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Diarrhoea is relatively common in young children and usually passes after a day or two.

Cause

There are numerous possible causes of diarrhoea, including food poisoning, but by far the commonest in children is a viral infection, such as in gastroenteritis. Like vomiting, diarrhoea can accompany many infections, both bacterial and viral. Less commonly it may be a signpost to more serious illness such as appendicitis.

Chronic or persistent diarrhoea commonly follows a bout of gastroenteritis, in which case the persistence of the diarrhoea is due to lactose intolerance. The lining of the wall of the bowel is (temporarily) damaged during the bout of gastro, so that it cannot absorb complex sugars (including lactose). Lactose is a component of milk and causes a watery, often sweet smelling diarrhoea which may burn the child’s buttocks. The treatment is a lactose-free milk (unless the child is still breastfed). The condition usually resolves itself within a few weeks as the lining of the bowel wall heals.

Other causes of chronic diarrhoea include Giardia, coeliac disease, and other less common conditions. Some toddlers with chronic diarrhoea may be drinking too much fruit juice. In many toddlers, no cause for the diarrhoea is found (toddler’s diarrhoea).

Clinical features

Diarrhoea is defined as the passage of large, loose, frequent or watery bowel movements. The colour may vary from brown to green, and the smell can be offensive. The most serious problem associated with diarrhoea is the possibility of it leading to dehydration.

Investigations

If the diarrhoea is due to a specific virus, germ or parasite, stool specimens (see p. 51) may reveal which organism is responsible.

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‘Colic’ is one of the most vexing and difficult problems in infancy, equally common in breastfed and bottle-fed babies. One recent Australian study found that 60% of parents reported that their babies had suffered from ‘colic’. The fact that it is so common is little consolation for parents faced with a baby who is crying, fussing, and irritable for no apparent reason, and who cannot be made to settle. It is very distressing for mothers and other family members, and often exasperating for doctors and nurses as well.

There have been scores of articles and research reports published over the years, yet still little is known about the cause of ‘colic’ and the most appropriate and effective management of it. Everybody has a different view of what ‘colic’ is, and there are many different opinions about virtually every aspect of the condition.

Cause

There have been dozens of opinions expressed as to the cause of ‘colic’, ranging from medical conditions in the baby to maternal anxiety and inappropriate handling of the baby.

Some of the medical reasons given include gastrointestinal (gastrooesophageal reflux, excess gas), infections (ear or urinary tract infections), hernias (inguinal, umbilical), neurological (irritable nervous system, neurological immaturity), allergy (mother’s diet, milk given to baby), nappy rash and other sources of irritation. Crying has been blamed on feeding techniques, either too much milk or milk given in the wrong way. Emotional problems in the mother have been blamed, as has a difficult temperament in the baby. Other babies are said to have a problem of too much wind, though this has never been proven to be a cause.

It is probable that a very small proportion of babies who are said to have ‘colic’ suffer from an identifiable medical problem. However, the common ‘diagnoses’ of too much wind or milk allergy are made far too frequently, with very little evidence that they represent real conditions in this age group. The vast majority of babies have no clearly recognisable cause for their difficult behaviour.

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I’d like to know how anybody with kids ever has sex.

HUSBAND

If having sex was as hard to do before we had kids as it is now, we would have never had kids, because we would never have had sex.

WIFE

In a sense, all sex in a crowded home becomes group sex. Privacy, quiet, and confidentiality are luxuries that few families have, and the more loving, open, and involved the family, the less likely it is that the parent can find much time to have open, free, expressive sex.

Here are some of the types of sexual adjustment to kids and parenting that I noted in the thousand couples. As you read these types, remember the words of David Lodge: “Literature is mostly about having sex, and not much about having children. Life is the other way around.”

The Sneaks: This is the couple who is ever vigilant for an opportunity to “do it” when the kids aren’t around. Their sex life ends up determined by the kids’ schedules, with husband and wife sending immediate “urgent” signals when the kids might be gone for a few hours. Unfortunately, the home schedule may be so hectic that even the “sneaks” run out of time before they run out of chores, and this involuntary “sneaking” for urgent sex can disrupt a more natural flow of sexual interaction between husband and wife.

The Parental Celibates: This couple has given up on sexuality, holding out for the time when all children are gone from the home to college or career. By mutual and usually covert agreement, they have decided that the effort to fit sex in secretly is just too tiring,

or detracts too much from enjoyment of the experience. There may be a few “celibacy slips” when sexual expression is enjoyed, but these events are few and far between.

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Then promise me you will love me forever.

WIFE

As with all events in life, love changes. I mentioned earlier that every love eventually is broken by illness, separation, or death. It is the process of loving that constitutes our wellness, our ability to achieve super marital sex. The process of loving is infinite even if people aren’t.

Marion Richards, in her book Centering, writes, “The product is not what binds the artist to his craft. Nor the actor to the theater. Nor the person to his being. It is the transformations.” We should commit to process, not people, to a process of vulnerability and the sharing of self, not the struggle to keep love alive as somehow separate from us.

Remember, love is a decision and a decision is necessary to end it. Even in grieving, there comes a time when the decision to “un-bond,” must come. Unbonding does not cancel the memory, the love trace, but it requires a change in the relationship because of the loss of the physical presence of the loved person. Ending is as much a part of loving as beginning.

The love decision is never mutual. Author Zick Rubin points out that the decision to separate comes when one partner feels that the costs of being in a relationship exceed the perceived benefits and

one partner is willing to take a chance, to try for another bonding. As I discussed in Chapter Three, we all “dump” and “get dumped.” It is part of the process of loving and being loved. To believe that any relationship or bond is forever is self-deception. To remember that loving is forever is the ultimate human hope.

A bond’s end is one of the most painful of human experiences, but as writer Shirley Luthman writes, “I don’t believe people put themselves through very painful situations unless that is the only way they can learn what they need to know.” Researcher Clark Moustakas states that the very power of the loving process is its continued jeopardy of changing and ending. This is a universal truth for all living systems.

“I never thought I would hurt like this. I feel it everywhere, in every inch of my body. I’m sick, heartsick,” reported the wife. “I’m sorry I ever loved, and I would have never loved if I knew I was going to pay this price.” She should have known. It is the very nature of love to contain in its intensity its own destruction, as a star explodes from its own heat. The decision to end will never be mutual; we all end up hurt. Understanding this will not lessen the pain, but it may free us for a focus on the joy of the process, for it is the process, not the product, that is forever.

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The trigeminal or fifth cranial nerve carries sensation from the face to the brain.

It consists of three separate branches, the upper or ophthalmic branch covers the sensation from the forehead and around the eye, the maxillary or middle branch covers the area over the cheek, and the lower or mandibular branch covers the area of the lower jaw.

Tic douloureux or trigeminal neuralgia is a disorder where there are paroxysms of severe pain in the distribution of the nerve, usually of one branch. The cause is unknown and it tends to affect those over 50 years of age and women more than men.

The spasms of pain may occur spontaneously or may be triggered by eating, smiling or other muscular movements. There may be long remissions between attacks.

There are other causes of pain in the face but the attacks of this disorder are so typical that diagnosis is not usually difficult.

Pain-relieving drugs are of little use, as the attacks come on suddenly and then depart before any pain-relieving drug could work; but considerable relief can usually be obtained by the use of drugs to control epilepsy.

Where this fails to control the paroxysms of pain, injection of the nerve with alcohol or operations to divide the nerve may give relief.

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The Australian College of General Practitioners, in an endeavor to upgrade the status of general practitioners and to broaden their knowledge, has introduced a post-graduate diploma. This is obtained by examination.

But the prerequisite is at least five years’ graduation and at least three years in general practice.

The universities also award post-graduate diplomas, such as the MS (Master of Surgery), the DPM (Diploma of Psychological Medicine), or the DA (Diploma of Anaesthetics). So by checking the letters after a doctor’s name one can usually determine his speciality and how well qualified he is in that branch.

The various medical colleges also conduct training courses and award fellowships to indicate a doctor has gained special knowledge and training and may be considered a specialist in that branch of medicine.

However, it is well to remember that a string of post-graduate diplomas and degrees alone does not necessary make a brilliant doctor.

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Symptoms which might make your doctor suspect lung secondaries are breathlessness, cough (especially coughing up blood) and chest pain. Your doctor may well want to check your lungs even if you have none of these symptoms. This is because they are such a common site and because secondary deposits here may be quite big before they produce any symptoms. Also it is easy to check the lungs—firstly by clinical examination, and secondly with a chest X-ray. Your doctor examines the lungs firstly by tapping his or her fingers. The lungs should sound hollow because they should be full of air. If part of the lung is solid or filled with fluid, it won’t sound hollow. Next, your doctor listens with the stethoscope, to check the sound of your breathing. If the bronchial tubes are narrowed, a whistling sound may be heard through the stethoscope. If part of the lung is not working, the sounds of air moving in and out will be absent there. If the lining of the lung is roughened, a rubbing sound may be heard. Your doctor may ask you to say something—usually ‘ninety-nine’—while he or she listens through the stethoscope. This is because the sound of your voice travels better through solid lung than through fluid.

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Fat babies often grow up to be obese adults and the idea that a fat baby is a healthy baby is fast disappearing among parents.

Unfortunately, in the process, many parents have been made to feel guilty.

Recent advice to parents has been that the child should stay on the breast for as long as possible, the introduction of solids should be delayed and, when baby signals he is full, feeding should be discontinued.

This is still good advice, but may not prevent obesity.

A recent Canadian trial appears to indicate that differing feeding techniques seem to have little influence on whether a child gets fat or not.

What is suggested is that fat babies, like fat teenagers and adults, seem to have less activity than their thinner contemporaries.

I know that I, along with many doctors, have indicated disbelief when confronted by a grossly overweight individual who protests: “But doctor, I really don’t eat much.” This may be true more often than we were inclined to believe.

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1. Partitioning procedures or gastroplasties

These produce a small stomach pouch of 15-30cc connected to the lower pan of the stomach by a narrow opening or ‘stoma’. The effect of these procedures is to limit the patient to a very small meal which empties only slowly through the narrow stoma producing a feeling of satiety lasting 3-4 hours. Total daily food intake is, therefore, vastly reduced.

In order to achieve a good weight reduction with these procedures, patients must be prepared to make sacrifices and to be disciplined in the way in which they eat. This is not an easy way out and the patient must be strongly motivated to lose weight otherwise they may not feel that the sacrifices are worth while. They must:

• Adhere to a diet of easily masticated foodstuffs such as cereals, vegetables and white meats. Red meat is difficult to eat and the diet can seem boring.

• Measure food volumes and eat no more than 5 dessertspoons of food per meal. To eat more may cause vomiting and may stretch the pouch.

• Chew each small mouthful of food to a pulp before swallowing otherwise the food pieces may block the stoma causing vomiting and pain.

• Avoid high calorie semi-liquid foods such as chocolate and ice cream as these liquefy and pass rapidly through the stoma, causing weight regain or preventing weight loss.

• Avoid solids when rushed or upset as vorniting is more likely in this situation.

• Take daily multivitamins and occasionally take iron if required.

With discipline, excellent weight reduction can be achieved with the average loss being 35kg and some patients losing much more. Two common methods used are ‘stapling’ and ‘banding’.

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Some scientists have decided to use a 50 grams carbohydrate portion of white bread as the reference food because it is more physiological—typical of what we actually eat On this scale, where the G.I. factor of white bread is set as 100, some foods will have a G.I. value over 100 because their effect on blood sugar levels is higher than that of bread.

The use of two standards has caused some confusion but it is possible to convert from one to the other using the factor 1.4 (100/70—white bread has a G.I. value of 70 when glucose is the reference food).

To avoid confusion throughout this book, we refer to all foods according to a standard where glucose equals 100.

he higher the G.I. factor, the higher the blood sugar levels after consumption of the food. Foods with a high G.I. usually have both a higher peak and maintain a higher blood sugar level for longer.

Rice Bubbles (G.I. factor equals 89) and baked potatoes (G.I. factor equals 85) have very high G.I. factors, meaning their effect on blood sugar levels is almost as high as that of an equal amount of pure glucose (yes, you read it correctly).

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