tag:theconversation.com,2011:/global/topics/childhood-conditions-29085/articlesChildhood conditions – The Conversation2018-08-23T07:37:09Ztag:theconversation.com,2011:article/1015712018-08-23T07:37:09Z2018-08-23T07:37:09ZGirls have ADHD too – here’s why we may be missing them<figure><img src="https://images.theconversation.com/files/232659/original/file-20180820-30596-1nvkzhk.jpg?ixlib=rb-1.1.0&rect=51%2C8%2C5760%2C3819&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/568445317?src=Ut9NIY-6obZd6MzLaDDAYA-1-44&size=huge_jpg">Photographee.eu/Shutterstock</a></span></figcaption></figure><p>Asked what they know about attention-deficit hyperactivity disorder, or ADHD, many people will likely tell you that it mostly affects children, and mostly boys. However, recent research has shown that neither of these perceptions is entirely true.</p>
<p>There is a striking difference in the sex of children diagnosed with ADHD, with boys more likely to be diagnosed than girls (the ratios can be <a href="https://ac.els-cdn.com/S0890856709626125/1-s2.0-S0890856709626125-main.pdf?_tid=40e10c3a-8325-4253-9198-ac40767130e5&acdnat=1534503684_50f3a9a490211d0a288261a94f413acb">as high as 9:1 in some studies)</a>. However, these studies are of children who have an established diagnosis of ADHD, and such estimates are affected by referral patterns (for example, parents may be more likely to take their sons in for an ADHD assessment), so they may not reflect the true sex ratio. </p>
<p>Indeed, when we estimate the occurrence of ADHD in the population as a whole, rather than just in children at clinics, we find that a lot more girls meet diagnostic criteria than is reflected in the estimates from clinics. The same equalising trend between the sexes is visible when looking at <a href="https://www.nature.com/articles/nrdp201520.pdf">adults with a diagnosis of ADHD</a>. Taken together, this suggests that there are a substantial number of girls with ADHD going undiagnosed in childhood, with potentially serious implications for the effects of their untreated symptoms in childhood, adolescence and adulthood.</p>
<h2>Why are girls less likely to be diagnosed?</h2>
<p>One reason that fewer girls are diagnosed with ADHD is that girls may be more likely to have the inattentive-type ADHD symptoms, rather than the hyperactive and impulsive symptoms that are more common in boys. The issue is that while inattention and an inability to focus will cause problems for a child, such symptoms may be less disruptive and noticeable for parents or teachers, which means that these children’s ADHD may go unrecognised.</p>
<p>Considering that diagnostic criteria were <a href="https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.151.11.1673">created based on studies of boys</a>, they are likely to be better geared towards the identification of ADHD in males. This has led to a stereotypical image of ADHD as a “disruptive boy”, even though it is becoming more widely recognised that <a href="http://journals.sagepub.com/doi/pdf/10.1177/1087054711416909">ADHD also affects large numbers of females</a> and adults. </p>
<p>If a male stereotype is seen as the norm, potentially only the girls with the most severe, or most “male-like”, symptoms that manifest as disruptive behaviour will be identified. We cannot definitively say that affected girls are not getting referred to clinics, but if they are, and if the symptoms of their ADHD are somewhat different to those seen in boys, they may well receive alternative diagnoses, <a href="https://theconversation.com/why-is-adhd-more-common-in-boys-than-girls-92151">such as anxiety or depression</a>, instead.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232663/original/file-20180820-30605-1posep5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232663/original/file-20180820-30605-1posep5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=291&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232663/original/file-20180820-30605-1posep5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=291&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232663/original/file-20180820-30605-1posep5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=291&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232663/original/file-20180820-30605-1posep5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=366&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232663/original/file-20180820-30605-1posep5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=366&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232663/original/file-20180820-30605-1posep5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=366&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The stereotypical disruptive behaviour of boys isn’t the only symptom of ADHD.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/59907679?src=j1z5w-x03zZGDo9GxG5qDQ-1-14&size=huge_jpg">Suzanne Tucker/Shutterstock</a></span>
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</figure>
<p>In <a href="https://link.springer.com/article/10.1007/s00787-018-1211-3">our study</a>, published in the European Journal of Child and Adolescent Psychiatry, we aimed to identify which symptoms were the best predictors of an ADHD diagnosis and the likelihood of receiving medication, and whether these differed between boys and girls. </p>
<p>We used a large population dataset, the <a href="https://ki.se/en/meb/the-child-and-adolescent-twin-study-in-sweden-catss">Child and Adolescent Twin Study</a> from Sweden, which could be linked with Swedish registries holding information on individuals who had received a diagnosis of ADHD and been prescribed stimulant medication for ADHD. This means that we were able to link population data with clinical data, without needing to look only in clinics, where ADHD patients are more frequently boys.</p>
<p>True to our expectations, what we found was that hyperactivity, impulsivity and behaviour problems in girls were stronger predictors of clinical diagnosis and being prescribed medication than in boys. </p>
<p>This suggests that these sorts of behaviours are more likely to lead to clinical recognition of ADHD among girls. It supports the idea that unless girls with ADHD display more of these disruptive behaviours associated with the stereotypical image of the condition, they may be more likely to be missed. This highlights potential issues with the male-centric nature of the current ADHD diagnostic criteria and current clinical practice.</p>
<p>When we looked at the presentation of ADHD in the population, we found that the inattentive presentation was most common across both sexes. But among those that had been clinically diagnosed, a combination of both inattentive and hyperactive or impulsive symptoms was most common. What this again points to is that people with primarily inattentive symptoms may be less likely to be diagnosed with ADHD as children. </p>
<p>We also found that a greater percentage of girls than boys presented with predominately inattentive symptoms at the whole population level. Since children with inattentive symptoms are sometimes overlooked, this could partially explain why the ratio of boys to girls diagnosed with ADHD is higher than the estimated ratio for ADHD occurrence in the population as a whole.</p>
<h2>Identifying undiagnosed ADHD</h2>
<p>ADHD is associated with a wide-range of functional impairments, educational and occupational difficulties, family and social relationship problems, and problematic substance use. When it goes unrecognised, opportunities to provide treatment are lost, which can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520745/pdf/1741-7015-10-99.pdf">lead to worse long-term outcomes</a>. As such, it is important to ensure that girls with ADHD are identified and treated in childhood.</p>
<p>It is clear that we need to work towards a better understanding of how ADHD manifests in girls as, while less visible or disruptive, inattentive symptoms can be very impairing, potentially over an entire lifespan. Given that the diagnostic criteria are primarily based on studies in boys, we need more studies to look at ADHD in girls, to develop better instruments to assess and diagnose it that are more sensitive to the way it affects females.</p><img src="https://counter.theconversation.com/content/101571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Florence Mowlem is supported by a PhD studentship from the MRC/IoPPN Excellence Award.
CATSS is supported by the Swedish Council for Working Life, funds under the ALF agreement, the Söderström-Königska Foundation, and the Swedish Research Council (Medicine and SIMSAM). This research was also supported by a grant (IG2012-5056) from The Swedish Foundation for International Cooperation in Research and Higher Education.</span></em></p>Being inattentive and unable to focus rather than disruptive means that ADHD in girls is going undiagnosed.Florence Mowlem, PhD Candidate in Social, Genetic and Developmental Psychiatry, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/603662016-10-07T00:58:39Z2016-10-07T00:58:39ZExplainer: what causes knock knees and do they have to be treated?<figure><img src="https://images.theconversation.com/files/135108/original/image-20160823-30238-1ul0z13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Is it normal for kids' knees to knock together? When does it stop being normal?</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Knock knees, also known as genu valgum, is a type of knee alignment seen when a child (or adult) stands up straight with their knees together, but their feet and ankles stay apart. The opposite type of alignment, called bow legs (genu varum), is when someone stands with their feet and ankles together, and there is a gap between the knees. </p>
<p>Knock knees are usually assessed by directly measuring the angle of the shin bone to the thigh bone (tibiofemoral angle) or by measuring the distance between the ankles (intermalleolar distance). Sometimes photographs or x-rays can be taken to calculate these measures.</p>
<p>Knock knees (and bow legs) are a normal part of a child’s growth and development. The <a href="http://www.ncbi.nlm.nih.gov/pubmed/8459023">classic</a> pattern of changes at the knee with age in Caucasian children is bow legs at birth, straightening out at two years, going into knock knees at four years, and straightening out between six to 11 years.</p>
<p>There might be some ethnic and gender variation to the timing and severity of knock knees. For example, the knees of <a href="http://www.ncbi.nlm.nih.gov/pubmed/23946543">south Indian children</a> tend to straighten out sooner after birth, and go into knock knees earlier but with less severe angles. Girls seem to show a higher knock knee angle than boys at all ages.</p>
<p>However knock knees can be a problem. While most cases are a normal variant of growth (physiological knock knees), further investigation is needed (pathological knee knocks) if the knock knee angle is large, if they appear late or worsen after eight years of age, occur on only one leg, are painful or cause a limp. </p>
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<a href="https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/135109/original/image-20160823-30209-5q0doe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Knock knees, normal legs and bow legs.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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</figure>
<h2>What causes pathological knock knees?</h2>
<p>Pathological knock knees can occur in some neurological conditions, such as cerebral palsy or spina bifida, as a result of the altered muscle pull on the bones. </p>
<p>So pathological knock knees may be one of the early signs of an underlying disorder. Bone diseases resulting from poor mineralisation, such as <a href="http://www.ncbi.nlm.nih.gov/pubmed/15205623">rickets</a>, may present through large knee angles during childhood. When pathological knock knees are seen in combination with short stature and other bone and joint misalignment, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/24432110">skeletal dysplasia</a> or <a href="http://www.ncbi.nlm.nih.gov/pubmed/18388709">metabolic bone disorder</a> may be the cause. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/26914720">Obesity</a> during adolescence is also associated with more severe knock knees, and is more commonly seen in children with <a href="https://theconversation.com/what-are-flat-feet-in-children-and-are-they-something-to-worry-about-60365">flat feet</a> and those with hypermobile (overly flexible) joints.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=364&fit=crop&dpr=1 600w, https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=364&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=364&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=457&fit=crop&dpr=1 754w, https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=457&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/135111/original/image-20160823-30252-2qvd27.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=457&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Pathological knock knees.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
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</figure>
<h2>Do they have to be treated?</h2>
<p>It is usually parental concern for the way a child looks when standing or walking that sparks initial review by a health professional. Children presenting with physiological knock knees do not require treatment or ongoing monitoring, as they will grow out of it with time. </p>
<p>Conservative treatments may be beneficial such as <a href="http://www.ncbi.nlm.nih.gov/pubmed/26700568">exercises</a> and weight loss programs to reduce obesity and improve knee movement in children, or <a href="http://www.ncbi.nlm.nih.gov/pubmed/21273902">knee braces and foot orthoses</a> for painful osteoarthritis associated with knock knees in adults. However, these interventions require more scientific evidence to support their use as there currently isn’t much.</p>
<p>Children with severe or worsening pathological knock knees might need orthopaedic surgery to correct their knee alignment, particularly in the presence of persistent pain or disability, regardless of the underlying cause. </p>
<p>There are many operations for pathological knock knees. A hemiepiphysiodesis is a type of “guided growth” operation involving the placement of staples or a plate on the inside part of the knee to slow down growth while the outside part of the knee continues to grow. This then corrects the knee angle to a straighter position. A <a href="http://www.ncbi.nlm.nih.gov/pubmed/23965916">study</a> reporting outcomes two years after this operation showed correction in 34 of 38 knock knees. </p>
<p>Another surgical procedure for pathological knock knees is a wedge osteotomy, where the top of the shin bone or bottom of the thigh bone is cut and a small portion removed to correct the knee alignment. In a <a href="http://www.ncbi.nlm.nih.gov/pubmed/22706968">study</a> of 23 adolescents and adults with painful arthritic knock knees, a wedge osteotomy was found to show improvements in walking ability and alignment after two years. </p>
<p>Orthopaedic surgery is rarely needed. For most kids, knock knees are just a normal part of growing up.</p><img src="https://counter.theconversation.com/content/60366/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Burns receives funding from NHMRC (National Health and Medical Research Council of Australia, Centre of Research Excellence #1031893, European Union Collaborative Research Scheme #1055131), NIH (Inherited Neuropathies Consortium RDCRC #U54NS065712 supported by NINDS/ORDR and NCATS), Muscular Dystrophy Association USA (#250931), CMT Association of Australia, Multiple Sclerosis Research Australia, Sydney Southeast Asia Centre, New Zealand Neuromuscular Research Foundation Trust, Thyne Reid Foundation, Elizabeth Lottie May Rosenthal Bone Bequest.. </span></em></p><p class="fine-print"><em><span>Verity Pacey receives funding from The Menzies Foundation, Arthritis Australia, Osteogenesis Imperfecta Society of Australia, Rheumatology Health Professionals Association and The Ian Potter Foundation.</span></em></p>Knock knees (and bow legs) are generally a normal part of a child’s growth and development. But if they persist, they can become problematic.Joshua Burns, Professor of Allied Health (Paediatrics), Children's Hospital at Westmead, University of SydneyVerity Pacey, Senior Physiotherapist, The Children's Hospital at Westmead, and Lecturer in Physiotherapy, , Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/603652016-07-28T19:43:50Z2016-07-28T19:43:50ZWhat are ‘flat feet’ in children and are they something to worry about?<figure><img src="https://images.theconversation.com/files/130646/original/image-20160715-2120-1rq9jhc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If your child has flat feet do you have to do something about it?</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>This is part of our series on kids’ health. Read the other articles in our series <a href="https://theconversation.com/au/topics/kids-health">here</a>.</em></p>
<hr>
<p>Children with flat feet, also called <em>pes planus</em>, have a flattening of the arch during standing and walking. Flat foot is normal in infants and young children (<a href="http://www.ncbi.nlm.nih.gov/pubmed/16882817">up to 44% of three- to six-year-olds</a>). At this age, in the absence of any associated symptoms, treatment is highly debatable.</p>
<p>Flat foot usually naturally corrects itself as muscles strengthen and soft tissues stiffen. The height of the arch in the foot increases with age <a href="http://link.springer.com/article/10.1186/s13047-016-0156-3">until about nine years</a>. The problem is when flat foot persists, spontaneously occurs in older children or later in life, or is associated with pain and disability.</p>
<p>Flat feet can be flexible or rigid, painful or painless and associated with a tightness of the calf muscles (Achilles tendon). The majority of flat feet are painless, but when pain is present it is usually during weight-bearing activities such as walking and running. The pain can be in the sole of the foot, the ankle, or non-specific pain all around the foot area.</p>
<h2>What causes flat feet?</h2>
<p>A complex and sophisticated interaction of bones, ligaments, muscles and nerves within and above the foot defines its anatomy and function. Anything that interrupts the integrity of these structures leading to a collapsed arch can cause symptomatic flat feet. </p>
<p>Examination of the foot begins with an examination of the entire child, because the flat foot may have an underlying cause. Common disorders causing symptomatic flat foot include: <a href="http://www.ncbi.nlm.nih.gov/pubmed/24977941">cerebral palsy</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/15991869">some forms of muscular dystrophy</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/26058561">juvenile arthritis</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=burns+evolution+pes+cavus">inherited disorders affecting the nervous system</a>, and <a href="http://www.ncbi.nlm.nih.gov/pubmed/17143900">some</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/25821089">connective tissue</a> <a href="http://www.bjj.boneandjoint.org.uk/content/53-B/1/72">disorders</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130648/original/image-20160715-2144-40j19w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A normal foot compared to a flat foot.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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</figure>
<p>Flat foot can also originate from unusual anatomy such as a tarsal coalition (bones joined together), ligament or muscle damage, restricted ankle movement, outward rotated lower legs, and knock knees (where the legs bow inwards at the knee). </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/20567243">Obesity</a> can result in collapse of the arches by the increased load on the foot. If <a href="http://www.ncbi.nlm.nih.gov/pubmed/24889987">knock knees</a> also develop, the middle of the foot will tend to turn out (abduct). The foot will point outwards when walking, instead of straight ahead, which is inefficient and can cause early fatigue.</p>
<p>Footwear in early childhood has been thought to cause flat foot. Recent research <a href="http://www.tandfonline.com/doi/abs/10.1080/19424280903386411">questions</a> this theory, as populations that habitually walk barefoot have flatter arches than populations that wear shoes. It is likely that children who wear shoes, are not physically active and have flat feet will have decreased muscle activation in their feet and thus impaired foot function and weakness.</p>
<p>Some older children and adolescents develop flat feet in the absence of any disorder or associated factors. Understanding the role of the <a href="http://www.ncbi.nlm.nih.gov/pubmed/25818718">small foot muscles</a> in stabilising the arch and promoting normal function of the foot and entire lower extremity might hold the answer. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=368&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=368&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=368&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=462&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=462&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130649/original/image-20160715-2122-43d1gd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=462&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Whether or not flat foot needs to be treated is up for debate.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Does flat foot need to be treated?</h2>
<p>Treatment of flat foot is subject to great controversy. Reaching an agreement between health-care providers on how we should define and classify a flat foot is difficult. Consequently, evidence from the published research is too limited to draw definitive conclusions about treatments for children’s flat feet. </p>
<p>A recent <a href="http://www.ncbi.nlm.nih.gov/pubmed/23147627">review of studies</a> found limited evidence to justify non-surgical treatments for flat foot.</p>
<p>Flat feet require treatment only if clearly associated with pain or decreased function. Managing the underlying cause or disease is of highest priority; just treating the symptoms should be secondary. </p>
<p>If flat foot is observed in a child who is overweight and has knock knees, or in a child with excess joint flexibility and poor footwear, each of these factors could be contributing to the symptoms, and each should be addressed. </p>
<p>If a child’s quality of life is affected by how their feet look, feel or function, then the associated issues should be addressed.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p>
<p><em><a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">Nightmares and night terrors in kids: when do they stop being normal?</a></em></p>
<p><a href="https://theconversation.com/bed-wetting-in-older-children-and-young-adults-is-common-and-treatable-60248"><em>Bed-wetting in older children and young adults is common and treatable</em></a></p>
<p><a href="https://theconversation.com/migraines-in-childhood-and-adolescence-more-than-just-a-headache-60712"><em>Migraines in childhood and adolescence: more than just a headache</em></a></p>
<p><a href="https://theconversation.com/drafts/61902/edit"><em>‘Slapped cheek’ syndrome: a common rash in kids, more sinister in pregnant women</em></a></p>
<p><a href="https://theconversation.com/teenage-pain-often-dismissed-as-growing-pains-but-it-can-impact-their-lives-62827"><em>Teenage pain often dismissed as ‘growing pains’, but it can impact their lives</em></a></p>
<p><a href="https://theconversation.com/is-hip-dysplasia-in-my-newborn-something-to-worry-about-61901"><em>Is hip dysplasia in my newborn something to worry about?</em></a></p>
<p><a href="https://theconversation.com/what-it-means-when-kids-walk-on-their-toes-59081"><em>What it means when kids walk on their toes</em></a></p>
<p><a href="https://theconversation.com/childhood-shyness-when-is-it-normal-and-when-is-it-cause-for-concern-60364"><em>Childhood shyness: when is it normal and when is it cause for concern?</em></a></p><img src="https://counter.theconversation.com/content/60365/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Burns receives funding from: NHMRC (National Health and Medical Research Council of Australia, Centre of Research Excellence #1031893, European Union Collaborative Research Scheme #1055131), NIH (Inherited Neuropathies Consortium RDCRC #U54NS065712 supported by NINDS/ORDR and NCATS), Muscular Dystrophy Association, CMT Association of Australia, Multiple Sclerosis Research Australia, Sydney Southeast Asia Centre, New Zealand Neuromuscular Research Foundation Trust, Thyne Reid Foundation, Elizabeth Lottie May Rosenthal Bone Bequest. </span></em></p><p class="fine-print"><em><span>David Little receives funding from: NHMRC (National Health and Medical Research Council of Australia, Project Grants #1106982 and #1066357), Australian Orthopaedic Association Research Foundation, NF Clinical Trials Consortium, Elizabeth Lottie May Rosenthal Bone Bequest. He is a paid consultant for Orthopediatrics. In the past he has received research support from Novartis Pharma, Amgen, Celgene, and N8 Medical.</span></em></p><p class="fine-print"><em><span>Polina Martinkevich does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Flatfoot is normal in infants and young children, and in the absence of any associated symptoms, treatment is highly debatable.Joshua Burns, Professor of Allied Health (Paediatrics), Children's Hospital at Westmead, University of SydneyDavid Little, Professor Paediatrics & Child Health, University of SydneyPolina Martinkevich, Research assistant, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/603642016-07-27T18:10:33Z2016-07-27T18:10:33ZChildhood shyness: when is it normal and when is it cause for concern?<figure><img src="https://images.theconversation.com/files/131868/original/image-20160726-26512-1qp0too.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If the child is shy with other kids their age, or doesn't warm up to strangers after a time, this may be a concern.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/brontelockwood/4182757885/">Bronte Lockwood/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><em>This is part of our series on kids’ health. Read the other articles in our series <a href="https://theconversation.com/au/topics/kids-health">here</a>.</em></p>
<hr>
<p>When parents observe shyness in their child, they may wonder if it is normal or cause for concern. For instance, in social situations, the child may cling to their parent, be hesitant to speak, reluctant to interact with others, and play alone when in groups more often than other children their age.</p>
<p>Shyness is of more concern if it is <a href="http://www.ncbi.nlm.nih.gov/pubmed/9249961">persistent rather than temporary</a>. Some children are “slow to warm up” or engage with others, but do engage well after initial hesitancy. Also, some children grow out of shyness during primary school. However, other children demonstrate persistent shyness over time.</p>
<p>Shyness <a href="http://www.ncbi.nlm.nih.gov/pubmed/20205182">with other children</a> is of more concern than shyness with adults. It is common for children to be wary of adults, particularly men, but less common for children to be wary of children around their own age.</p>
<p>Shyness is of concern if it results in playing alone when in groups of children. When children engage in interaction with peers they learn skills that serve as a foundation for normal development, such as how to understand other people’s feelings and perspectives, take turns in play and conversation, negotiate a mutually enjoyable joint activity, reciprocate friendly overtures and express their point of view in a way that is acceptable to others. </p>
<p>Children who engage in very little social interaction in comparison to children their age are <a href="http://www.ncbi.nlm.nih.gov/pubmed/18851686">missing out on these</a> important, cumulative learning experiences. As a result, their social cognition, social skills and sense of self may be less mature than those of other children their age.</p>
<h2>Shyness and making friends</h2>
<p>Shyness with familiar social partners <a href="http://onlinelibrary.wiley.com/doi/10.1002/icd.1853/abstract">is of more concern</a> than shyness with strangers. It is of particular concern if children are shy with other children their own age they see regularly, such as childcare or school classmates. Shyness with familiar classmates suggests children may be worried about how other kids treat them, or whether they will be liked and accepted.</p>
<p>Shyness is of more concern if a child is poorly treated by other children than if a shy child is well treated by other children. Shy children are <a href="http://www.ncbi.nlm.nih.gov/pubmed/18999325">more likely than other children</a> to be excluded and victimised by kids their own age and to have <a href="http://www.ncbi.nlm.nih.gov/pubmed/12625449">trouble making friends</a>. Being excluded and victimised are damaging to children’s emotional health and sense of self, especially when these conditions persist over time. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132092/original/image-20160727-7041-ub58nf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hiding behind a parent is pretty normal, but usually kids warm up to strangers fairly quickly.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>Although shyness tends to be equally prevalent in boys and girls, <a href="http://onlinelibrary.wiley.com/doi/10.1002/icd.1853/abstract">shy boys sometimes encounter more</a> difficulties with friends <a href="http://www.ncbi.nlm.nih.gov/pubmed/12625449">than shy girls</a>. This is probably because shyness is a violation of norms for males to be bold and self-assertive. However, it is important to keep in mind <a href="http://link.springer.com/article/10.1007/s11199-014-0361-0#page-1">both shy boys and girls</a> can encounter peer exclusion and victimisation.</p>
<h2>What you can do</h2>
<p>Children need help from adults to stop exclusion and victimisation by other children. When parents become aware their child is being excluded or victimised by other children at childcare or school, they should contact the childcare centre or school to advocate on their child’s behalf.</p>
<p>Shyness is of concern if it interferes with your child’s or family’s routines or activities, or if your child often appears miserable or complains of being lonely. For instance, if shyness prevents your child from attending other children’s birthday parties or school, or prevents your family from visiting friends, then you <a href="http://www.ncbi.nlm.nih.gov/pubmed/19707867">should consider seeking help</a> from a child psychologist.</p>
<p>Online programs to help children and parents cope with child shyness and anxiety are starting to become available and provide convenient help for a lower cost (<a href="http://www.brave-online.com/">Brave Online</a>, <a href="http://www.centreforemotionalhealth.com.au/pages/coolkidsonline.aspx">Cool Kids Online</a>). </p>
<p>Parents can also do many things themselves to help their shy child. They can arrange play dates and help the child join a group extracurricular activity. Parents can also talk to children about their friendships and act as a sympathetic source of encouragement and constructive ideas. </p>
<p>If a child is upset about a problem with a friend, parents can encourage the child to try to resolve the problem in a way that preserves the friendship, instead of ending the friendship, as well as encourage the child to develop other friendships.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p>
<p><em><a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">Nightmares and night terrors in kids: when do they stop being normal?</a></em></p>
<p><a href="https://theconversation.com/bed-wetting-in-older-children-and-young-adults-is-common-and-treatable-60248"><em>Bed-wetting in older children and young adults is common and treatable</em></a></p>
<p><a href="https://theconversation.com/migraines-in-childhood-and-adolescence-more-than-just-a-headache-60712"><em>Migraines in childhood and adolescence: more than just a headache</em></a></p>
<p><a href="https://theconversation.com/drafts/61902/edit"><em>‘Slapped cheek’ syndrome: a common rash in kids, more sinister in pregnant women</em></a></p>
<p><a href="https://theconversation.com/teenage-pain-often-dismissed-as-growing-pains-but-it-can-impact-their-lives-62827"><em>Teenage pain often dismissed as ‘growing pains’, but it can impact their lives</em></a></p>
<p><a href="https://theconversation.com/is-hip-dysplasia-in-my-newborn-something-to-worry-about-61901"><em>Is hip dysplasia in my newborn something to worry about?</em></a></p>
<p><a href="https://theconversation.com/what-it-means-when-kids-walk-on-their-toes-59081"><em>What it means when kids walk on their toes</em></a></p><img src="https://counter.theconversation.com/content/60364/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heidi Gazelle has received funding from the National Institute of Mental Health and the National Institute of Child Health and Human Development . </span></em></p>If a child is shy and poorly treated by other children their age, this may be cause for concern.Heidi Gazelle, Senior Lecturer in Developmental Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/590812016-07-26T19:51:28Z2016-07-26T19:51:28ZWhat it means when kids walk on their toes<figure><img src="https://images.theconversation.com/files/122809/original/image-20160517-15937-1yzsovy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are a number of reasons some children struggle to walk with a flat foot. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>This is part of our series on kids’ health. Read the other articles in our series <a href="https://theconversation.com/au/topics/kids-health">here</a>.</em></p>
<hr>
<p>When toddlers are learning to walk, many spend some time walking up on their tip toes, which is known as toe walking. Commonly this is to get into things they aren’t meant to, but as they perfect their walking, they walk more with their whole foot on the ground. </p>
<p>The majority of toddlers will walk with their whole foot by the time they are three. Some toddlers are unable to walk with their whole foot, and this is something that should be checked out by a health professional.</p>
<h2>Causes</h2>
<p>Toe walking can be <a href="http://www.ncbi.nlm.nih.gov/pubmed/20692159">classified</a> into four groups. Some neurological conditions such as cerebral palsy or muscular dystrophy cause the calf muscle to be tighter or change the way it works. This makes it hard or impossible for the child to get their heels onto the ground to walk with their whole foot. </p>
<p>There are also orthopaedic conditions such as congenital talipes equinovarus (also known as club foot) or <a href="https://en.wikipedia.org/wiki/Sever%27s_disease">calcaneal apophysitis</a> (inflammation of the growth plate in the heel) which cause toe walking. The structural change in the foot or leg makes getting the heel to the ground impossible or painful. </p>
<p>However, some children who can get their heels to the ground prefer to walk up on their tip toes. This group of children also has other behavioural characteristics, such as delays in achieving milestones or ritualistic behaviours. Here toe walking is associated with autism spectrum disorders or <a href="http://www.rch.org.au/uploadedFiles/Main/Content/cdr/Dev_Delay.pdf">developmental delay</a>. </p>
<p>Then there are healthy children with no medical conditions who still persist in walking on their toes. This is known as <a href="http://www.merriam-webster.com/medical/idiopathic">idiopathic</a> toe walking and is diagnosed through exclusion of all other medical conditions known to cause toe walking. Idiopathic toe walking has historically been called <a href="http://europepmc.org/abstract/med/3293753">habitual toe walking</a> with the presumption that the child has formed a habit of walking on their tip toes. It has also been called <a href="http://europepmc.org/abstract/med/6185459">familial toe walking</a>, as some studies report family members sharing the trait. </p>
<p>Idiopathic toe walking affects between <a href="http://pediatrics.aappublications.org/content/130/2/279.short">5%</a> and <a href="http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-12-61">12%</a> of healthy children and researchers don’t know its causes. </p>
<p>There may be a genetic cause as it is often seen in multiple family members. There are also other features often observed in children with this gait type. In some small studies, children with idiopathic toe walking have also shown <a href="http://www.jpeds.com/article/S0022-3476(97)70236-1/abstract">speech and language delays</a> and challenges with <a href="http://jcn.sagepub.com/content/29/1/71.short">motor skills and sensory processing</a> such as difficulty with balance and seeking out movement. </p>
<p>The most common observation in idiopathic toe walkers is tight calf muscles. This can make getting the heel to the ground even harder and can cause pain when children are trying to play sport. As you can imagine, children may be teased for walking differently. </p>
<h2>What can be done?</h2>
<p>No single treatment permanently fixes idiopathic toe walking. Often time is the greatest fixer as the children get heavier and the toe walking gets harder to maintain. </p>
<p>However, as many children with idiopathic toe walking also have tight calf muscles, many health professionals recommend treatment primarily focused on making these muscles longer. Tightness in calf muscles in adults has been known to cause trips, falls and foot and leg pain. </p>
<p>Treatment for idiopathic toe walking can be broken into two types: conservative and surgical. </p>
<p>Conservative treatment includes verbal reminders, stretching, heavy footwear, full-length orthotics, ankle foot orthotics, <a href="http://jcn.sagepub.com/content/early/2016/04/08/0883073816643405.abstract">whole-body vibration</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/26733505">vinyl, carpet or gravel flooring</a>, plaster casts to stretch the calf muscles, and injections of Botox into the calf muscles. Surgical intervention has primarily focused on lengthening the Achilles tendon.</p>
<p>Many of these treatments have limited evidence supporting their use. </p>
<p>At present, the <a href="http://www.ingentaconnect.com/content/mjl/sreh/2014/00000046/00000010/art00001">best evidence</a> supports plaster casts or surgery. Both of these treatments have shown the greatest improvement in the length of the calf muscles. Yet <a href="http://journals.lww.com/jpo-b/Abstract/2000/01000/Idiopathic_Toe_Walking__Does_Treatment_Alter_the.10.aspx">one longitudinal study</a> found that many children who had been treated with serial casts or surgery still continued to toe-walk for up to 13 years after treatment.</p>
<p>Having multiple treatment options with varied success makes it hard for parents to choose the best treatment option. It’s also a challenge for doctors in knowing what treatment to recommend. </p>
<p>Researchers agree that keeping calf muscles long enough to easily make heel contact with the ground is important for children who are diagnosed with idiopathic toe walking. If this isn’t able to happen, a health professional will commonly then encourage treatment. There is also agreement that any child who is unable to get their heels to the ground at any time or continues to toe walk after three, should be assessed by a health professional.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p>
<p><em><a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">Nightmares and night terrors in kids: when do they stop being normal?</a></em></p>
<p><a href="https://theconversation.com/bed-wetting-in-older-children-and-young-adults-is-common-and-treatable-60248"><em>Bed-wetting in older children and young adults is common and treatable</em></a></p>
<p><a href="https://theconversation.com/migraines-in-childhood-and-adolescence-more-than-just-a-headache-60712"><em>Migraines in childhood and adolescence: more than just a headache</em></a></p>
<p><a href="https://theconversation.com/drafts/61902/edit"><em>‘Slapped cheek’ syndrome: a common rash in kids, more sinister in pregnant women</em></a></p>
<p><a href="https://theconversation.com/teenage-pain-often-dismissed-as-growing-pains-but-it-can-impact-their-lives-62827"><em>Teenage pain often dismissed as ‘growing pains’, but it can impact their lives</em></a></p>
<p><a href="https://theconversation.com/is-hip-dysplasia-in-my-newborn-something-to-worry-about-61901"><em>Is hip dysplasia in my newborn something to worry about?</em></a></p><img src="https://counter.theconversation.com/content/59081/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Williams consults in private practice and for an education company providing paediatric podiatry education. Dr Williams in the past has received funding from the Australian Podiatry Education and Research Foundation for research into idiopathic toe walking. </span></em></p>Some toddlers are unable to walk with their whole foot on the ground. This should be checked out by a health professional.Cylie Williams, Adjunct Post Doctoral Research Fellow, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/628272016-07-24T20:03:49Z2016-07-24T20:03:49ZTeenage pain often dismissed as ‘growing pains’, but it can impact their lives<figure><img src="https://images.theconversation.com/files/131531/original/image-20160722-21037-qied6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Between a third and half of all adolescents aged 13 and over report back pain about every month or more often.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>This is part of our series on kids’ health. Read the other articles in our series <a href="https://theconversation.com/au/topics/kids-health">here</a>.</em></p>
<hr>
<p>Most of us know someone who has “a bad back”. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25572198">Research</a> tells us up to 70% of people will experience back pain at some stage during their lives. But what about when a child or teenager complains of musculoskeletal pain such as back or neck pain?</p>
<p>The most common type of musculoskeletal pain is spinal (back or neck pain), and many more adolescents complain of pain than is commonly recognised. Between one-third and half of all adolescents aged 13 and over report <a href="http://www.scielo.br/pdf/rbfis/2016nahead/1413-3555-rbfis-bjpt-rbf20140149.pdf">back pain about every month or more often</a>. In fact, the prevalence of these conditions rises so sharply in early adolescence the rates approach adult levels by 18 years.</p>
<p>It’s becoming increasingly clear so-called non-specific “musculoskeletal conditions”, the leading causes of disability worldwide, are significant health issues in children. By non-specific conditions we mean pain that cannot be attributed to a defined and diagnosable anatomical cause. In adults, these conditions are recognised as complex disease states that have biological, psychological and socio-environmental underpinning.</p>
<h2>Aren’t they just growing pains?</h2>
<p>In the absence of an identifiable injury such as a sprain or fracture, we often disregard childhood and adolescent spinal and musculoskeletal pain. A common belief is that pain in kids will just go away or be forgotten when life takes over.</p>
<p>However, for a significant proportion of adolescents, non-specific pain has extensive impacts on health and quality of life. For example, in a study in <a href="http://www.ncbi.nlm.nih.gov/pubmed/22304903">Western Australia</a>, about 20% of 17-year-olds reported either missing school, seeking health care, taking medication, interference with normal activities, or interference with physical/sporting activities due to back pain. </p>
<p>Worryingly, there is <a href="http://www.ncbi.nlm.nih.gov/pubmed/16481960">evidence</a> persistent pain symptoms in adolescence predict chronic pain problems in adulthood.</p>
<p>The blame for pain in kids is often directed at school bags, computer and small-screen device usage, posture, or other biomechanical targets. It is also sometimes believed (permanent) damage is being done to the spine, with lifelong consequences. </p>
<p>However, there is little evidence this is true. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22078064">Studies</a> show socioeconomic, lifestyle, cognitive and psychological factors are just as strongly, or even more strongly, related to pain, particularly chronic pain, as physical factors. </p>
<p>These societal beliefs about physical causes of pain may be not only incorrect, but detrimental if they cause worry about the spine being fragile and discourage children from physical activity.</p>
<h2>Back pain and health</h2>
<p>Health issues such as excess weight and obesity, diabetes, substance use and poor mental health among children are causes for concern, and the targets of national public health campaigns. </p>
<p>Recent <a href="http://www.scielo.br/pdf/rbfis/2016nahead/1413-3555-rbfis-bjpt-rbf20140149.pdf">evidence</a> has shown these general risk factors for poor health and chronic disease cluster in children with spinal pain. At this point, it is not possible to say whether pain precedes poorer general health or vice-versa. Relationships between them are likely to be complex. </p>
<p>However, given the high rates of musculoskeletal pain across the population, and in particular in kids with other health risks, a case can be made for considering the influence of pain in the effectiveness of lifestyle-related public health campaigns. For instance, pain could be an important barrier to participation in physical activity. </p>
<p>Addressing health behavioural risk factors, such as inactivity, weight gain, diet and even substance use, when treating young patients with pain is likely to be important. This will be important whether these behavioural risks are (partially) responsible for the pain itself or develop in response to painful symptoms.</p>
<p>Unfortunately, to date we don’t really understand the complex interaction between painful events, the growing body and broader health influences, and other social or environmental influences from family, health care providers and schooling. In particular, we know very little about what brings on the initial episodes of painful conditions and whether this underpins the link with future chronic pain.</p>
<p>Given wide recognition that early life events are critical in shaping health as people grow older, understanding the context of common painful conditions in early life is critical to inform future health.</p>
<h2>Overdiagnosis and overtreatment</h2>
<p>It is important we provide effective treatment to those at risk of developing persistent pain. It is also important we don’t create medical problems out of transient aches and pains. We definitely don’t want to be sending every child who complains of back or neck pain off for diagnostic tests and intensive treatments. A problem currently is we don’t have sufficient quality evidence to enable us to decide who we should be concerned about, and who can be reassured and sent on their way.</p>
<p>While we don’t have good evidence about what specific treatments are effective for childhood and adolescent spinal pain, it is possible to engage the community in better conversation about what causes “non-specific” musculoskeletal conditions.</p>
<p>The role of social influences needs closer examination, and pain must be considered within the broader context of chronic disease and long-term health risk factors. A shift away from the narrow and outdated focus on school bags, posture and damaged spines is a must. Efforts to update the narrative around pain are as important for children as for adults.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p>
<p><em><a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">Nightmares and night terrors in kids: when do they stop being normal?</a></em></p>
<p><a href="https://theconversation.com/bed-wetting-in-older-children-and-young-adults-is-common-and-treatable-60248"><em>Bed-wetting in older children and young adults is common and treatable</em></a></p>
<p><a href="https://theconversation.com/migraines-in-childhood-and-adolescence-more-than-just-a-headache-60712"><em>Migraines in childhood and adolescence: more than just a headache</em></a></p>
<p><a href="https://theconversation.com/drafts/61902/edit"><em>‘Slapped cheek’ syndrome: a common rash in kids, more sinister in pregnant women</em></a></p><img src="https://counter.theconversation.com/content/62827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Williams receives funding from National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Steve Kamper receives research funding from the National Health and Medical Research Council of Australia</span></em></p>The blame for pain in kids is often directed at school bags, computer and small-screen device usage, posture, or other biomechanical targets.Christopher Williams, Research Fellow at Hunter Medical Research Institute, Hunter New England Local Health District, University of NewcastleSteve Kamper, Senior Research Fellow, Musculoskeletal Division, The George Institute for Global Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/619022016-07-21T20:06:05Z2016-07-21T20:06:05Z‘Slapped cheek’ syndrome: a common rash in kids, more sinister in pregnant women<figure><img src="https://images.theconversation.com/files/129662/original/image-20160707-30685-w0jonf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While very common and not too serious in kids, slapped cheek can be serious, and even fatal, if a foetus is infected through its mother.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/71894657@N00/5898031994/">Jon Large/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><em>This is part of our series on kids’ health. Read the other articles in our series <a href="https://theconversation.com/au/topics/kids-health">here</a>.</em></p>
<hr>
<p>In 1974, while screening blood donations for hepatitis B, an Australian virologist <a href="http://www.ncbi.nlm.nih.gov/pubmed/46024">accidentally discovered</a> a new parvovirus (parvo meaning “small”). Many other parvoviruses that cause infection in animals were known, but this was the first to be found in humans.</p>
<p>This human parvovirus (hPV) was named B19 because it was found in sample 19 of panel B in the batch of tests. It was not known what disease, if any, it caused <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC497769/">until 1981</a>, when it was found to be a cause of “aplastic crisis” – severe, life-threatening anaemia in children.</p>
<p>Then, in 1983, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2129271/pdf/jhyg00013-0091.pdf">it was shown to be the cause</a> of the common childhood rash-illness, erythema infectiosum (also known as “slapped cheek” syndrome or “fifth disease”). Now that rubella and measles are rare in countries with widespread immunisation, erythema infectiosum is the commonest cause of infectious childhood rash.</p>
<p>“Slapped cheek” describes the typical bright red rash on the face caused by hPV infection; on the limbs and body the rash typically has a lacy appearance. Other symptoms, if any, are mild and short-lived in most people, but adults, particularly, can have pain in the joints of the hands, wrists and knees. </p>
<p>One in five people will have <a href="http://www.health.nsw.gov.au/Infectious/factsheets/Pages/parvovirus-B19-and-(fifth-disease).aspx">only vague symptoms</a>, such as mild fever or feeling generally unwell, or none at all. Children who contract the virus are not excluded from childcare, school or work, but are <a href="http://www.health.nsw.gov.au/Infectious/factsheets/Pages/parvovirus-B19-and-(fifth-disease).aspx">advised to rest at home</a> until they feel better.</p>
<h2>How hPV causes disease</h2>
<p>Human parvovirus infects the precursors of red blood cells in the bone marrow and temporarily stops them developing. This causes anaemia, which is usually mild, short-lived and insignificant in otherwise healthy people.</p>
<p>As the body’s immune system responds, hPV is removed and red blood cell production resumes normally. The rash and joint pains are due to the body’s immune response.</p>
<p>People whose immune systems are suppressed for any reason can have prolonged, chronic infection with severe anaemia, but no rash. Other very rare complications <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2000-cdi2403s-cdi24msa.htm">have been reported</a>, including include encephalitis (inflammation of the brain) and various blood and autoimmune diseases, but their overall frequency and significance are unknown.</p>
<p>The virus spreads by droplets in our breath or, rarely, by transfusion of blood. It can also spread from a pregnant woman to her foetus. Typically, a week or two after contact with an infected person, there are some vague symptoms such as mild fever and malaise and the rash appears a few days later. </p>
<p>Outbreaks of hPV infection occur in prolonged epidemics lasting many months, usually in late winter and early spring. Epidemics mainly occur among primary-school-aged children and usually last for a year or more. Then there are few if any cases for two to four years, then another epidemic starts.</p>
<p>During outbreaks about 50% of susceptible children (those who haven’t had it before and thus aren’t immune) in affected schools and their household contacts will be infected. The rate of infection in other susceptible contacts, such as schoolteachers, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3059196/">is about 20%</a>.</p>
<p>The proportion of people with hPV antibodies in their blood, indicating past infection and immunity, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3059196/">increases with age</a> from about 15% in preschool children, to 50% in young adults and 85% in the elderly.</p>
<h2>Pregnancy and hPV infection</h2>
<p>When a pregnant woman is infected with hPV, the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2000-cdi2403s-cdi24msa.htm%20**">likelihood that her foetus will be infected</a> is about 50%. Most will have no significant ill-effect – the only evidence that the foetus has been infected is hPV antibodies in the baby’s blood. However, when the mother’s infection is in the first trimester, there is an <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2000-cdi2403s-cdi24msa.htm**">increased risk of miscarriage</a> (about 10%). </p>
<p>Later in the first half of pregnancy, between nine and 20 weeks, foetal infection can cause severe anaemia (about 3% risk). Foetuses have a high turnover of red blood cells. When new red cell development is interrupted by infection of their precursors, production cannot keep up with demand. </p>
<p>Severe foetal anaemia can cause heart failure, which in turn causes swelling throughout the body – a potentially fatal condition known as hydrops fetalis.</p>
<p>Hydrops usually develops five to eight weeks after the mother’s infection. It causes foetal death <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2000-cdi2403s-cdi24msa.htm">in up to a third of cases</a>. A similar proportion of cases recover spontaneously. If detected in time, hydrops often can be treated successfully by blood transfusion into the uterus. </p>
<p>In skilled hands this is a safe procedure, which has been used to treat foetal hydrops for many years. Because timing is critical, it is important to confirm the mother’s hPV infection as soon as possible after it is suspected. This is done by testing her blood for a type of hPV antibody that is detectable for only a few weeks (immunoglobulin M), or by showing an increase in the level of immunoglobulin G, which persists indefinitely after infection.</p>
<p>Once the mother’s infection has been confirmed, frequent ultrasound examinations over the next few months are recommended, to detect the rare cases of hydrops. If it occurs, the mother should be referred to an experienced foetal medicine specialist.</p>
<p>There is no specific treatment or vaccine for hPV infection. Fortunately, it is nearly always mild or asymptomatic, but we need to know more about the very rare, but potentially serious, complications.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p>
<p><em><a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">Nightmares and night terrors in kids: when do they stop being normal?</a></em></p>
<p><a href="https://theconversation.com/bed-wetting-in-older-children-and-young-adults-is-common-and-treatable-60248"><em>Bed-wetting in older children and young adults is common and treatable</em></a></p>
<p><a href="https://theconversation.com/migraines-in-childhood-and-adolescence-more-than-just-a-headache-60712"><em>Migraines in childhood and adolescence: more than just a headache</em></a></p><img src="https://counter.theconversation.com/content/61902/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lyn Gilbert does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>“Slapped cheek” describes the typical bright red rash on the face caused by human parvovirus infection.Lyn Gilbert, Clinical Professor in Medicine and Infectious Diseases, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/607122016-07-20T20:05:10Z2016-07-20T20:05:10ZMigraines in childhood and adolescence: more than just a headache<figure><img src="https://images.theconversation.com/files/131170/original/image-20160720-7910-13e4qch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Childhood migraine has been found to be associated with early stress. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p><em>This is part of our series on kids’ health. Read the other articles in our series <a href="https://theconversation.com/au/topics/kids-health">here</a>.</em></p>
<hr>
<p>Headaches are uncommon in toddlers. But between the ages of three and seven, around 5% to 50% of children experience headaches of some type. From seven to 15 years, <a href="http://www.ncbi.nlm.nih.gov/pubmed/24641507">headache prevalence peaks at up to 75%</a>. The vast majority of headaches experienced are tension-type headaches that don’t need specific treatment. But a quarter of these troublesome headaches are migraines.</p>
<p>Migraine headaches are the most common type of severe headache. They occur when networks of sensory and regulatory nerves deep in the brain are disordered. The details of exactly how migraines work are not yet fully understood but research in this area has made <a href="http://www.ncbi.nlm.nih.gov/pubmed/25926442">rapid progress</a>, especially in the last decade.</p>
<p>Many adults who have a lifelong problem with migraines first experience them in childhood or adolescence. Migraine headaches occur in 15% to 18% of children, and the prevalence peaks between the ages of 11 and 13. </p>
<p>These figures are <a href="http://onlinelibrary.wiley.com/doi/10.1046/j.1468-2982.2003.00568.x/abstract;jsessionid=FD02A127FD1AA7945BFA23D52E93FF69.f02t02?userIsAuthenticated=false&deniedAccessCustomisedMessage=">similar in adults</a>. The worst 10% of adult sufferers account for 85% of the overall time lost to headaches. This suggests that if you don’t get effectively treated or grow out of your adolescent migraines, they <a href="http://link.springer.com/article/10.1007/s10194-009-0133-3">may get progressively worse</a>.</p>
<p>Much of <a href="http://www.ncbi.nlm.nih.gov/pubmed/27322543">the risk of having migraines is genetic</a> so it is no surprise that two-thirds of childhood migraine sufferers have a <a href="http://www.ncbi.nlm.nih.gov/pubmed/25304765">family history of disabling migraine</a>.</p>
<h2>What causes childhood migraine?</h2>
<p>There are some significant differences between migraines that occur early in life and those that occur later. A clear link between <a href="https://www.sciencedaily.com/releases/2010/01/100106003608.htm">childhood adversity</a> and migraine predisposition throughout life is <a href="https://consumer.healthday.com/head-and-neck-information-17/migraine-news-477/emotional-abuse-during-childhood-linked-to-migraine-risk-708301.html">emerging from current research</a>. </p>
<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2009.01558.x/full">influence is likely to be complex</a> and is currently poorly understood. It may well be that prolonged exposure of a developing brain to excessive stress causes neuroplastic changes or altered biochemistry that create a migraine-prone brain forever after.</p>
<p>Early onset of migraine symptoms indicates a child is at increased risk of a number of other conditions characterised by severe episodes of symptoms that occur in a cyclical fashion, such as abdominal pain, vertigo and <a href="https://en.wikipedia.org/wiki/Torticollis">torticollis</a> (where the position of the head or neck is abnormal or asymmetrical). These “<a href="http://bit.ly/29PldsO">episodic syndromes</a>” are highly distressing and disabling. They may reflect a common disorder of pain processing and are considered variants of migraine.</p>
<p>There are documented associations of early-onset migraine with <a href="http://onlinelibrary.wiley.com/doi/10.1046/j.1468-2982.2003.00486.x/abstract?userIsAuthenticated=false&deniedAccessCustomisedMessage=">emotional and behavioural difficulties</a>. Understanding these relationships better will contribute enormously to potential prevention strategies but also perhaps to new treatment approaches. </p>
<p>The most <a href="http://www.ncbi.nlm.nih.gov/pubmed/21044280">common triggers</a> for childhood migraine are similar to adults: emotional stress, sleep deprivation, skipping food, menstruation and <a href="http://www.ncbi.nlm.nih.gov/pubmed/19545255">weather</a>. </p>
<p>Hormonal fluctuations during <a href="http://www.ncbi.nlm.nih.gov/pubmed/27017029">young women’s periods</a> are one of the most consistently disabling trigger factors and many sufferers may need oral contraceptives to regulate hormone levels. It seems these common triggers may all <a href="http://www.ncbi.nlm.nih.gov/pubmed/26639834?log$=activity">increase oxidative stress</a> (chemical not emotional stress) in the brain. </p>
<p>It will no doubt be welcome news that while chocolate remains a common scapegoat in headache causation, the <a href="http://www.ncbi.nlm.nih.gov/pubmed/25567457">scientific evidence for this belief is thin</a>.</p>
<h2>How to treat childhood migraines</h2>
<p>It’s important to accurately evaluate frequent or severe childhood headaches given these children’s quality of life is <a href="http://pediatrics.aappublications.org/content/112/1/e1.short">severely impaired</a> and the long-term impacts may be substantial. </p>
<p>The doctor needs to thoroughly explore psychological and social factors, which may require tact and time for trust to develop. School absences must be prevented or mitigated so the child does not fall behind her peers either academically or socially. Having a <a href="https://www.migrainetrust.org/wp-content/uploads/2015/12/CIRC_School-Policy-Guideline-Headache-FINAL-10Oct11.pdf">formal plan</a> may help the school accommodate young headache sufferers. </p>
<p>The Royal Australian College of General Practitioners has published <a href="http://www.racgp.org.au/afp/2015/june/managing-childhood-migraine/#15">recommendations for GPs</a> to use analgesics or migraine drugs (known as triptans) to treat migraine, but to also focus on addressing possible environmental, social, and psychological factors that could be at play. </p>
<p>Treatment of migraines in childhood support the idea that it is virtually a different disorder compared to adults. Thankfully, simple pain relief such as non-steroidal anti-inflammatories (NSAIDs) including aspirin and ibuprofen are more effective than in adults. Allowing the child to sleep if they want to is also very effective. </p>
<p>The triptans – standard drugs for aborting attacks in adults – <a href="http://www.neurology.org/content/48/4/1100.short">do not seem to work</a> as well in children. The response to medication becomes more <a href="http://www.ncbi.nlm.nih.gov/pubmed/27316535">“adult-like”</a> after puberty. </p>
<p>First-line preventive treatments used in adults, such as propranolol (a heart medication), amitriptyline (an antidepressant) and sodium valproate (usually used to treat epilepsy) have <a href="http://www.ncbi.nlm.nih.gov/pubmed/15012660">not been thoroughly studied</a> for efficacy in children, though they do appear safe for short- to medium-term use. </p>
<p>Decisions about prevention against frequent, disabling attacks require careful thought and are probably best done in conjunction with a paediatrician or paediatric neurologist. Treatment plans for preventing frequent and severe headaches may need to include input from a multidisciplinary team to ensure triggers are addressed by all available means, not just pharmacological ones.</p>
<p>In general, while migraine remains a lifelong predisposition when it starts in childhood or adolescence, the outlook is pretty positive. From the peak of the mid-teenage years, both the frequency and average severity of acute migraine attacks tends to drop off the older you get until a <a href="http://www.ncbi.nlm.nih.gov/pubmed/20713557">second peak in the 50s</a>. </p>
<p>For such a common and disruptive condition, it is perhaps a bit surprising we don’t know more. Effective early intervention and well-organised diagnosis and treatment of childhood migraines may save severe adult sufferers from decades of underachievement and frustration.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p>
<p><em><a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">Nightmares and night terrors in kids: when do they stop being normal?</a></em></p>
<p><a href="https://theconversation.com/bed-wetting-in-older-children-and-young-adults-is-common-and-treatable-60248"><em>Bed-wetting in older children and young adults is common and treatable</em></a></p><img src="https://counter.theconversation.com/content/60712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Vagg does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many adults who have a lifelong problem with migraines first experience them in childhood or adolescence.Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Barwon HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/602482016-07-19T20:08:40Z2016-07-19T20:08:40ZBed-wetting in older children and young adults is common and treatable<figure><img src="https://images.theconversation.com/files/130164/original/image-20160712-9307-rv5oz1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">About 0.5-3% of older children and young adults still wet the bed at night.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>This article is part of our series looking at health conditions in children. Later in the week, we’ll have others about childhood migraines and slapped cheek disease. Read yesterday’s article about nightmares and night terrors <a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">here</a>.</em></p>
<hr>
<p>Bed-wetting is surprisingly common in older children and young adults. Lack of public awareness and stigma associated with bed-wetting means few seek professional help despite successful treatments being available.</p>
<p>Bed-wetting (enuresis) is a sleep problem. It occurs when individuals are unable to wake to urinate when the bladder is full. </p>
<p>Three main factors affect bed-wetting:</p>
<ol>
<li><p>a large volume of urine produced at night which depends on the amount and type of drinks consumed (for example, alcohol is a diuretic), as well as the effect of inadequate amounts of the hormone vasopressin. Vasopressin is normally secreted in larger quantities at night causing the kidneys to make less urine. Some people secrete less vasopressin than normal during sleep, resulting in <a href="http://www.ncbi.nlm.nih.gov/pubmed/2705537">larger volumes of urine being produced</a>.</p></li>
<li><p>a small bladder or a bladder that contracts more than normal during sleep and holds less urine at night. Caffeine and constipation can affect the bladder. </p></li>
<li><p>people who sleep deeply as well as those with sleep problems find it difficult to wake when the bladder is full during sleep. Tiredness, medication with a sedative effect, as well as alcohol can also affect sleep arousal.</p></li>
</ol>
<p>Therefore, when the urine volume exceeds what the bladder is able to hold, wetting occurs if the person is unable to wake to void.</p>
<h2>How common is it?</h2>
<p>About <a href="http://www.ncbi.nlm.nih.gov/pubmed/16643494">0.5-3% of teenagers</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/9458510">young adults</a> wet the bed at night. Most of them have always wet, but <a href="http://www.ncbi.nlm.nih.gov/pubmed/12460356">20% start</a> after being previously dry (secondary enuresis). Reasons for secondary enuresis identified in young people include <a href="http://www.ncbi.nlm.nih.gov/pubmed/26428651">post-traumatic stress disorder</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/20354997">anorexia nervosa</a> (with <a href="http://www.ncbi.nlm.nih.gov/pubmed/16643494">resolution of bed-wetting</a> when their weight increases).</p>
<p>Unlike younger children, bed-wetting tends to persist and be more severe in older children and young adults, with 50-80% wetting <a href="http://www.ncbi.nlm.nih.gov/pubmed/14764133">at least three nights per week</a>. Those with a history of bed-wetting associated with bladder problems and those with severe bed-wetting when they were younger are <a href="http://www.ncbi.nlm.nih.gov/pubmed/16945646">more likely to continue</a> to wet as adults. </p>
<h2>Impact of bed-wetting</h2>
<p>Because of the stigma and shame associated with bed-wetting, its devastating impact on young people is often unappreciated. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3708079/">Studies</a> have <a href="http://www.ncbi.nlm.nih.gov/pubmed/21784481">shown</a> young people with bed-wetting have lower self-esteem and higher risk of depression. </p>
<p><a href="http://search.informit.com.au/documentSummary;dn=047555473066657;res=IELHEA">Young adults have reported</a> their condition has affected their work performance, choice of jobs, relationships and decision to have a life partner. </p>
<h2>Treatments</h2>
<p>Although effective treatments are available, <a href="http://www.ncbi.nlm.nih.gov/pubmed/9458510">most adults erroneously believe</a> their problem is not treatable. Some <a href="http://www.ncbi.nlm.nih.gov/pubmed/9458510">20-50% of young adults</a> have never sought professional help about their problem, and continue to suffer in silence. </p>
<p>The principles for treating bed-wetting are the same for adults and children, and those who seek treatment <a href="http://www.ncbi.nlm.nih.gov/pubmed/9458510">usually respond well</a>. However a <a href="http://www.ncbi.nlm.nih.gov/pubmed/12460356">quarter of young people</a> have problems adhering to the treatment prescribed, suggesting a different approach may be needed for this population.</p>
<p>Urotherapy is conservative treatment centered around education and reinforcing good bladder and bowel habits such as drinking well, minimising caffeine and alcohol, going to the toilet regularly and managing constipation. Sometimes these simple measures can alleviate bed-wetting.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/19643460">Desmopressin</a>, a synthetically made vasopressin, <a href="http://www.ncbi.nlm.nih.gov/pubmed/7970999">has been effectively used</a> in young people. Desmopressin decreases overnight urine production, increasing the likelihood of being dry and sleeping through the night. However, there is no sustained effect, and wetting <a href="http://www.cochrane.org/CD002112/INCONT_desmopressin-for-bedwetting-in-children">usually recurs</a> when desmopressin is stopped. </p>
<p>Imipramine, an antidepressant, is an <a href="http://www.cochrane.org/CD002117/INCONT_tricyclics-and-related-drugs-treating-bedwetting-children">older treatment that has also been used</a> for bed-wetting. The exact mechanism of action is unknown but may be related to its effect on <a href="http://www.cochrane.org/CD002117/INCONT_tricyclics-and-related-drugs-treating-bedwetting-children">reducing spasm in the bladder</a>. Imipramine has risks for serious side-effects such as irregular heart rhythm and treatment effects are not sustained when stopped.</p>
<p>Bed-wetting alarm training is one of the most effective treatments for bed-wetting, and the <a href="http://www.ncbi.nlm.nih.gov/pubmed/15846643">only one that has a sustained effect</a>. Alarms train the individual to wake to urinate when their bladder is full and to withhold urinating at other times.</p>
<p>Bed-wetting alarm sensors are usually worn in the underpants or placed on the bed as a mat. They detect wetness and emit a noise or vibration. Arousal to the alarm signal and going to the toilet at that point is essential for treatment success. If the individual cannot wake to the alarm, they will need support from a family member or friend. </p>
<p>Although bed-wetting alarms are the treatment of choice for bed-wetting, young people may find alarm training embarrassing and difficult to do. Alarm training generally takes two to three months and can cease after 14 consecutive dry nights have been achieved.</p>
<p>Although treatments are available for older children at paediatric centres, there are currently no services for young adults. It is time to raise awareness that bed-wetting in young people is both common and treatable and to request more services and research to help this vulnerable population.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p>
<p><em><a href="https://theconversation.com/nightmares-and-night-terrors-in-kids-when-do-they-stop-being-normal-60257">Nightmares and night terrors in kids: when do they stop being normal?</a></em></p><img src="https://counter.theconversation.com/content/60248/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrina Ha Yuen Caldwell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Lack of public awareness and stigma associated with bed-wetting in older children means few seek professional help despite successful treatments being available.Patrina Ha Yuen Caldwell, Staff Specialist, Centre for Kidney Research, The Children's Hospital at Westmead; Senior Lecturer, Discipline of Paediatrics and Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/602572016-07-18T20:06:43Z2016-07-18T20:06:43ZNightmares and night terrors in kids: when do they stop being normal?<figure><img src="https://images.theconversation.com/files/127027/original/image-20160617-30170-1lf6c9z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Night terrors and nightmares are very different things and need to be managed differently. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/clement127/15444970547/">clement127/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><em>This article is part of our series looking at health conditions in children. Later in the week, we’ll have others about childhood migraines and bed-wetting in older kids. Read yesterday’s article about asthma <a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277">here</a>.</em></p>
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<p>Two of the most common causes of night waking in children are night terrors and nightmares. Parents often get them confused but they are different, as is how they should be managed. </p>
<p>Before we can understand night terrors and nightmares, we need to understand normal sleep. All children and adults cycle through stages of deep sleep, also known as non-rapid eye movement (non-REM), and light sleep, also known as REM. </p>
<p>We fall immediately into deep sleep where we typically stay for the first few hours of the night. Thereafter, we cycle through deep and light sleep. These sleep cycles last 30-60 minutes in children and around 90 minutes in adults. When we come into light sleep, we can wake up briefly, look around the room, adjust the bedclothes, and if everything is OK, go back to sleep again.</p>
<p>Night terrors and nightmares happen in different parts of the sleep cycle and in different parts of the night. Night terrors usually happen before midnight and occur when the child is “stuck” between a deep and light sleep stage. Their body is therefore “awake” but their mind isn’t. In contrast, nightmares tend to occur after midnight and happen during the light sleep stage, when we do most of our dreaming.</p>
<p>During a night terror, the child has a sudden onset of screaming, can have their eyes open or shut, can breathe rapidly and have a fast heartbeat. They look terrified and can get up and run around. However, because they are not truly awake, children have no memory of the event in the morning. If their parent tries to comfort them with a hug, the child will typically push the parent away.</p>
<p>During nightmares, however, children will usually wake up completely from their bad dream and be scared. They welcome a hug and can remember what happened in the morning.</p>
<h2>Managing nightmares and night terrors</h2>
<p>These differences give us an insight into how best to manage night terrors and nightmares. </p>
<p>For night terrors, parents would do best to check their child is OK (hasn’t got their leg stuck in the cot, for example) and then leave them be if it is safe to do so. Many parents continue to try to comfort their child but this usually results in the child waking up completely and being very confused and hard to re-settle. </p>
<p>Children who are having a nightmare need to be comforted by their parent and returned to bed once they have calmed down.</p>
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<a href="https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/127029/original/image-20160617-30196-orw4li.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Children will usually wake up from nightmares, remember the content, and be scared.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/whoisthatfreakwiththecamera/8184672835/">Michael Day/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>For almost all children, night terrors and nightmares are a part of normal development and not a cause for concern. Both can run in families. </p>
<p>For some children, who have frequent nightmares and show other signs of distress, such as changes in their appetite or recurrent body pains (think headaches and stomach pains), or who appear withdrawn or upset, nightmares can be a sign something else is going on. </p>
<p>These children should be seen by a health professional, who can work with the child and the family to identify and address underlying issues, such as problems at school with learning or bullying or family problems including violence.</p>
<h2>How to treat them</h2>
<p>Night terrors that persist and occur around the same time each night can be treated with a technique called “scheduled awakening”. This involves waking the child up around 30 minutes before their night terror. This is thought to reset the sleep cycle, thereby helping them avoid getting “stuck” between deep and light sleep stages. </p>
<p>Parents need to persist with this technique for at least three weeks to know if it helps or not.</p>
<p>Triggers common to both nightmares and night terrors include illnesses and lack of sleep. While illnesses are hard to avoid, parents can ensure their child has adequate sleep, starting with a good bedtime routine. </p>
<p>There are many helpful resources on how to help children sleep including the <a href="http://www.raisingchildren.net.au">Raising Children Network</a> and the <a href="http://www.sleephealthfoundation.org.au">Sleep Health Foundation</a>. Ensuring a good nights’ sleep for children can benefit not only the child, but the rest of the family as well.</p>
<hr>
<p><em>Further reading:</em></p>
<p><a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277"><em>Do kids grow out of childhood asthma?</em></a></p>
<p><a href="https://theconversation.com/a-snapshot-of-childrens-health-in-australia-62500"><em>A snapshot of children’s health in Australia</em></a></p><img src="https://counter.theconversation.com/content/60257/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harriet Hiscock is affiliated with the Sleep Health Foundation (member, GP Education subcommittee) and is an Expert Content Advisor to the Raising Children Network.
Harriet Hiscock has received NHMRC project grants to evaluate sleep strategies for infant sleep problems and sleep problems in primary school aged children and in children with ADHD.</span></em></p>Before we can understand night terrors and nightmares, we need to understand normal sleep.Harriet Hiscock, Principal Fellow, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/625002016-07-17T20:09:18Z2016-07-17T20:09:18ZA snapshot of children’s health in Australia<figure><img src="https://images.theconversation.com/files/130637/original/image-20160715-2110-in0zi4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The overall infant mortality rate more than halved between 1986 and 2014. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>Today, we start our series looking at health conditions in children. Later in the week, we’ll have articles about childhood migraines, bed-wetting in older kids, and nightmares and night terrors.</em></p>
<p><em>The infographic below provides a snapshot of children’s health in Australia, from mortality and chronic conditions to the risk factors adversely affecting our children’s health.</em> </p>
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This infographic provides a snapshot of children’s health in Australia, from mortality and chronic conditions to the risk factors adversely affecting our children’s health.Alexandra Hansen, Deputy Editor and Chief of Staff, The Conversation AUNZEmil Jeyaratnam, Data + Interactives Editor, The ConversationLicensed as Creative Commons – attribution, no derivatives.