eating problems, killing off or upping appetites that can start a vicious cycle of repetitive illness and malnutrition.

Children who manage stress well have good physical and mental health. They usually have a healthy self-esteem and a sense of humour, and have a consistent and cohesive family structure with open communication lines in the family.

Sense and sensibility

At the end of the day, ensuring a complete and balanced nutrition for our children comes with applying common sense.

Forbidding certain foods is almost guaranteed to send your children bingeing on these foods. Rather than taking the extreme measure of forbidding foods, allow for limited consumption and offer alternatives in the form of tasty but healthy snacks and desserts.

Eating together as a family provides quality family time for all as feelings of unity and belonging are fostered across the dinner table. It is also a chance for parents to lead by example, showing good attitudes towards food, and displaying appropriate table manners and social skills.

Furthermore, meals prepared and eaten at home are more nutritious as parents have control, ensuring the use of healthful ingredients without the need for deep frying and the over-use of salt. More fruits and vegetables can be served alongside complex carbohydrates and quality protein and food hygiene observed.

Finally, having a good night’s sleep is the round-up needed for total well being. No amount of nutrition will be of any good if the body is ravaged and worn out. Sleep gives the body the chance to repair, recoup and rebuild, affecting not just the physical but the emotional and spiritual levels as well. For this reason, sleep has been hailed as the silent healer.

Handling picky eating

Picky eating is usually an issue with parents of young children. Persistent picky eating may lead to limited or imbalanced nutrient intake.

However, the problem is transient as picky eating is a phase that occurs in about 25% of children aged from three to seven years of age. The habit rarely extends to adolescence or adulthood. Some ways to overcome picky eating are as follows:

How to help your child overcome her fear of washing hair.

MY daughter will be four years old in two months’ time. She is terrified of washing her hair. This has been a problem for her from very young.

I have tried many ways to get her to relax when taking a shower. For example, she role-plays washing hair for her Barbie doll, plays with her toys in the bathtub and sing songs.

When I asked her why she was so scared of washing her hair, she told me she was afraid that water would get into her eyes. She asked me to get her a pair of goggles. – Worried Mother

Your daughter may have gotten soap suds into her eyes, nose or mouth when washing her hair. Listen carefully to what she has to tell you about her problems with hair washing.

Don’t be too quick to brush aside her feelings. She may be sensitive to the way you approach her problem. The more time you spend listening attentively to your child, the better she will feel.

Many children around this age have problems with water and soap getting into their eyes. They worry even at the anticipation of having their hair washed. Sometimes no amount of coaxing can convince them.

Your child needs to feel she is in control when it comes to washing her hair. You can make suggestions but the final decision lies with her. When one way does not work, try another. Let her find the most suitable way to wash her hair so that she will be reassured that she will not get water into her eyes.

Try out her suggestion of using goggles. Focus on the best way for her to have her hair washed. A suggestion coming from your daughter is always worth trying because she feels she has the power to make a change.

Offer to let her wash your hair to show you how she wants her hair washed. Organise a family hair wash session where everyone gets a hair wash. Explore different ways of washing hair, for example, using a towel to cover the face or having hair washed with the head tilted to the back. This is a fun way for everyone in the family to help your daughter work out her problem.

You may want to give her a mirror to look at how her hair is being washed while you are doing it. Children feel less fear when they can see what is going on.

Use a cooperative approach instead of providing her with the answers that you think may work. Be patient with her. It may take some time before she feels reassured. Children in their early childhood years build their confidence gradually but surely.

To settle her fears, you need to help her work on possible solutions. Avoid telling her what is best for her; rather, let her try to work it out using different approaches. While it may take time for her to let go of her fears, your support and trust can make a big difference.

Games can teach children the spirit of cooperation.

YOUNG children play games mainly for fun. Many children’s games help them learn to problem-solve, and develop motor and language skills. However, competition is often the focus of most games our children play.

Childhood games such as musical chairs or cat-and-mouse emphasise on winning. At the end of the game, those who lose will be sidelined and often feel like failures.

Children need games that focus on getting along and playing as a team. Instead of pushing or trying to outdo each other, children can also enjoy games that require them to help one another achieve success. Children as young as two years of age can care and feel for others.

The game of musical chairs, often played at children’s parties, can be upsetting to those who get eliminated because they did not sit on a chair when the music stopped.

This game focuses on who ends up as the winner and does not centre on children’s involvement. Children would shove and push one another to get a seat so that they can win.

Parents should consider games that are not only fun but encourage children to be part of a community. While we are eager to get our children to develop competitive skills, we do not want them to trample on others along the way.

Children can learn from an early age that they garner more from helping others to succeed than concentrating on self-gain only.

Here are some suggestions on how to make games less competitive and teach children to be more cooperative:

Musical chairs

Tell children that this game will require them to work together to find a place for everyone. They can be creative in the way they all sit together.

Set up two lines of chairs for as many children there are in the game. As the music plays, the children will walk around the chairs.

Remove one chair before the music stops. Everyone will find a place for one another to sit down. They can share their seats. By the end of the game, when there is only one chair left, children can decide what they want to do so everyone can still be together.

Mother, may I?

The whole family can play this game. For starters, a parent can take the lead by giving out the instructions. All the other players will stand a distance from the parent. One by one, each player will ask: “Mother, may I?”

The parent will say, “Yes, you may. Take a baby (small) step/mama (medium) step/papa (large) step.”

As each player approaches the parent, she/he gives him a peck on the cheek. The last player gets a big hug to end the game. Everyone applauds when the last player reaches the parent. This game is great fun for very young children and pre-schoolers.

Eeney Teeny Miney Moe

A game of tag on the reverse. The “key” player, who has his eyes closed, will choose from the circle of players by chanting, “Eeney Teeny Miney Moe!”

If his or her finger is on a player, he will touch the other person’s hand. If the key player can tell who the person is, the other person will take over his place. Everyone gets a turn to be the key player.

I ‘8’ it

This is a game of cooperation for a group of nine children. One player becomes the storyteller and tells a story, such as “I went to the market and bought home a big fish. I placed the fish on my dining table, and then I went to take a shower. When I got back, all I found was a fish bone on the table. I wonder who did it?”

Each player sitting in a row will use a number in his reply, “I ‘one’ it” until the last player says, “I ‘eight’ (sounds like ate) it.” Children in their late pre-school years and early primary school years enjoy playing this story-telling game immensely. Each child can tell his or her own story.

Mirror, mirror

This is a game for partners to imitate each other’s movements as quickly as possible. A more challenging version for older children is to eliminate the leader. Players are to move and simultaneously mimic each other.

The gift box

Make a gift box with a mirror inside it. Have the children sit in a circle. As each of them open the lid and look inside the box, they will marvel at the wonderful present that awaits them.

Each player has to say something nice about what is inside without revealing what they see. Of course, each player gets to see his or her own image.

A great game for primary school-age children who often make negative remarks about themselves.

Picky eaters can develop problems in growth and development, including social and academic performance.

MOST mothers will agree that it is nerve-wracking when their child refuses to eat or is extremely fussy about food. Besides normal weight gain, meeting the nutritional needs of the child is the other main concern.

“Probably the most universal complaint of parents is that their child is not eating the food, or amount of food, offered,” said Prof Dr Mauro Fisberg, paediatric nutritionist and head of the paediatrics department at Federal University of Sao Paulo, Brazil.

There are many ways to get a picky eater to finish his meal.

Dr Fisberg was invited by PaediaSure Complete (Abbott Nutrition) to come to Kuala Lumpur recently to share his expertise on the latest developments on picky eating and other feeding problems.

An author of six books on children’s eating disorders, Dr Fisberg said that in general, paediatric clinics record about 10% to 25% of children as being picky eaters.

“Picky eating is becoming a major concern because it can contribute to under-nutrition, (thus) impairing children’s growth and development which includes social and academic performance as well,” he said.

Studies have shown that picky eating can lead to growth complications, increased chronic illness and increased risk of developing eating disorders later in life.

In some cases, picky eating may also cause short-term nutritional deficiencies and produce life-long implications such as social and emotional problems, including aversion to touch, lethargy or lack of interest in playing or learning.

There is no standard definition of picky eating but researchers typically examine a variety of factors, including nutrient intake composition, weight of child, food volume and duration of refusal.

These children also tend to eat small amounts, prefer only selected foods such as carbohydrates or dairy products, avoid trying new foods and take a long time to eat their meals.

There is usually a combination of reasons for picky eating, including physiological factors such as appetite, genetics and growth. Psychological issues such as the struggle for autonomy, changing emotions and moods, and level of affection or adverse interaction between mother and child could also lead to the problem.

Children also go through picky eating phases.

“We do not know why a child who has been eating the same food for a few months simply refuses to eat it the next day,” said Dr Fisberg.

However, he said a majority of picky eaters take after examples set by their parents at home, as many studies indicate that food rejection is a learnt behaviour in almost all cases.

“However, contrary to what many people think, we cannot solve problems of poor appetite in a day or even a week,” he said,

“It all starts with recognising that the child has a right to preferences and aversions. Forcing a child to eat what he does not like is not going to make things better. Make a list of his or her preferences and every week, add two new types of food,” he advised.

Dr Fisberg said sometimes the use of oral supplements was important to maintain balanced nutrition in children.

Dr Pedro Alarcon, paediatric gastroenterologist and international medical director with Abbott Nutrition, said a 2003 study conducted in Taiwan and the Philippines showed that nutritional supplementation increased not only the weight but also the height of children.

The study was done on 92 children aged three to five who were classified as picky eaters. The children were separated into two groups and monitored for three months. One group only received nutritional counselling while the other, nutritional counselling combined with nutritional supplement.

After 60 days, the second group of children recorded significant weight gain compared to the first. Both groups also recorded increases in height.

“That was surprising for us too because we were only expecting weight gain,” he said.

In a year, said Dr Alarcon, a child roughly gains 3cm in height but the children in the study gained more than half of that within three months.

Overall, 28% of children in the second group developed upper respiratory infections compared to 51% in the group which only received nutritional counselling.

“Nutrition in the future will not only target, weight, height and less illness in children, but also more body immunity, brain development or even stronger gastrointestinal defence,” said Dr Alarcon.

In another study headed by Dr Fisberg in 2002 on children aged three to five, adding synbiotics (prebiotics and probiotics) to oral supplements showed that there were more sick days recorded in groups which did not take synbiotics. The period of the study was four months.

“Paediatric oral supplementation should be considered as part of a comprehensive strategy when dealing with picky eating to prevent children from becoming undernourished,” said Dr Alarcon.

Dr Fisberg said probably the most prescribed solution by doctors for picky eating is appetite stimulants, mainly to avoid mothers forcing their children to eat.

“I would not recommend that because the stimulants probably work for one or two weeks only, after which the body will adapt to it,” he said, adding that vitamin supplements should only be recommended if the child has a specific vitamin deficiency.

Dr Alarcon added that picky eating in children below one year old is rare and thus should be checked to ensure there were no other health problems.

After one year, a child may also develop some picky eating because that was when they achieve autonomy and have new habits and ability, hence become less interested in food, said Dr Fisberg, adding that weight gain may slow down at that time too.

Generally, when should parents be concerned that their child is having a picky eating problem?

“Usually one month is enough to rule out other possibilities such as medical problems and to see if the picky eating problem is serious,” said Dr Fisberg, who also anchors a television programme called Body Sciences on University TV in Sao Paulo.

Positive reinforcement

Tips to cultivate healthy eating habits:

1. Avoid distractions during mealtime.

2. Adopt a neutral attitude – do not pressure a child to eat.

3. Encourage appetite by limiting snacks and balancing food portions.

4. Limit duration of meal time.

5. Provide age-appropriate foods.

6. Introduce new foods to a child gradually and regularly.

7. Encourage children to eat independently – do not spoonfeed a child who is old enough to use utensils.

8. Allow children to make a mess when they eat.