Antidepressants Blog

KNOCK KNEES

Knock knees is a common condition in toddlers and becomes most obvious at around 3 years of age, disappearing by the time the child starts school. When the child stands, the knees touch but the ankles are separated by a gap of 5 cm or more. The condition is very rarely due to an underlying medical or orthopaedic cause but it can run in families. In the vast majority of cases, knock knees are considered to be normal and of no consequence. Some children may appear clumsy when they run, but most have no problems at all. Treatment is rarely required for children with knock knees. If your child is overweight, losing weight can help to resolve the problem. In more severe cases, night splinting or special shoes may be prescribed.

‘PIGEON TOES’ (IN-TOEING)

Babies and toddlers have a normal tendency towards having feet that point inward. This may also be accompanied by bowing of the legs. Pigeon toes are usually due to a particular alignment of the thigh and hip bones, which are turned inward.

This condition usually corrects itself naturally as the child grows. Very occasionally pigeon toes are seen as part of an underlying neurological condition, such as cerebral palsy.

Some toddlers and young children with pigeon toes may appear clumsy, but usually most parents come to the doctor because of concerns about the way the child’s feet look, or about marked wearing on one side of the shoes. Treatment is rarely necessary, although in severe or persistent cases, night splints or special shoes are sometimes used. Surgery is rarely necessary.

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When a child limps he carries his weight more on one leg than on the other, usually because of pain although a limp can also be painless.

Cause

There are numerous possible causes for a limp, ranging from a bruised leg or foot, a tight shoe, or a wart on the sole of the foot, to a broken bone (fracture), or cerebral palsy. A bone tumour can cause a limp, but these tumours are rare.

Clinical features

The child’s limp favours the good leg, and puts as little weight as possible on the leg that is causing pain. Sometimes the child will be able to point to the area of pain, but more often it is generalised and the muscles themselves are sore from straining due to the limp.

When to see your doctor

Any child who has a limp that persists for more than a day, which does not have an obvious cause such as a tight shoe, should be seen by a doctor without delay.

You should also see your doctor:

• your child has an unexplained fever;

• your child refuses to walk at all;

• there is obvious swelling of part of the hip or leg, especially around a joint.

Treatment

Treatment depends on establishing the particular cause of the limp. In minor injuries, rest may be all that is required. Problems of a more serious nature should be referred to a specialist for further assessment.

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This is the commonest disease of the hip joint in childhood. Cause

The cause of irritable hip is uncertain, but the condition has been attributed to viruses and trauma.

Clinical features

A child with an irritable hip is usually between 2 and 5 years of age. He is generally well, and may have only the slightest fever. He has a noticeable, but painless limp, and when examined has difficulty in moving his leg to the side.

Investigations

X-rays of the hip as well as blood tests are usually normal. Follow-up X-rays are usually performed a month later to monitor progress.

• if your child suddenly develops an unexplained limp;

• if he is also unwell or has a fever;

• if he complains of pain in the hip joint or knee.

Treatment

The preferred treatment once the diagnosis of irritable hip has been made is bed rest for a week. Your doctor will generally refer your child to a paediatric orthopaedic surgeon, who may advise the short-term use of traction.

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If CDH is detected during infancy, treatment is usually simple and straightforward, resulting in total correction. The later it is diagnosed, with subsequent delay in the commencement of treatment, the more difficult it is to correct, and the more uncertain the final result.

All newborn babies suspected of having a dislocated hip are placed immediately in a special harness or splint, which holds the hip in the socket of the hip joint by keeping the thighs apart. This is worn for around 3 months and can be removed at bath time. Although it may look awkward, the splint causes the baby no discomfort.

If treatment is started after the child is 1 year old, then traction and often surgery are needed, followed by 6 to 9 months in a plaster cast (which is changed every few weeks to allow for growth).

When to see your doctor

If you notice any of the features described above, see the doctor. If there is any doubt, an X-ray or ultrasound can confirm the diagnosis. Referral to a paediatric orthopaedic surgeon for a specialist opinion may be advisable.

Prevention

Every baby should be examined fully straight after birth, and again at 6 weeks, including a check for CDH. If there is a family history of CDH or your baby was born by a breech birth, special care needs to be taken with t the examination. While CDH cannot be prevented, early detection and immediate institution of treatment are very important.

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It used to be thought that a baby was incapable of very much interaction with the environment, and that he simply lay there sleeping and feeding until he began to develop more sophisticated capacities from about 6 weeks of age. It was also thought that young babies could not feel pain. Research over recent decades has shown that these theories are simply not correct. From the moment of birth, a baby has a rich and ever-expanding repertoire of physical and social responses to the environment. Far from lying there passively, each baby is capable of initiating and modulating interactions with care-givers. All parents will be aware of their baby being able to make and sustain eye contact, being alert to sounds, and responsive to feeding. He has a rich range of communication skills.

You need to take time to learn how your baby communicates. There is great variation in how babies react to the environment. Some like lots of stimulation — to be held, rocked, talked to — while others are easily overwhelmed and need ‘space’ and time to themselves, so that they can self-regulate and readjust after a period of stimulation. Some babies will avert the gaze or become irritable with too much stimulation, and parents can read this as a signal that the baby wants to be left alone for a while (see Colic, p. 93).

You need to be very patient in the first few months as you learn how to ‘connect’ with your baby. Let him dictate the pace.

As the baby grows older, there is a rapid progression in all aspects of development. His capacity for social interaction becomes more sophisticated. There is increased eye contact, smiling, following, and the baby is more alert. He begins to vocalise and engage in reciprocal ‘talking’ with care-givers. Then follow more babbling and eventually, speech. As the baby learns to reach for toys, then pull himself along on the floor, then sit, crawl and walk, he is increasingly able to explore his environment. This is an important part of learning.

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When you check the chemical names of what is in your painkiller against the above list, you may not find one or more of the ingredients. A likely reason is that the missing ingredient is a sedative. Ask if you are not sure. If you have been prescribed a painkilling mixture that includes a sedative, I suggest you ask for a change. The sedative will just make you more sleepy and used without doing anything for your pain. If you want to have a sedative to help you relax it is better to take it separately. You will then be able to adjust your dose of painkiller according to your pain and your dose of sedative according to your degree of relaxation.

My advice is similar if you are prescribed a painkilling mixture of morphine and alcohol. If you are taking morphine in liquid form, ask whether it contains alcohol. If you want alcohol, you will probably prefer to take it separately in a form that you enjoy and in the amount that suits you, rather than mixed with your painkiller.

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