Index:

HEALTHY LIFE:
Rules and Limits!! // I don't want to go to school  // Anxiety and fears // In case of distraction and agitation // And what about homework? Create the right environment // 
SAFETY:
Travel Pharmacy Bag // Bullying in school // Correct use of the expansion chamber // 
HEALTH PROBLEMS:
Specific learning difficulties // Bedwetting // Does my child have chickenpox? // Anaphylaxis  // Scabies // My child has hit his/her head // Childhood obesity // Diarrhoea in children // Painful Pronation // My child has a fever // 

HEALTHY LIFE
 

Rules and Limits!!

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.

I don’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.

Anxiety and fears

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.

In case of distraction and agitation
 

Text by Paediatrician: Dr. Luís Gonçalves

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Em casa, proporcione um ambiente estruturado, com horários e rotinas.

At home, provide a structured environment, with schedules and routines.

Help your child understand what adults expect from him/her by setting clear and coherent rules to guide their actions.

Create opportunities to be with your child without giving them orders, scolding or correcting them. Give your attention in a positive way (if only for 15 minutes daily).

Self-esteem:
Help your child to increase confidence in themselves through praise.

Self-control:
Establish and apply methods that allow self-control, such as study hours, lists, schedules.

Play family games that help to increase attention and concentration (memory games, categories, mazes, differences, etc.).

Divide your child's tasks into smaller tasks that can be done in short intervals.

Build with your child a map/calendar with the school tasks they have to do and the organization of their time in the face of such tasks, setting task times and free time. Place the map in a visible and easy to consult place.

Make requests simple and direct, always maintaining eye contact with your child and making sure he/she understands.

Choosing a sport structured by your child is essential, it improves health and concentration.

And what about homework? Create the right environment

Text by Paediatrician: Dr. Luís Gonçalves

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When doing homework and studying, make sure your child has a spacious, well-lit table in a place without distractions (TV, Internet, Mobile).

Do not allow him/her to be connected to the internet while doing homework - Between replying to messages from friends, playing games or searching the internet, it is more likely that they will take triple the amount of time and no learning will be achieved.

Ask the teacher how much time your child is supposed to spend doing homework and what they think are your child's specific difficulties. Give feedback on the time spent and the degree of difficulty of the homework.

Depending on the hours available, the volume of work, and specific study needs, help him/her adapt and change this schedule whenever it makes sense.

Rest and play are important and beneficial for the development and success of learning, so make sure your child's time is allocated according to these priorities. Count the time spent each day. Make time-saving a challenge (homework/games).

It is important that you allow your child to solve problems and challenges for themselves, thus contributing to their self-confidence, determination, and autonomy.

Be available, stay close, and help them to think if they are having difficulties.

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

Bullying in school
 

Text by Paediatrician: Dr. Luís Gonçalves

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Promote dialogue by increasing proximity to your child so that he/she feels safe and supported.

After knowing what happened, avoid phrases like "it serves you right", "didn't I warn you?". The situation they are experiencing is already problematic and humiliating for them.

Promote the sharing of solutions to the problem - Help them build all possible solutions.

Praise and value your child, teach him/her to like you and face problems. Hang phrases like "I believe in myself" or "I have value!" In their room.

Tell your child that together they will be able to overcome the situation. And how this has happened to other children / young people who have managed to overcome it!

Prevention plan:

• Keep a safe distance from bullies;

• Guarantee a support network, sharing this subject with a friend (or group);

• Ask for help from adults at school who can help you.

• In the event of a confrontation:

• Stop and think - Think about the consequences if he/she also hurts someone;

• Act with confidence, determination and stay calm - "Enough, I don't like what you are doing";

• Leave or escape the place and look for a safe place and/or an adult.

After the confrontation:

• Do not stop going to school as long as there is no real danger - and face fear with the support of colleagues and teachers;

• Stay close to others;

• Always choose more effective ways to interact and relate to others.

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 for 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

Specific learning difficulties

Text by Paediatrician: Dr. Filipe Fernandes

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We speak of learning difficulties when a child is unable to learn a subject or task for which there are supposed to be no difficulties at his/her age.

It is important to distinguish between general learning disabilities, such as delayed cognitive development or autism spectrum disorder, and specific learning difficulties (SpLDs).

SpLDs are the most common cause of school failure, resulting from a specific deficit in the brain's ability to receive, process or communicate information. These difficulties should not result from lack of practice, the teaching method used, anxiety and depression, behavioural disorders or due to peripheral perceptual deficits (vision or hearing). 

The main sign of an SpLD is a significant difference between the expectations placed on the child's school performance (taking into account his intellectual functioning, behavioural and family adequacy and emotional well-being) and the child's effective school performance. The child shows an adequate level of reasoning and understanding of tasks and subjects but fails in their learning and evaluations.

It is necessary to properly assess children who have school learning difficulties in order to obtain a diagnosis that allows the support and monitoring that the child needs. It is necessary to collect information in an interview with parents, teachers, observe the child and apply standardised tests of cognitive performance. Early detection makes it possible to establish interventions aimed at the child's difficulties, significantly improving the child's performance and decreasing frustration.

The most common SpLDs:

• Dyslexia - difficulty in learning to read;

• Dysgraphia / Dystography - difficulties in learning to write;

• Dyscalculia - difficulties in learning calculus, arithmetic facts, or quantities;

• Dyspraxia - difficulties in motor skills or motor coordination;

The Attention Deficit (difficulties in orienting, maintaining, and dividing the attention focus, impulsivity, difficulties in planning), with or without hyperactivity, is also frequently present together with SpLDs.

The SpLDs are permanent and the child needs follow-up to rehabilitate or remedy his/her difficulties. Support and adequacy measures in the school environment are often necessary to minimise the impact of SpLDs on the child's school career.

It is important to reiterate that SpLDs are independent of the child's intellectual functioning. An SpLD should not prevent any child from growing up in a healthy way, from fulfilling their intellectual potential, and being happy. Einstein and Steve Jobs had SpLDs (dyslexia) and were extremely successful individuals.

Bedwetting

Text by Paediatrician: Dr.ª Patrícia Mendes

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Children develop the ability to retain urine for some time, usually by 3-4 years of age, first during the day and then at night.

The involuntary loss of urine during sleep (wetting the bed) of a child aged 5 years or more is called nocturnal enuresis and it is relevant if it occurs two or more times a week and/or it has repercussions for the child and family.

It is a frequent situation, being more prevalent in boys and decreases with age. At 5 years old, 20% of children are enuretic and the frequency decreases up to 5% by 10 years old, but it can last until adolescence or even adulthood.

When there are no other urinary disorders during the day, we consider it to be monosymptomatic nocturnal enuresis and when there are others, the situation is called polysymptomatic nocturnal enuresis. Bedwetting is also classified as primary if the child has never acquired urine control during the night or secondary when there has been a period of at least six months of continence.

Find out the causes and treatments in the full article Nocturnal enuresis (bedwetting) - Not a case of laziness or sloppiness by Dr. Patrícia Mendes.

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

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.

My Child has 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 of 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.

Diarrhoea in children

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.

My child has a fever

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.

• 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.

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).