Index:

HEALTHY LIFE:
Child's fears and anxieties // My child doesn't want to go to school // Limits and rules!!!  // Oral hygiene // What about tantrums?// Mealtimes // Children and the sun//  Help the child to give up the dummy // Sleep time // Potty Training // It's time to play
SAFETY:
Travel pharmacy bag // Transportation in the car// Preventing child drowning // Correct use of the expansion chamber
HEALTH PROBLEMS:
Anaphylaxis// Scabies //The child hit his/her head // Childhood obesity //  My child has diarrhoea // Painful pronation // Does my child have chickenpox? // Managing fever in Paediatrics

HEALTHY LIFE

Child’s fears and anxieties

Text by Paediatrician: Dr. Luís Gonçalves

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Anxiety and fear can arise at any time in the child's life.

Understand that your child is having a hard time. He/she is not being deliberately tricky or difficult. He/she is having a hard time and needs your help.
By talking about what worries the child, you are demonstrating that you care about them and this will help them feel supported.

Don't expect things to change overnight. Stay calm and encourage the child not to give up.
Help the child make a list of concerns and fears so that he/she can express their feelings and then find solutions for each one.

Do not criticize, mock or humiliate the child with what causes their anxiety. A fear is a fear, whether you understand it or not, and can be the source of a lot of emotional turmoil.

Draw a picture of these worries and a picture of your child overcoming fear. Place this drawing in a visible place at home.
Remember to value your child for using new strategies and trying to overcome their difficulties. Reward and praise these efforts.

Tell him/her: When you notice that you have “negative thoughts”, like “I will fail”, say: “STOP!”. Imagine a STOP sign in your head or imagine saying STOP loudly. Immediately replace negative thinking with a more positive or pleasant one, for example "I will make an effort" or "I can do it".

Practice "going to a happy place” that is calm and tranquil, real or imaginary.

Practice relaxation exercises.

My child doesn’t want to go to school

Text by Paediatrician: Dr. Luís Gonçalves

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Work out what discourages your child and show him/her the positive aspects of school, cultivate an interest in learning and school from an early age.

Try to understand the origin of the refusal to go to school. In a friendly and calm way, do not devalue what your child says, listen carefully and try to understand his/her discomfort.

Get to know the classroom environment and interaction with peers, as well as the most used teaching methods.

It may be important to share the situation with the teacher but be careful that your child does not feel embarrassed by this.

Help your child to study and develop his/her study methods, thus increasing his/her ability to understand and be interested in the subjects and increase his/her success, always taking care so that these moments do not turn into disagreements or feel like some sort of punishment - always highlighting the importance of autonomy.

Help the child to organize a study schedule so that he/she can achieve a balance between schoolwork and free time.

Make your home available for group work, study or even leisure.

Find out with your child what he/she likes to do and provide busy moments with these activities.

Promote visits, trips to places that promote fun learning so you can increase the interest in learning.

What are your interests and your child's vocation? What does it take to get there? Do research together, clarify doubts.

Limits and Rules

Text by Paediatrician: Dr. Luís Gonçalves

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Every day, over time, promote conversation and the relationship with your child, put yourself in his/her place, so that they feel safe and supported by their parents.

>> Negotiate – If there is no negotiation, it will be very difficult to comply with what was stipulated by you. Establish times for departures, appropriate to their age, situation and depending on the results achieved during the week.

>> Naturally promote dialogue, without him/her feeling the pressure of having to answer a survey, creating the habit of leaving each other notes or messages, promoting periodic conversations.

>> Accountability – Sentences like “because I said so” or “just do as you’re told” do not help to build healthy relationships between parents and children. Choose to say: "it is the best decision considering the other options" ... or, "so tell me, why do you disagree?" or even, “we will look at all the options together”. Try to hold him/her accountable, transmitting confidence and, in the first phase, give them responsibilities that they know they will be able to fulfil, thus promoting success.

>> Shouting and accusations add nothing to communication.

>> Pass on to your child the importance of feeling good about who he/she is, of thinking for themselves and making their own decisions.

>> Show an interest in what your child says and what happens to them. Meet your child's group of friends. At this stage of childhood, friends are very important and significant figures in the construction of identity.

Oral hygiene

Text by Paediatrician: Dr. Pedro Costa e Cruz

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Why?
The brushing of teeth is a decisive factor in preventing cavities and is part of an adequate oral hygiene routine that must be implemented as soon as it is necessary.

When?
As soon as the first tooth comes through. At that point, it is important to brush your teeth twice a day (with bedtime brushing being the mandatory one). Brushing the pre-eruption gums is not mandatory, but it can soothe some of the gum discomfort that precedes the eruption of the tooth.

How?
The way of washing depends on the child's age and autonomy. So, according to the Norms of the General Health Directorate:

• Up to 3 years of age: Brushing must be performed by parents, using an appropriately sized soft finger or brush.
• From 3-6 years old: Encourage the child's progressive acquisition of autonomy, properly supervised and using a soft brush of adequate size. At these ages, an electric brush can be used.
• From 6 years old: Brushing by the child, supervised on a regular basis.

The toothpaste to be used must contain fluoride (1000 ppm in the first 6 years and 1500 ppm in the following years). The amount is, as a rule, similar to the size of the child's little fingernail.

First visit to the Dentist?
In the absence of pathology, the first visit to the Dentist should occur from the age of 3-4 years (age at which, in most cases, there is collaboration by the child).

What about tantrums?

Text by Paediatrician: Dr. Luís Gonçalves

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Tantrums are inevitable !!
The secret is in the management of tantrums! And above all, changing the child's “interest / tantrum focus” at that moment to “another” that may be more attractive!

Parents must be consistent and coherent in applying the rules and limits and fully comply with what they have stipulated. There should be no opposing views from the parent (at least in front of the child!)

Remember that the punishment / consequence must be proportional to the severity of the tantrum and not to the adult's frustration. Your child must clearly understand the consequences of his/her inappropriate behaviour, so as not to repeat it (he/she knows they will have a consequence).

Parents should clearly communicate their confidence in their child's cooperation by saying “when… (e.g., you do this), then afterwards (e.g., you can go and play)” instead of “if you don't ... you can't” .

Avoid / Pre-empt the tantrum by providing warnings that an activity / game will end soon – thus giving the child time to get used to the idea. 

Any efforts by your child to cooperate should be noted and valued by parents.

In the same way, instructions must be formulated positively, avoiding the use of "stop" and "do not do". When giving an order, be gentle, respectful, but firm. Give your child time to respond to instructions.

Avoid too many questions and arguments. Verbal battles should be avoided, and your child should be given clear instructions, not more than twice, of what it is you would like them to do.

Ignore the provocation. Parents should remain calm and ignore any irritation or protest at what they have said.

Mealtimes

Text by Paediatrician: Dr. Luís Gonçalves

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Food is not just about nutrition; it should also be a moment of pleasure!

But this is not always the case. And for all of us parents, mealtime can become a real torment for us and our children.

The main rule is to know that there are no rules. However, it must be: to believe that we will all be able to feed our children, just like other parents and other families do!

The second rule should be to persist, persist and persist without being forceful... and never give up! It has been proven that it takes 8 to 11 attempts to get used to a new food! The sweet taste is innate, however it is necessary to learn to like others (salty, acidic, bitter), as this takes time. Today we can manage one, two spoonful’s, tomorrow we will manage some more for sure.

When the child does not have any neuromotor disorder, there is no reason why he/she should not eat according to the paediatrician's recommended diet plan.

From the age of one, the child is prepared to try “food from the pot”, that is, he/she must have a diet equal to that of their family, as long as it is seasoned, with small amounts of salt and fat and sugars are avoided.

Learn some "tricks" to make mealtimes moments of harmony and family health. Read the full article AND MEALTIME IS... A MOMENT OF PLEASURE OR BATTLE? Written by Dr. Luís Gonçalves.

Children and the sun

Text by Paediatrician: Dr. Víctor Miranda

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Children should spend most of their time outdoors. Sun exposure is beneficial for the production of vitamin D, essential for healthy bone growth.

However, children's skin is more sensitive and thinner, and should be protected from an early age, with some authors suggesting that children up to 3 years old should not have direct sun exposure.

The damage caused by overexposure accumulates, which can damage the eyes and the skin, causing sunburn and increasing the risk of skin cancer in adulthood.

However, the degree of sensitivity of children's skin is variable. The most susceptible children have fair skin, with signs or freckles, blue / green eyes, are red heads or blond and have a family history of melanoma.

What care should we take?

1. Avoid sun exposure between 11am and 5pm, because UV radiation is more intense during this period.
2. Use sunscreen on exposed skin areas on the beach, at the pool and when doing outdoor activities, even on overcast days. You should choose a product with protection against UVA and UVB, with a factor greater than 30 (the higher factors are more effective in protecting against sunburn), water resistant and hypoallergenic. Up to 2 years old, mineral sunscreens (based on titanium dioxide or zinc oxide) are recommended. Children who have signs or spots should use a higher protection factor.
3. Apply the sunscreen about 30 minutes before sun exposure and reapply as regularly as needed (bathing, perspiration), but at least every two hours. Special attention should be paid to cover all the regions most prone to sunburn: face, nose, ears, neck, shoulders, hands, feet, flexion zones.
4. Under 6 months the child should always be in the shade. Sunscreen can be placed on the exposed areas, as part of the solar radiation is reflected by the sand, water and floor.
5. The most suitable equipment includes wearing protective clothing (protecting arms, torso and legs), wide-brimmed hat to protect the face, nose, ears and neck, sunglasses with adequate protection against UV rays.
6. Reinforce water intake to prevent dehydration.
7. Parents and caregivers should set an example, also protecting themselves appropriately.

The education of children on the risks of sun exposure is part of child prevention measures, so that they can enjoy outdoor activities in a safe and healthy way.

Help the child to give up the dummy

Text by Paediatrician: Dr. Luís Gonçalves

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Giving up a dummy can be a time of great anxiety and tension for many children. Here are some tips for parents and educators: 

• Do not force or use drastic methods, such as placing substances with an unpleasant taste on the dummy, this does not work.
• If the dummy is used to help them fall asleep, while trying to leave it, give the child some treats at bedtime; read with them, talk to them or tell them a story.
• Avoid criticism and negative comments, such as “Oh, you look ugly with that dummy” or “You look like a baby”.
• Gradually begin to restrict the use of the dummy. Propose to keep it in a place agreed by both of you and only use it when it is very necessary (when you go to sleep, when you are sadder, sicker or scared).
• You can exchange the dummy for another toy that your child wants, but never make this attitude a habit, so that they don’t use the power of the dummy to achieve all their wishes.
• With your child, agree on a date to give up the dummy, motivating him to do so, but without pressure, praising them for being grown up and giving them strength, support and confidence to do so on the agreed date.
• Little by little, give examples of people that your child admires who managed to give up their dummy (like an older brother, for example, or a cousin), also conveying the idea that it was difficult for them, so that he/she doesn't feel inferior in any way.
• Never forget to praise your child for every progress and reward them with treats and activities together.

Finally, after having a good conversation at home with your child, you can enjoy coming to HPA Gambelas and leaving the dummy on our “Magical Pomegranate tree”, just like other children who also went through the same “weaning”.

Sleep time

Text by Paediatrician: Dr. Luís Gonçalves

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The time to go to bed, but they are not tired yet...

Pre-empt what will happen. "In 10 minutes, it's time to go to sleep." Your child will feel less tense if they know what is about to happen, they will lie down with less resistance and will fall asleep more quickly.

Schedules
Set and stick to a time for bedtime routines to start.

Routines
Brushing your teeth, changing your nappy, putting on your pyjamas, are signs that tell you bedtime is approaching. Be consistent with sticking to daily routines.
Turn down the lights in the room and check the room temperature, which should not be too hot or cold.

Share a quiet activity in the room. Choose something simple, fun and that will entertain your child without provoking excitement.

The simple habit of reading a story before bedtime can help the child to feel calm, at a time that is often associated with insecurities or fears of the dark.

Talk about the day that is ending and the good times ahead for the next day.
Encourage your child to give a kiss / hugs good night to the rest of the family.

Some children also like to wish the moon and stars, their favourite doll or pet a good night.

Sweet Dreams!

Potty training

Text by Paediatrician: Dr. Luís Gonçalves

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Giving up the nappy (Potty Training) is just another step in your child's life…

This is a continuous and sometimes slow process, so start introducing the habit of the potty, asking how their tummy is doing, if they already feel the tightness of being full.

Giving up nappies requires training, and while some children need a few days to succeed, others need months.
At an early stage, you can set times (for example, after meals) to sit the child on the potty, without a nappy, while singing or reading a story. Make it a habit to do it in the bathroom.

You can use books with pictures on the theme to motivate the child. And exemplify that all members of the family (parents, siblings ...) have the same habit!
Use a colourful potty, display images related to the theme that the child can imitate (for example: child lowering his pants, child sitting on the potty, child washing their hands, etc.).

Buy underwear with the child's favourite characters. Enthuse him/her with the use of the underwear and not the nappy, as if it were a game!

Whenever progress is made (even if it is a rough attempt at success), tell them how well they are doing and how proud you are. But do not overdo the praise, as it may make the child anxious and afraid of failing.

React in a serene and positive way to “accidents” during the training phase. Accidents will happen!! Minimize dirt and stress.

Good luck!

It’s time to play

Text by Paediatrician: Dr. Luís Gonçalves

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When it’s time to play, don't think about anything else or do anything other than play with your child. Take the opportunity to release the child in you!

Playing teaches the child to wait for their turn and to develop other social interaction skills and behaviour that can teach them rules of social coexistence.

Allow your child to take the lead with the game and follow their cues / opinions. In this game, do not control, give instructions or direct your child.

Decide what your child will be doing throughout the game; decide what you’re doing when it’s your turn.

When they seem to be having a hard time, mention it and offer words of encouragement and strength. Supporting and encouraging children's exploration of problems tends to increase their problem-solving skills.

Praise when they succeed, no matter how big or small that success may be.
 
Express your emotions when playing!! And have fun...

SAFETY

Travel pharmacy bag

Text by Paediatrician: Dra. Inês Serras

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Traveling is more and more frequent, whether for work or holiday, particularly with children.

What to take as medication for the trip usually comes at the time of packing, for those traveling with children.

The needs of each family will depend on the ages of the children, the destination and the duration of the trip.

When traveling abroad, we must take into account that the food, the climate and the customs may be different from ours, which may entail some increased health risks. In order to protect ourselves from any unforeseen circumstances, we must know what diseases may arise and the health resources that exist in the region.

In general, the travel pharmacy bag may contain:

• Single vials of saline, thermometer, bandage, disinfectant single vials (e.g. Betadine), bandages, sterile compresses, scissors, tweezers, etc.
• Antipyretics / anti-inflammatories: paracetamol and ibuprofen with reference to doses according to the child's weight (very useful in situations of fever or acute pain - ear pain, sore throat, etc.).
• Oral antihistamines or ointment in case of allergy
• Probiotic and oral rehydration solution, for cases of diarrhoea and vomiting
• Usual medication, in the case of pre-existing illness or other medications that may be useful, according to the child's history.
• Repellent with adequate protection against insects that transmit malaria, dengue and yellow fever in endemic countries. The repellent must contain DEET or IR3535.
• Sunscreen and moisturiser after sun exposure
• Nasal decongestant, for nasal congestion
• Laxative / enemas for constipation issues

Before traveling, you should contact your paediatrician, in order to personalise this list, according to your child's possible needs.

Pay special attention to medicine packaging.

In the case of air travel, remember that there are specific rules for the transport of medication in hand luggage, in order to be able to access the drugs during the trip, or in case of loss / delay of hold baggage (you can consult the specifications of each airline in the respective website).

Ideally, you should have a copy of the prescription, containing the name of the active substance and the dose of the usual medications, for security control at the airport.

Solid medications, such as pills or capsules, have no restrictions. The same is not true in the case of syrups, carried in hand luggage. These must be transported in sealed packages, with a maximum volume of 100mL (a maximum of 1 Litre per passenger), in a plastic bag, similar to hygiene items.

If you are going to travel within Europe, consider taking the European Health Insurance Card (link on the website), which allows you to access public health care in the country where you are located. If traveling outside Europe, it is advisable to take out travel insurance.

A very complete source of travel information can be found at: www.travelhealthpro.org.uk

Transportation in the car

Text by Paediatrician: Dra. Inês Serras

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Because children are our greatest treasures, transporting them safely is a priority. Road accidents are the leading cause of mortality in children under 10 years of age, demonstrating the importance of meticulous compliance with all recommended rules, regardless of the length of the journey.

The rules for transporting children in the car have undergone some changes over time. In Portugal, the transportation of children is regulated in article 55 of the Highway Code. Children under 12 years of age and under 135 cm in height must be transported by an approved restraint system adapted to their size and weight.

Currently, there are 2 types of regulations for the approval of child restraint systems (SRC):

>> ECE Regulation R44-04 older, which classifies SRC by weight groups, and according to the variety of car models (universal, semi-universal and specific to some vehicles) in which they can be installed.

>> Regulation ECE R129 (better known as i-Size): most recent, the future. It aims to simplify the entire process of choosing and using child restraint systems.

Chairs homologated by Regulation R44-04

Seats homologated by the Regulation R 129

Ten steps for choosing the appropriate restraint system (car seat) for your child:

1. Check which CRS is suitable for your child, given their weight and height.
2. The car seat must be approved according to regulations R44-04 or ideally R129. Check the label.
3. Choose a seat that can be turned in the opposite direction of travel for as long a period as possible.
4. It is not advisable to use second-hand chairs or those over 4-6 years old, as they may not provide the necessary protection.
5. Make sure your child is properly attached to the restraint system (ideally a 5-point belt)
6. Check SRC compatibility with your vehicle.
7. Make sure your child is comfortable.
8. In the case of lift seats, the use of backrest lifts is recommended.
9. Look for “seats” that passed the Swedish “Plus test” (only valid in rear facing seats)
10. Buy your seat at a specialty store, where they can help you choose the most suitable option.

Frequently asked questions regarding the transport of children and CRS

How should I transport my child, forward or rear facing?
The child must travel in the opposite direction to that being driven for as long as possible, which, in the most recent recommendation, will be at least until the age of 15 months. It is even demonstrated that this benefit exists up to 3-4 years. This is the safest form of transport, not only due to the disproportionately large size of the head compared to the body, at younger ages, but also due to the immaturity and weakness of the neck muscles to better support the weight of the head, in a situation of sudden braking or accident.

Can I transport my child in the front seat?
The safest and mandatory option will be transportation in the rear seats. There are only 2 exceptions in which the child will be able to travel in the front seat: in the case of being less than 3 years old and being in an SRC in the opposite direction of travel, safeguarding that the passenger's airbag is deactivated; or in the case of age over 3 years, when there are no seat belts in the rear seat or in the case of a commercial vehicle.

Which is the safest rear seat?
The rear seat considered to be the safest is the one in the middle position, due to the greater distance from the collision site during a side impact. However, this seat often does not have an ISOFIX system. As for the sides, left vs. right, with the entry and exit of passengers on the pavement side being the safest, this would be the ideal choice for placing the SRC.

When should I change my seat?
This transition should be made when the top of the head is above the upper edge of the back of the seat, or when the shoulders exceed the height of the belt slots by more than 2cm when they are already in their highest position.

Until when do I have to transport my child to an SRC?
The most certain answer is that you should keep the car seat for as long as possible, as long as the child remains comfortable. However, Portuguese legislation only requires its use up to 12 years old or 135 cm in height.

To learn more about child road safety you can consult:
www.ansr.pt; www.apsi.org.pt: 

Preventing child drowning

Text by Paediatrician: Dr. Pedro Costa e Cruz

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Drowning is the second leading cause of accidental death in children, with the majority of cases occurring in June, July and August.

Drowning is a very quick and silent event that can occur in very small amounts of water (a small child can drown in less than a foot of water). In recent years, efforts have been made to promote preventive measures, highlighting the important role of the Association for the Promotion of Child Safety (APSI) - according to the same, there have been, in the last 15 years, 238 drownings with fatal outcome, in addition to 572 hospitalizations following deaths due to submersion episodes (many with permanent sequential neurological injuries).

What measures, then, can we take to minimize drowning?

• Identify high-risk groups: age group 0-4 years old, male, adjacent chronic diseases (epilepsy, cardiac arrhythmias).
• Recognition of the most problematic places: swimming pools, followed by rivers, streams and lagoons and, finally, the beaches. At home, buckets or tanks with water and full bathtubs.
• Prevention at multiple levels:
• Physical environment: minimize contact with potentially dangerous spaces through the installation of physical barriers, such as self-closing gates and fences around swimming pools, tanks and wells.
• Parental: constant supervision of children in the vicinity of risky places, avoid the presence of dolls or buoys in water (which may attract the child). Discourage diving without prior knowledge of the water depth.
• Development of skills in the child / adolescent: Know how to identify the danger, promote basic notions of swimming (especially after 12 months of age), aquatic safety and safe rescue, stimulate the request for early help, avoid areas without supervision.
• Use of appropriate material: Personal flotation devices (life jackets).
• Parents and caregivers with cardiopulmonary resuscitation training.
• Raise public awareness and highlight children's vulnerability.

Drowning is, in fact, preventable.

We must recognize the need for the implementation of preventive measures so that we can all provide healthy and safe growth for our children.

Correct use of the expansion chamber

Text by Paediatrician: Dra. Inês Serras e Dr. Luís Gonçalves

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The inhalation method is the one used for administering drugs for the treatment of respiratory diseases.

There are two forms of administration: by aerosol or via an expansion chamber. The aerosol is less and less recommended, as it is more expensive and time-consuming to administer. The expansion chamber is the preferred means of administration, as it is faster, more practical and more comfortable for the child. The sizes of the chambers vary according to the child's age:

• 0-18 months: small mask (yellow)
• 1-5 years: medium mask (orange)
• Above 5 years: without mask the application is oral.

The effectiveness of the treatment depends on the correct use of the device. You should always take your inhalation device when you go to consultations / permanent care.

Preparation

The child should be standing or sitting, ideally calm.

• Remove the cylindrical container from the packaging, heat it between your hands and adapt it again; remove the protective cap and with the inhaler upright (L) insert the mouthpiece at the back of the expansion chamber
• If the child is under 5 years old, adapt the mask to the mouth of the expansion chamber. The mask must adapt to the face so that there are no leaks. Apply the mask to the child's face.
• If the child is over 5 years old, apply the mouthpiece of the expanding chamber between the teeth, with the tongue under it.

Taking medication

• Press the inhaler only once (1 "puff")
• If the child is under 5 years old: wait for 5 slow breaths (the valve must move during breathing)
• If the child is over 5 years old: ask them to inhale slowly and pause 4 seconds, keeping their lips tightly closed.
• If more than one puff has been prescribed, remove from the mouth and wait 30 seconds to 1 minute for further inhalation.
• Shake the inhaler and repeat steps 1 and 2/3.

Cleaning the chamber

• Disassemble all possible parts and place them in a container with warm water and dishwashing liquid for 15 minutes.

HEALTH PROBLEMS

Anaphylaxis

Text by Paediatrician: Dr. João Tavares

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What is Anaphylaxis?
It is an immediate, acute and systemic hypersensitivity reaction, in which the signs and symptoms reflect the physiological effects of the release of cellular mediators (peripheral mast cells and basophils from the blood) that cause vasodilation and smooth muscle spasm, particularly at the bronchial level. It occurs after exposure to a specific antigen.

What are the causes?
The most common causes are hypersensitivity to food, drugs and stings. Among the food antigens, the most common are eggs, milk, nuts, peanuts and seafood, rarely presenting before 12 months of age. Antibiotics, namely penicillin and cephalosporins, and topical anaesthetics are frequent agents at later ages.

What are the symptoms?
Symptoms usually appear seconds to minutes after exposure to the antigen (which may or may not have been previously known). There is usually flushing, itching that is localized to generalized, cutaneous lesions, dizziness, tearing, red eye, lip and perioral oedema. It may be associated with shortness of breath, difficulty in swallowing, cramps, nausea, vomiting. Anaphylactic shock, angioedema and bronchial obstruction are usually manifestations of serious illness and, in these cases, represent a paediatric emergency.

How can I help my child? Should I go to the hospital?
If an anaphylactic reaction is suspected, medical observation should take place. In mild cases, supportive treatment may be sufficient, and an analytical study may help to define the ethology. The treatment of choice is adrenaline (increases peripheral vascular resistance, relaxes smooth muscle and relieves oedema and urticaria) and can be administered through injectable pens previously prescribed by the attending physician or in a hospital setting in cases with no prior history.

Depending on the severity of the situation, there may be additional therapies. Due to the risk of biphasic reaction with reappearance of symptoms 6-24 hours after the initial manifestation, they should be kept under clinical observation during this period.

What happens after discharge?
Confirmed cases of anaphylaxis should be referred to an Immuno-allergology consultation, in order to identify / optimize eviction of the antigen and conduct of action in the event of a new anaphylactic reaction.
For further clarification, consult your attending physician.

Scabies

Text by Paediatrician: Dr. João Tavares

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What is Scabies?
Scabies, also known as sarcoptosis, is a cutaneous ectoparasitosis caused by the Sarcoptes scabiei variant hominis, with high worldwide incidence and is frequent in paediatric ages. It is highly contagious, with transmission by direct skin contact or, less frequently, by fomites, that is, through surfaces/objects, reaching all age groups and social classes.

How can it manifest itself?
It is usually manifested by an initially localised rash (with posterior spread), which is very itchy and frequently affects multiple cohabitants or those who have had direct contact. In the youngest children (usually in the first two years of life), this may be more predominant on the palms and soles and may be associated with a non-specific conditions, itchiness being often absent and, initially manifested as sleep/eating disorders and irritability. Even after effective treatment, itchy skin can be maintained for 2-4 weeks after treatment, without indicating a lack of cure.

How is the diagnosis made and where should I go?
The diagnosis is clinical and can be made by a paediatrician / dermatologist. You can go to the Permanent Assistance Service or schedule a Paediatrics / Dermatology appointment. After the treatment is carried out, a clinical reassessment is recommended after two weeks to confirm the cure. In particular cases, due to clinical doubt or lack of therapeutic response, confirmation by microscopic observation may be used.

How is it treated?
Curative treatment is generally topical, adapted to age and on a case-by-case basis, and is generally extended to the entire household (classmates and asymptomatic teachers do not require treatment). Supportive treatment should not be overlooked, with a view to minimizing itching and associated secondary injuries and optimizing skin regeneration. Concomitant treatment of fomites (sheets, clothes, etc.) is essential to prevent reinfection.

Can the child return to school after treatment?
After 24 hours of effective treatment, the child can return to school activities and parents can return to their daily routines - all without restrictions.

For further clarification, consult your attending physician.

The child hit his/her head

Text by Paediatrician: Dr. António Salgado

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Head injuries are common in paediatrics, especially in the first years of life, mainly due to accidents.

Most of them are mild and without consequences, but a major cause for concern for parents, with some symptoms that, if present, should prompt a check-up by a medical professional, due to the increased risk of intracranial injury.

After a head injury, children and/or young people should be monitored for signs and symptoms that can determine the severity of the situation. These, although more frequent in the first 12 hours after the trauma, should be monitored until about 48 hours later.

If present, they may require an image examination.

Therefore, they must be observed if:

• Exaggerated drowsiness with difficulty awakening and outside the usual sleep times
• Change in habitual behaviour (agitation, irritability)
• Persistent vomiting (3 or more)
• Severe and worsening headache (no improvement with paracetamol)
• Seizure or fainting
• Lack of strength or “numbness” on one side of the body
• Change in vision, speech or gait (imbalance)
• Exit of blood or liquid through the nose or ear
• If he/she is less than 2 years old and there is a bulging of the anterior fontanelle (“soft spot”)
• Haematoma (bruising) on the head that was not previously present
• High impact fall: drop of more than 90 centimetres in children under 2 years old or more than 1.5 meters in children over 2 years old, road accident, being hit by a moving vehicle or a penetrating wound
• If you have a bleeding wound or enlarging bruise

If you do not have any of these signs and symptoms, you can apply ice on the spot, administer paracetamol (except when the headache worsens - should be checked by a medical professional) and promote a calm environment.

Do not forget that prevention is better than cure.

Children should always wear a helmet when they ride a bicycle or skateboard, they should always have an adult nearby when they ride, comply with safety rules for transportation by car and the rules of traffic should be taught as soon as they are understood, stairway barriers should be put in place and infants should never be left on high places without adult supervision.

Childhood obesity

Text by Paediatrician: Dr. Víctor Miranda

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Childhood obesity has become a major public health problem in recent years.

Given the current knowledge that wrong eating habits and being overweight can have a detrimental effect on life, it is essential to give due importance to this topic.

The calculation of the body mass index, based on height and weight, is the parameter that defines excess weight and obesity, according to percentile curves adjusted for the child's age and gender.

Overweight and obese children are at increased risk for various diseases in paediatric and adult age, including asthma, high blood pressure, osteoarticular pathology (knees and back), liver disease, sleep apnoea, diabetes, myocardial infarction and some types cancer.

The balance between genetic factors, food intake (in quantity and quality) and physical activity, result in an appropriate or exaggerated weight in each situation. In assessing excess weight and obesity, additional tests may be necessary to understand the case in question more completely.

To help children have a healthy weight, it is necessary to invest in adequate food (with several servings of fruit and vegetables a day, it is important to make good choices in the food bought for home), in reducing “screen time” and sedentary activities , schedule daily physical activity, drink water (avoid juices and soft drinks), promote adequate hours of sleep.

The goals must be realistic and phased, and the whole family must be involved in the purpose of achieving a healthier weight for the child. You can always seek help from your attending physician and nutritionist / exercise technicians.

My child has diarrhoea

Text by Paediatrician: Dr. António Salgado

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What is diarrhoea?
Diarrhoea is an increase in the volume of stools compared to what is normal for your child.

In babies, who usually have more intestinal transits, it means that the stools are more watery or even more frequent.

Older infants may show only an increase in the number of daily stools (usually 3 or more).

What causes diarrhoea?
The most common causes of diarrhoea are viral infections and side effects after taking antibiotics. Bacterial infections are less frequent.
 
If the dejections are accompanied by blood and mucus (similar to “snot”), the probability of bacterial infection is greater and the child must be observed and eventually, a culture from the faeces collected, to exclude these causes.

What should I do?
Your child can continue to eat a normal diet, namely: white meats, rice, bread, pasta, milk and yogurt (lactose free), fruits and vegetables (except, for example, some fruits such as plum and green leafy vegetables). Fatty foods and sugary drinks should be avoided.

If he/she is being breastfed, you must maintain this.
Food should be offered, without insisting, as he/she may have less appetite.

Liquids should be reinforced, being offered more times a day and an oral hydration solution (which exists to promote balanced hydration) can be administered.

To promote normalisation of intestinal transit, pre and probiotics can be administered (with several options available).

There are other medications, such as antisecretaries, among others, that should be administered only on the recommendation of your doctor..

When should he/she be checked?

• If he/she shows signs of dehydration, such as dry tongue, crying without tears, less urination, sunken eyes or depressed fontanelle (“soft spot”)
• If he/she is prostrate (sleepy and less reactive to stimuli) or with irritability and moaning.
• If the bowel movements are very frequent (more than 6 in 12 hours) and/or they leak out of the nappy.
• If there is persistent vomiting (after the second consecutive)
• If the diarrhoea is bloody.
• If he/she is less than 12 months old and has not eaten or drunk anything for more than a few hours.
• If he/she has continuous, severe and/or persistent abdominal pain.
• If he/she has a high fever (> 39.5 ° axillary) which is proving difficult to lower (even after medication). 

Painful pronation

Text by Paediatrician: Dr. João Tavares

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What is painful pronation?
Painful pronation is an elbow injury that occurs frequently and exclusively at paediatric age. It is a subluxation (partial separation of articular surfaces) of the head of one of the bones of the forearm, the radius, in the area of ​​the elbow. It is the most frequent elbow injury in children and usually occurs between 12 months and 4 years.

Under what circumstances does it occur?
It usually occurs when the child's upper limb is suddenly pulled upwards when the child's forearm is prone (that is, with the palm of the hand pointing backwards). This movement is frequent when the child is lifted off the ground by the hands, with the elbows stretched (common when he stumbles and is pulled by the hand so as not to fall to the ground) or, in a similar movement, when he “hangs” by one or both hands in a higher place.

Why does it happen?
With the previously described movement, the head of the radius is pulled out and the ligament that “holds” it in place (annular ligament) slides into the joint, staying between the two structures and preventing the return of the radius head to its natural position. This is because the ligament in children is thin and elastic. With growth, it becomes thicker and stronger, so the injury does not happen when you are older.

How does it manifest itself?
After the injury, the child will feel pain if he tries to supine the forearm (movement contrary to pronation, that is, turning the palm forward), because they will be 'tightening' the ligament that left the site. Thus, the child avoids making this movement and will tend not to use the involved limb, keeping it still, next to the body, with the elbow extended or slightly flexed and the forearm in pronation. Usually, parents notice that if they offer the child a toy, they always use the other arm.

How is it diagnosed?
The diagnosis is clinical, that is, through the physical examination of the child and the clinical history provided by the parents. Routine radiography or other complementary diagnostic tests are not required. If the trauma was more complex than a simple "pull", there may be a bone fracture - but in this case, there are other findings on physical examination, such as joint swelling and local pain, even with the arm at rest.

How is it treated?
The treatment consists of a manoeuvre performed by a doctor. There is no need for anaesthesia or sedation - although it is painful for the child, the manoeuvre is quick. Specific manipulation is performed on the affected upper limb, which returns the structures to their normal position. The success of the manoeuvre is confirmed when the child moves the arm again, which usually occurs a few minutes later - some children may take longer than others to move the arm, for fear that it will hurt again. After that, it is not necessary to immobilize the arm or take rest.

Can it happen again? How to prevent it?
After the episode, the annular ligament becomes more "lax" so recurrence is more likely. Until the ligament becomes stronger and more tense, which happens at 4-5 years of age, painful pronation can happen again, so it is important to avoid pulling the child by the arm. If the situation is repeated, the child should be taken to the doctor, so that he can perform the manoeuvre - parents should not try to do it, even if they have seen him do it once or more.

Are there any long-term consequences?
No, the child will not have sequelae or limitations in the future, even if the episodes are recurrent.

Does my child have chickenpox?

Text by Paediatrician: Dr. António Salgado

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Chickenpox is an infection caused by the Varicella-Zoster virus. It is very contagious, being contagious through contact with the child's nasal secretions and saliva or with the contents of the skin vesicles.

The first symptoms can appear up to 21 days (3 weeks), after contact with another person with chickenpox.

Initially, red spots appear, dispersed throughout the body, which progressively evolve to papules and small vesicles of transparent content, which subsequently dry up. These cause itching.

A characteristic of chickenpox is that these 4 phases can be observed simultaneously in the same child, which does not happen with other rashes.
They also affect the scalp and mucous membranes (mouth).

It takes an average of 6 to 9 days to heal.

It is a school-avoidance disease and children are contagious until all the vesicles are in a crusted phase.

Symptoms other than itching can be general malaise, fever and pain referred to the mouth (resulting from thrush caused by the virus).

What should I do?
There are some measures that can help to relieve itching, such as: cutting short nails, bathing with warm water and soap-free washing solution, using non-abrasive skin products and strengthening skin hydration.

They must be observed by the doctor, who will eventually prescribe:

• Antihistamine, to prevent itching
• Paracetamol for fever, because ibuprofen should be avoided in this case
• Topical analgesia for thrush
• Moisturizing cream with calamine
• Soap-free washing solution
• Antiviral (acyclovir), if the child is observed within 48 hours of the beginning of the vesicles, which allows to decrease the intensity and duration of the disease, but only if administered at the right time

When should they be seen again?

There may be complications that should prompt a repeat observation, namely:

• Changes in the skin suggestive of infection - marked flushing, swelling, pus or pain
• Peri-ocular vesicles
• Presence of respiratory symptoms, such as coughing, especially if accompanied by persistent fever for more than 3-4 days, with closer peaks and prostration.
• Change in behaviour (increased drowsiness, irritability) or gait balance

Managing fever in Paediatrics

Text by Paediatrician: Dr. António Salgado

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What is fever and how to measure it?
It is the temperature 1°C above the average of the individual daily basal temperature, in the same measurement location.

The following values are considered fever:

• Rectal ≥ 38ºC
• Axillary ≥ 37.6ºC
• Tympanic ≥ 37.8ºC
• Oral ≥ 37.6ºC

Fever is a manifestation of fighting infections and therefore beneficial. When situations with a fever are severe (5% of cases), there are always other associated manifestations, the so-called “warning signs”.

What are the “warning signs” in a child with a fever?
In the presence of one or more of these warning signs, the child should be assessed:

• Irritability and/or groaning
• Excessive drowsiness or inability to fall asleep
• Inconsolable crying / Does not tolerate being picked up
• Pained expression
• Fast breathing with tiredness
• Purple lips or nails and/or intense and prolonged tremors in the thermal rise
• Cloudy and/or smelly urine
• Seizure
• Skin spots in the first 24 to 48 hours of fever
• Repeated vomiting between meals
• Insatiable thirst
• Total food refusal for more than 12 hours
• Difficulty in mobilizing a limb or gait change
• Fever lasting more than 5 days.

In a child with a fever, what are the "soothing signs"?
Although they may be uncomfortable for the child and may require medical observation, these signs suggest minor illness:

• Child who plays and has normal activity
• Open or easy smile
• Pain swallowing with white plaques in the throat and/or associated with red eyes and/or cough
• Painful, red, bleeding gums
• Oral thrush
• Mild (or moderate) diarrhoea without blood, mucus or pus
• Eats less, but does not refuse liquids
• Is soothed when picked up and behaves regularly
• Very frequent dry and irritating cough, which is the symptom that most disturbs the child
• Wheezing without breathing difficulty
• Red eyes with secretions
• Scattered red spots that appear only after the 4th day of fever.

What to do when the child/adolescent has a fever?

• Offer water and/or milk; adjust clothing and bedding according to the feeling of cold or heat; respect his/her appetite
• If he/she is comfortable, you don’t need to lower the temperature, but keep an eye out for “warning signs” (described above)
• If he/she is uncomfortable, you should take an antipyretic (which is also an analgesic, that is, it relieves pain); but you should not try to cool him/her with a bath, compresses, fans, etc
• As with antipyretics, you can also use paracetamol and/or ibuprofen (exceptions: allergy; age <6 months; chickenpox; diarrhoea and moderate to severe vomiting). They can be administered individually every 8h or, if febrile peaks are close, alternated up to 4h.

The antipyretic is considered to be effective if the temperature drops by 1.0º to 1.5ºC in 2 to 3 hours. The purpose of the antipyretic is to relieve the child's discomfort and not eliminate fever at all costs. Even if not medicated, the temperature will, as a rule, end up spontaneously dropping a few hours later, rising again after a few hours, and so on, until the disease passes.

When should a child / teenager with a fever go to the hospital/contact a paediatrician?

• Age less than 3 months of age (corrected age if premature)
• Age less than 6 months with axillary temperature ≥ 39.0ºC or rectal ≥ 40.0ºC
• Axillary temperatures greater than 40.0 ° C or rectal temperatures greater than 41.0 ° C
• Presence of one or more “warning signs” (described above)
• If a serious chronic disease coexists
• If fever has been present for 5 or more days, or if the fever reappears after 2 to 3 days at normal temperatures.
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Key points to remember

• Fever is just a symptom and not a disease
• The treatment of fever (antipyretics) does not shorten the duration of the fever or contribute to the resolution of the causative disease; if the temperature does not return to normal after the administration of antipyretics, alone, it is not a cause for concern as long as it drops from 1.0º to 1.5ºC
• The treatment of fever prevents febrile seizures which, globally, are uncommon (<1% of febrile episodes up to 2 years old, decreasing after that age); seizures frighten those who witness them, but, as a rule, they do not cause brain damage
• In the fever rising phase, cooling (with a bath, wet compresses, alcohol or fans) is not recommended: it does not contribute to the control of the disease, nor to the well-being of the child
• The presence of “warning signs”, the child's general condition and/or being less than 3 months old, are more important than the temperature degrees and/or the duration of the fever
• The appearance (or not) of the “warning signs” dictates the need (or not) to be observed, regardless of the day of fever
• Viruses, responsible for the vast majority of febrile episodes, last on average 4 full days (and 5 days, or more, in 30% of cases).