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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 1. - Back to School
RADIO 4
TUESDAY 06/09/05 2100-2130
PRESENTER:
MARK PORTER
REPORTER: CLAUDIA HAMMOND
CONTRIBUTORS:
NICKY SALT
IAN BURGESS
JOANNA IBARRA
CATTI MOSS
SARAH JANE DURMAN
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello and welcome back to another series of Case Notes.
The summer holidays are over, and children across the country are starting school this week, many of them for the first time. So today's programme is all about common problems in children of school age. I'll be finding out about the latest management of bed wetting or enuresis - which affects at least half a million children in the UK.
And as part of Radio 4's stress week I'll be looking at the stress of starting, or going back to school and how it often results in vague physical symptoms that can leave both parents and doctors scratching their heads.
But first a common pest, all too familiar to any parent who has a child at nursery or primary school. As many as 1 in 10 young children will become infested with headlice this term. We sent Claudia Hammond to find out what parents can do when their children bring more than their books home from school.
MONTAGE
So tell me what you did at school today.
Number work.
Number work and did you have to do some counting?
Yes.
Yes. And what else did you do?
HAMMOND
Jo has been checking her son's hair for lice ever since the eldest came home from school with a note about an outbreak of nits.
JO
I checked Barnaby on the Thursday night and he seemed perfectly clear and then Friday morning he woke up and he was scratching his head and I had a look and he was just rife. But he was on his way to school and so I did the conditioner thing and he seemed clear. I got them all out with the conditioner and then sent him off to school and when he came out of school you could almost see his hair was moving, it was disgusting.
HAMMOND
In the '80s less than 1 in a 100 school children had nits, now it's up to 1 in 10, with higher rates in cities. There are plenty of myths about lice and it's just not the case that they're only attracted to clean hair. Ian Burgess, director of the Medical Entymology Centre at Insect Research and Development:
BURGESS
Well that's unfortunately a modern myth that was designed to try and convince nice middle class families that they could lice as well. I suppose lice probably do prefer clean hair but actually it doesn't make much difference, as long as they can get to the skin underneath where there's blood under that then they're happy.
HAMMOND
The increase in infestations began in the early '90s for two reasons:
BURGESS
We started to find resistance to the insecticides - that is the insects got immune to it. And secondly, there was much more concern in the consumers' mind about the safety of insecticides. So there were some people who were less willing to use them. Although in fact there are still a lot of people using insecticides and sometimes using them much too much but they're not using them with success.
MONTAGE
Community Hygiene Concern how can I help you? Yes, yes. The bug buster kit? It's £6.95.
HAMMOND
Community Hygiene Concern is a charity which was formed to deal with the problem. They recommend a comb and conditioner method called bug busting, for which they produce their own special kit. Joanna Ibarra.
IBARRA
It's got a very clear picture of the different stages of lice.
HAMMOND
They're tiny aren't they.
IBARRA
Yes, they start off a millimetre long and then they become full grown - three millimetres.
HAMMOND
Yeah even the biggest one's tiny, I mean you can see why they're hard to - hard to get.
IBARRA
Well we've got a very special comb here, they've got a slant on the teeth which you don't find on any other comb.
HAMMOND
They do look very fine, if you've got thick hair at all you'd think that would be impossible to get it through but presumably you can.
IBARRA
No, we've spent a long time getting exactly the right space between the teeth, it very easily goes in at the roots of the hair.
JO
I normally bribe mine with either a treat after we've done it or they can watch a video while we're doing it. And if we're being really gross then we count the number of nits that we actually ...
HAMMOND
Oh that probably works quite well.
JO
With boys that does, yeah, my boys would be interested in that.
BURGESS
To be honest it's about as effective as the person who's doing it. So if you're dedicated towards doing it, you're prepared to devote time and energy, you also need a certain amount of skill and the right equipment because many people who try this use the wrong kit. And you have got to have children who are moderately cooperative. If you have six children, all with lice and they are all fidgety and they're throwing things at each other and fighting and then the doorbell goes in the middle of it you really have a problem. And you just cannot handle that.
HAMMOND
There are lots of types of combs for sale, with Joanna Ibarra's bug buster kits just over half of the cases were cured completely in a new trial published in the British Medical Journal Online. If combing sounds too much of a chore and you don't fancy using insecticides there is a new silicon based treatment which sounds promising. It contains dimeticone, similar to the substance found in colic drops for babies. Ian Burgess has been testing it and his trial was published in the British Medical Journal.
BURGESS
It's difficult to know exactly how it works but I think for want of a better way of describing it, it sort of shrink wraps the lice, a bit like wrapping them up in plastic. One thing we do know is that it messes up their ability to get rid of water, after all lice drink vast amounts of water in blood and they have to get rid of it somehow, not like a mosquito, when a mosquito takes blood it very quickly passes it through its body and then it pees or poos it out the back. Well lice can't do that, so they have to get rid of it some other way and using this type of shrink wrapping approach then you stop them losing their water and they quite literally bust a gut. Quite a lot of them you look at them afterwards and they are sort of deep red where the gut's exploded as a result of the conflicting osmotic forces inside where it can't get rid of the water.
HAMMOND
You've got a bottle of it just here and this just looks like a bottle of water.
BURGESS
It's a little bit more viscous than water, which makes it easier to control. Now if we open this bottle, I mean it has absolutely no odour and if I put it on my finger there and you see that it's very slightly oily as I spread it around but it's already starting to evaporate.
HAMMOND
Three quarters of the infestations were cleared up with this new product. Similar to the performance of the best existing insecticide treatments. The methods of testing vary so much that it's hard to compare the studies and this is an area where there's plenty of controversy and debate. So it will be up to parents to decide whether to choose it when it comes on to the market very soon.
PORTER
Claudia Hammond talking about a new alternative to pesticides in the ongoing battle against headlice.
My studio guest today is Dr Nicky Salt - a GP with a special interest in child health.
Nicky, there's no reason why parents can't combine that new treatment - dimeticone - or indeed pesticides with the mechanical combing. In fact mechanical combing's quite important isn't it.
SALT
Yes I think so. I mean if you look at either of the methods they're neither, as we've heard, better than 75% effective. So I think parents need all the weapons they can get and I tend to recommend to my parents that they use both - either one of the medications in addition to fine combing. And I think the trouble with fine combing is that often parents don't carry it on for long enough because it's so difficult to get rid of every last ...
PORTER
Well if there are eggs there in different parts of the life cycle, I mean you can expect to be combing for up to two weeks after the initial treatment, can't you, before you can catch every single one to be extra sure.
What other sorts of nasty things can children bring home from school - of course there's scabies which is related to nits?
SALT
Very similar in that it's another sort of parasitic infection, it tends to affect the skin rather than the hair. And characteristically you're supposed to get these little sort of red burrows and spots which occur in the webs of the fingers and around the feet. I don't know what your experience is, my experience is that often the rash is a bit less specific than that it can often look like sort of eczema or ...
PORTER
It does often yes, in fact we often treat it as eczema don't we to start with.
SALT
That's right yeah. I think the most helpful thing to distinguish there is that it is usually dreadfully itchy and that's one of the key points to look out for.
PORTER
But relatively easy to treat with pesticides once again. But the difference is whereas we wouldn't treat a household where a child had - if one of the children had headlice we'd only treat that child or only recommend treating that child, checking the others by all means, but with scabies we would treat the whole household wouldn't we.
SALT
Yes very important because otherwise you can end up needing repeated treatments to eradicate.
PORTER
I suppose the most common thing that children come back from school with are coughs and colds, I don't know about you but I get a lot of parents coming in saying there must be something wrong with little Johnny, ever since he started nursery school he's had a cold every week. But that's not that unusual is it?
SALT
Very normal, I mean I think if you look at the various estimates of how many coughs and colds children will get in the first few years of school it's 7 to 10 a year. So I say to my parents they're abnormal if they're not getting lots of coughs and colds. And I think it's reassuring because parents will often be concerned there's something wrong with their child's immune system or there's something very serious. Where it's just a normal amount of exposure and absolutely nothing to be worried about.
PORTER
It's just meeting these challenges for the first time.
SALT
Absolutely.
PORTER
And that's how you acquire your immunity. What about impetigo?
SALT
Again we see that quite commonly. I think the trick there is for parents to recognise it because again it responds very well to treatments but it's ...
PORTER
Perhaps we should explain what impetigo is.
SALT
Yes, it's a bacterial skin infection. From a parent's point of view it's usually an area of scabby skin, a bit red and inflamed, often with a yellowy crust and it can spread very quickly and is quite infectious. So I think it's an awareness that if a child has a scab that's spreading ...
PORTER
It's one of those things isn't it that schools don't like you going to school with impetigo.
SALT
Yes, they're very concerned about the infectivity because it probably with some reason is one that can spread. So I think getting the children treated quite early, because the children themselves are usually not ill with it, and getting them treated so they can get back to school's quite important.
PORTER
But once again easy to treat with the right treatment. Another condition that you often see in children of school age, younger children anyway, is conjunctivitis, and of course the schools don't like that either do they.
SALT
No and again I think a lot of the parents bring the children to me when the children themselves are again completely well but with a bit of a red eye or a bit discharge, mainly because the schools are worried about infectivity. I mean one of the interesting things about that is that one of the main treatments ...
PORTER
Chloramphenicol eye drops, yeah.
SALT
.. has just changed, so parents can buy it across the counter, which would make life easier. Although I think it is worth being aware that not every case of conjunctivitis is actually going to need ...
PORTER
It's like there's a bit of controversy raging at the moment, isn't there, about whether we should be treating with antibiotics at all. But of course the parents can now buy it without a doctor's prescription but they have to pay for it where they still get it free from us, so I suspect we're getting a lot of people. But if they have pressure from the school to clear it up ...
SALT
Yeah it's difficult. And I mean - because a lot of it initially will be treated as part of a viral infection or younger babies might have blocked tear ducts. I think it's really worth encouraging parents to try and keep the eyes clean by bathing. The difficulty is if the school's telling you you've got to get it treated it's a big incentive to take the antibiotics.
PORTER
Well conjunctivitis isn't the only infection in which the use of antibiotics is now frowned upon. The average GP will see as many as a dozen children a week with some form of earache. And, up until recently, antibiotics were routinely prescribed to nearly all children with infection of the middle ear - a condition known as otitis media. But not any more. Dr Catti Moss is GP in Northampton and sits on the Royal College of General Practitioners' Patient Participation Group.
MOSS
Some of this is caused by having infections in the ear but mostly the pressure's caused by colds blocking off the tube that ventilates the middle ear.
PORTER
So the - so although the child has a cold there isn't actually any active infection going on in the ear itself?
MOSS
There will be a viral infection in the nose but no, the ear itself, most of the time, isn't actually infected.
PORTER
So why do we still use so many antibiotics in cases like this?
MOSS
When I was a young doctor we were all taught that it wasn't safe not to treat ear infections with antibiotics, that there was a danger that the ear would perforate, that people's hearing would be affected and that it had bad effects. So there's a generation of mothers whose mothers were brought up with doctors telling them that. And then on the other side we've got doctors, if you've been giving antibiotics for ear infections for 20 years it's awfully difficult to realise that you haven't been doing people any good.
PORTER
But in these days of evidence base medicine we must obviously - I mean I know that we've looked at the use of antibiotics in ear infections - what does the data actually show, do they have any benefit?
MOSS
The data shows that they do have some benefit in a small proportion of children with ear infections. The group that have the benefit are the group that have both red ears when we look down them and have had their symptoms for three days or more. It's very difficult for us to understand that treating early doesn't give any better results but it doesn't.
PORTER
So the science has shown us that if a child has one red painful ear, that's been present for a day or two, it's a waste of time giving antibiotics completely?
MOSS
Totally. Your child is more likely to get better the same time or quicker without antibiotics.
PORTER
Okay, let's look at it from the other perspective - what's the downside of over-treating these children with antibiotics?
MOSS
Well I suppose the first and most important thing is resistant bugs. When I was a junior doctor the idea of resistant bugs wasn't something that patients thought was very important, although I as a very young doctor working in a burns unit actually had patients die from resistant bugs. But now everybody's dying from resistant bugs, it's in the news and everyone knows that giving too many antibiotics makes bugs more resistant and it's a bad thing.
PORTER
We are using far less antibiotics than we used to, I mean I think I saw some figures recently saying that the number of prescriptions to children had actually halved over the last decade. What do you think the gold standard management for earache should now be?
MOSS
I think the gold standard should be mothers waiting for three days before coming to the doctor but in those three days they should be giving their daughter or son plenty of painkillers, they should be treating the symptoms of their cold and their earache comfortably and then if it goes on for three days they should come to the doctor for the doctor to have a look and see is the ear red, does it need antibiotics?
PORTER
So from our point of view if the patient then comes in at that three day stage and both eardrums are red that would indicate that antibiotics may be warranted?
MOSS
It would indicate that that child is more likely to get better a little quicker if we give antibiotics than not.
PORTER
You say more likely to get a little quicker - can you quantify that?
MOSS
Well the research said that the average got shorter by 24 hours.
PORTER
The child got better 24 hours earlier than it would have if it hadn't been given the antibiotics.
MOSS
That's right.
PORTER
How aware do you think GPs are of the lack of evidence that antibiotics do any good in most cases of ear infection?
MOSS
I think you'd have to be a very badly educated GP not to be aware that there is evidence that antibiotics aren't much good. What's more difficult is getting GPs to actually buy into it. If you have no experience of sending people who have been expecting antibiotics away without antibiotics and then coming back happy it's quite difficult to do.
PORTER
Dr Catti Moss with some fairly clear cut advice. Unless your child has had earache for three days or more, and both ears are affected, antibiotics are unlikely to help - and even if he or she does qualify for them, the benefit is likely to be small - on average they only shorten the duration of symptoms by around 24 hours.
Now, does your son or daughter wet the bed? Most children will be dry at night by the age of three, but as many as half a million children between the ages of 5 and 16 still wet the bed regularly. It can be a source of major stress for both child and parent.
Sarah Jane Durman is a school nurse with a special interest in bedwetting.
DURMAN
If one parent did it then there's a 40% chance that the child will do it and if two parents did it then there's probably about a 70% chance that the children will do it. So it is a genetic link.
PORTER
And what sort of age are we talking about - when should parents start to worry that their child perhaps isn't as dry as they should be?
DURMAN
We don't actually start treating till the child is about seven, we will give the parents advice from the ages of five but main treatment starts at about seven and carries on until - until we succeed - we never give up on families.
PORTER
Where should parents go as their first port of call - presumably to their GP?
DURMAN
It depends, I mean yes GPs can deal with it but a lot of NHS trusts now run enuresis services which the parent can self-refer to.
PORTER
And what sort of things are parents likely to be offered?
DURMAN
We tend to sort of say there's three systems that might not be working in the child, so it might be that the child doesn't wake to the feeling of a full bladder, in which case they'll be offered an alarm. It might be that their bodies aren't producing a hormone which puts the kidneys to sleep, so that when the person goes to sleep their kidneys are asleep so they don't produce as much urine and then they can get the tablet from the GP. Or it might be that the bladder is actually too small and is very sort of irritable and twitchy, so it doesn't actually hold as much urine as we would expect for a child or an adult and again there is medication or there are sort of exercises that you can do.
PORTER
Let's go back to the first one - the alarm. Perhaps you could explain how that works.
DURMAN
Oh well it's sort of very barbaric in a way because they sound a bit like fire alarms. What it is a mat or a little thing that goes into the pants of the child and when the child starts to wet this then triggers an alarm and it then makes the most horrendous noise and the child is meant to realise that this noise is going, stop going to the toilet and dash out and go to the loo. We say to the parents it's not going to be a miracle cure, there are some children that just by the fact that they've got this alarm on their bed sort of just like Oh my god I can't sleep, I've got to get up and go to the toilet and it cures them. But we say this is a longer term and it may take several months.
PORTER
What about children who've got a small or irritable bladder and they simply can't last through the night?
DURMAN
We've discovered that a lot of children don't actually drink enough and of course if the urine is very concentrated the bladder becomes very irritable and things. And also children are sort of trained sometimes - you've got to go to the toilet every half hour and things because when they're being toilet trained the mother's desperate for them not to - not to be wet. So we try and encourage children to drink sort of a litre of water a day, not just drinking when they come straight home from school, you know they've got to have a drink with breakfast, they've got to have a full drink at breaktime, at lunchtime. So then the bladder will start to sort of realise what it's like to have the full sensation. We'll try and say to the child when you first get that funny feeling in your tummy when you want to go to the toilet then sort of try and ignore that a little bit or maybe go to the toilet, in case of an accident, and maybe wait 10 seconds, 20 seconds. If it is a real problem we can do sort of charts, there are various charts that we can use, to find out the actual size of the child's bladder and if the child does show to have a very irritable bladder there is medicine that you can take and we usually say take that for three months and then see if the problem goes and you get that medicine from the GP.
PORTER
And that's working to relax the bladder wall so that the bladder can expand up without sending those signals to the brain.
DURMAN
Yeah.
PORTER
Is there anything that parents can do themselves to work out what might be going wrong?
DURMAN
They can do things like look at the colour of their child's urine. Children in the clinic think I'm completely gross when I come out with things like this. But I actually say to the parents watch your child when they're going to the toilet, is it difficult for them to go to the toilet, do they have a real job to sort of actually squeeze the urine out or does it just come out in a normal stream. I ask the boys if they can sort of write their name with it and things - and boys always know what I'm talking about. The parents often sit there agog. I ask the parents whether the urine in the morning is a very dark concentrated smelly urine or whether it's sort of a normal daytime colour - very pale and not particularly smelly. If it's very pale it might mean that the kidneys aren't being put to sleep. If the urine is very strong and smelly it might mean that the child is not drinking enough and the urine is concentrated and irritating the bladder. There is a formula that you can use to see the size of your child's bladder and that's - you use your child's age plus one times 30 and that gives you the actual measurement of the child's bladder. You get your child to wee in a cheap plastic bottle from the pound shop, sort of thing, a lot of children quite enjoy that, but it's a way of telling that if you're expecting a child to have a 200 mil bladder and they're only weeing and producing 50 mils at the time, possibly they've got a small bladder and you need to sort of then start the treatment for that.
PORTER
What about the third group, you mentioned that there were a group who don't produce the right amount of hormones at night because normally when we go to sleep our kidneys, as you said earlier on, they partly shut down, we produce less urine, but there are some children who carry on producing urine at daytime rates, so it's not surprising that their bladder gets full, what can we do for them?
DURMAN
There has been - there's a medication that's been made, it's an artificial hormone, which is the hormone that we all manufacture when we go to bed and puts the kidneys to sleep and all children do is they take this just before they go to bed and literally it works in their bodies for eight hours and then when they get up in the morning they carry on as normal.
PORTER
I know it's very effective, I've used it, it seemed great - but what I tend to find is that you use it for a short period and the minute you stop it the problem comes back because the problem's actually not gone away, has it, they're still not producing that hormone themselves at night?
DURMAN
About 15% of children will become dry naturally over a period of time, over the year, well we say try it for three months and then have a week off and then see what happens. If not go back on the treatment. Because if it stops the problem for them okay they're using medication but it has stopped the problem, you know the parents haven't got to deal with the wet beds, the child's self-esteem, they're a normal child again.
PORTER
School nurse Sarah Jane Durman. You're listening to a Back to School Case Notes special, I'm Dr Mark Porter, and my guest is Dr Nicky Salt.
Nicky, childhood behavioural problems are a particular interest of yours and bedwetting can sometimes be a sign of emotional distress can't it.
SALT
It can. A lot of children who bedwet will have done so all alone and never been dry at night. In children who've been reliably dry at night and then who suddenly start bedwetting one of the things I'd certainly want to think about is whether that child could be feeling stressed or anxious, may well tie in with some life event, could be the birth of a new sibling, maybe going back to school.
PORTER
And that's because they're anxious and that's one - and they're not sleeping properly or why do we think it is?
SALT
It's probably one of the manifestations of anxiety, I mean obviously there are other things, one might thing about perhaps physical things like urine infections, but certainly it can be a way anxiety manifests. I think anxiety in children, very like in adults, can show in all sorts of different ways.
PORTER
Well what sort of things - I mean I think we're probably both familiar with seeing children who come in - they don't come in with anxiety and stress do they, they tend to come in with some other sign of that, so what sort of things are we talking about?
SALT
Well I mean sometimes it can be perhaps easier both for us and for parents to spot, so it maybe simple things like bad dreams, it might be changes in behaviour, perhaps an outgoing child becoming more withdrawn or with younger children they'll often become a bit more clingy and wanting to be with the mother. The other one that I think can be quite difficult, both for parents and for GPs to recognise, is sometimes children will present with physical symptoms, so although they're actually feeling anxious what they'll come to see me, as a GP, with or complain to their parent about might be a tummy ache or a headache.
PORTER
Now in the case of children who are going back to school, maybe for the first time, is it natural for them to be anxious about going to school for the first time and leaving mum often for the first time as well, so why does that manifest as a physical symptom, presumably is it a way of making sure they can stay at home?
SALT
I think it's - I think it's rarely that conscious and I think one of the things I often explain to parents that I see it isn't that the child is imagining the pain or putting it on, I think the child genuinely feels very worried and anxious and I think perhaps the way they're able to express that or manifest it is with the sort of physical symptom. Of course then the difficult thing is pulling out which of those symptoms are genuinely anxiety linked and whether anything else could be going on.
PORTER
Which is my next question. I mean what sort of clues do we, as doctors, look for, indeed what sort of clues could parents look for that might suggest that these are physical symptoms, real physical symptoms but prompted by an underlying stress or anxiety?
SALT
I think timing is a really useful one. I often ask the parents either if they can remember or sometimes to go away and actually just jot down when the symptoms occur and it's amazing how often you'll find that the tummy ache, because it often is a tummy ache, will not be there in the holidays or perhaps if there's a dad who's away travelling a lot the tummy ache might occur when the parent's away, sometimes it might occur when a parent's there but you will often see there's a very clear link to something happening in the child's life which obviously we wouldn't expect to happen with a purely physical symptom.
PORTER
One of the difficulties with dealing with these sorts of problems in children is that it's very difficult for them to talk about stress and anxiety other than they don't understand the concept, and if there isn't an obviously identifiable problem such as bullying at school or something that we can do something about how do we help them because at the moment what we tend to do is reassure the parents, I mean that's the easy bit - say look Mrs Bloggs there's nothing wrong with little Johnny's tummy, I think this is because he's going to school for the first time, but it doesn't actually help little Johnny does it.
SALT
No, I mean I think like an awful lot in medicine and in life prevention's better than cure. So I think that there's a lot to be done in terms of preparation, so going back to the beginning if the child's starting school, making sure that they have actually been apart from the parent before, they know what school's like, they've read the books, so preparing them. And then I think the reassurance is very important, not only do the parents need reassuring but the child does and I often explain to the child that they've got a pain in their tummy and it's a very real pain but that it's nothing to worry about, it's because they're worried and actually encouraging the children to understand that and also to give them a chance to talk about it can sometimes be quite helpful.
PORTER
It's also very important isn't it to keep the child at school because if the school's causing anxiety the more they avoid it the more anxious they get when they do go back.
SALT
It is and I think to get the school on board, most schools now are very good, so I think making sure that there's been communication between the parent and the teacher and often I'll get involved as the doctor and having a nice sort of programme whereby the school knows what's going on and really help the child to come into school and make it easy for them to go back in.
PORTER
Nicky Salt, thank-you very much. That's all we have time for.
If you would like more information on the subjects that we discussed today, then you can give the Radio 4 Action Line a ring 0800 044 044 or you can visit our website bbc.co.uk/radio4.
Next week's programme is all about choice in the NHS - including a look at a new system that, by the end of the year, will allow NHS patients to choose which hospital they would like to be referred to, and to book their own appointment directly with the specialist - at a date and time of their choosing. And, to help you make the right choice, we'll be looking at how you can tell whether a hospital - or a specialist - is up to scratch?
ends
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