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A migraine headache is a form of vascular headache. Migraine headache is caused by vasodilatation (enlargement of blood vessels) that causes the release of chemicals from nerve fibers that coil around the large arteries of the brain. Enlargement of these blood vessels stretches the nerves that coil around them and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the arteries magnifies the pain.

Migraine attacks commonly activate the sympathetic nervous system in the body. The sympathetic nervous system is often thought of as the part of the nervous system that controls primitive responses to stress and pain, the so-called “fight or flight” response, and this activation causes many of the symptoms associated with migraine attacks; for example, the increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea.

•Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed.
•The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches.
•The increased sympathetic activity also decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet.
•The increased sympathetic activity also contributes to the sensitivity to light and sound sensitivity as well as blurred vision.
Migraine afflicts 28 million Americans, with females suffering more frequently (17%) than males (6%). Missed work and lost productivity from migraine create a significant public burden. Nevertheless, migraine still remains largely underdiagnosed and undertreated. Less than half of individuals with migraine are diagnosed by their doctors.

JENNIFER MAYFIELD, M.D., M.P.H.,
Bowen Research Center, Indiana University,
Indianapolis, Indiana   A patient information handout on diabetes mellitus, written by the author of this article, is provided on page 1369.
 

New recommendations for the classification and diagnosis of diabetes mellitus include the preferred use of the terms “type 1″ and “type 2″ instead of “IDDM” and “NIDDM” to designate the two major types of diabetes mellitus; simplification of the diagnostic criteria for diabetes mellitus to two abnormal fasting plasma determinations; and a lower cutoff for fasting plasma glucose (126 mg per dL [7 mmol per L] or higher) to confirm the diagnosis of diabetes mellitus. These changes provide an easier and more reliable means of diagnosing persons at risk of complications from hyperglycemia. Currently, only one half of the people who have diabetes mellitus have been diagnosed. Screening for diabetes mellitus should begin at 45 years of age and should be repeated every three years in persons without risk factors, and should begin earlier and be repeated more often in those with risk factors. Risk factors include obesity, first-degree relatives with diabetes mellitus, hypertension, hypertriglyceridemia or previous evidence of impaired glucose homeostasis. Earlier detection of diabetes mellitus may lead to tighter control of blood glucose levels and a reduction in the severity of complications associated with this disease.

Diabetes mellitus is a group of metabolic disorders with one common manifestation: hyperglycemia. Chronic hyperglycemia causes damage to the eyes, kidneys, nerves, heart and blood vessels. The etiology and pathophysiology leading to the hyperglycemia, however, are markedly different among patients with diabetes mellitus, dictating different prevention strategies, diagnostic screening methods and treatments. The adverse impact of hyperglycemia and the rationale for aggressive treatment have recently been reviewed.1

 
See editorial
on page 1290.
 

In June 1997, an international expert committee released a report with new recommendations for the classification and diagnosis of diabetes mellitus.2 These new recommendations were the result of more than two years of collaboration among experts from the American Diabetes Association and the World Health Organization (WHO). The use of classification systems and standardized diagnostic criteria facilitates a common language among patients, physicians, other health care professionals and scientists.

Previous Classification

 
Diabetes mellitus that is characterized by absolute insulin deficiency and acute onset, usually before 25 years of age, should now be referred to as type 1 (not type I, IDDM or juvenile) diabetes mellitus.
 
 

In 1979, the National Diabetes Data Group produced a consensus document standardizing the nomenclature and definitions for diabetes mellitus.3 This document was endorsed one year later by WHO.4,5 The two major types of diabetes mellitus were given names descriptive of their clinical presentation: “insulin-dependent diabetes mellitus” (IDDM) and “non­insulin-dependent diabetes mellitus” (NIDDM). However, as treatment recommendations evolved, correct classification of the type of diabetes mellitus became confusing. For example, it was difficult to correctly classify persons with NIDDM who were being treated with insulin. This confusion led to the incorrect classification of a large number of patients with diabetes mellitus, complicating epidemiologic evaluation and clinical management. The discovery of other types of diabetes with specific pathophysiology that did not fit into this classification system further complicated the situation. These difficulties, along with new insights into the mechanisms of diabetes mellitus, provided a major impetus for the development of a new classification system.

The National Diabetes Data Group also established the oral glucose tolerance test (using a glucose load of 75 g) as the preferred diagnostic test for diabetes mellitus.3 However, this test has poor reproducibility, lacks physiologic relevance and is a weaker indicator of long-term complications compared with other measures of hyperglycemia.6 Furthermore, many high-risk patients are unwilling to undergo this time-consuming test on a repeat basis. The new diagnostic criteria also address this issue.

Changes in the Classification System

The new classification system identifies four types of diabetes mellitus: type 1, type 2, “other specific types” and gestational diabetes. Arabic numerals are specifically used in the new system to minimize the occasional confusion of type “II” as the number “11.” Each of the types of diabetes mellitus identified extends across a clinical continuum of hyperglycemia and insulin requirements.

 
Any patient with two fasting plasma glucose levels of 126 mg per dL (7.0 mmol per L) or greater is considered to have diabetes mellitus.
 
 

Type 1 diabetes mellitus (formerly called type I, IDDM or juvenile diabetes) is characterized by beta cell destruction caused by an autoimmune process, usually leading to absolute insulin deficiency.2,7 The onset is usually acute, developing over a period of a few days to weeks. Over 95 percent of persons with type 1 diabetes mellitus develop the disease before the age of 25, with an equal incidence in both sexes and an increased prevalence in the white population. A family history of type 1 diabetes mellitus, gluten enteropathy (celiac disease) or other endocrine disease is often found. Most of these patients have the “immune-mediated form” of type 1 diabetes mellitus with islet cell antibodies and often have other autoimmune disorders such as Hashimoto’s thyroiditis, Addison’s disease, vitiligo or pernicious anemia. A few patients, usually those of African or Asian origin, have no antibodies but have a similar clinical presentation; consequently, they are included in this classification and their disease is called the “idiopathic form” of type 1 diabetes mellitus.2,7

Type 2 diabetes mellitus (formerly called NIDDM, type II or adult-onset) is characterized by insulin resistance in peripheral tissue and an insulin secretory defect of the beta cell.2,7 This is the most common form of diabetes mellitus and is highly associated with a family history of diabetes, older age, obesity and lack of exercise. It is more common in women, especially women with a history of gestational diabetes, and in blacks, Hispanics and Native Americans. Insulin resistance and hyperinsulinemia eventually lead to impaired glucose tolerance. Defective beta cells become exhausted, further fueling the cycle of glucose intolerance and hyperglycemia. The etiology of type 2 diabetes mellitus is multifactorial and probably genetically based, but it also has strong behavioral components.

Types of diabetes mellitus of various known etiologies are grouped together to form the classification called “other specific types.” This group includes persons with genetic defects of beta-cell function (this type of diabetes was formerly called MODY or maturity-onset diabetes in youth) or with defects of insulin action; persons with diseases of the exocrine pancreas, such as pancreatitis or cystic fibrosis; persons with dysfunction associated with other endocrinopathies (e.g., acromegaly); and persons with pancreatic dysfunction caused by drugs, chemicals or infections.2,7 The etiologic classifications of diabetes mellitus are listed in Table 1.2

TABLE 1
Etiologic Classifications of Diabetes Mellitus 
 
Type 1 diabetes mellitus*

Type 2 diabetes mellitus*

Other specific types:

Genetic defects of beta-cell function
Genetic defects in insulin action
Diseases of the exocrine pancreas
Pancreatitis
Trauma/pancreatectomy
Neoplasia
Cystic fibrosis
Hemochromatosis
Others
Endocrinopathies
Acromegaly
Cushing’s syndrome
Glucagonoma
Pheochromocytoma
Hyperthyroidism
Somatostatinoma
Aldosteronoma
Others
Drug- or chemical-induced
Vacor†
Pentamidine
Nicotinic acid
Glucocorticoids
Thyroid hormone
Diazoxide
Beta-adrenergic agonists
Thiazides
Phenytoin
Alfa-interferon
Others Infections
Congenital rubella
Cytomegalovirus
Others
Uncommon forms of immune- mediated diabetes
Other genetic syndromes sometimes associated with diabetes
Down syndrome
Klinefelter’s syndrome
Turner’s syndrome
Wolfram syndrome
Friedreich’s ataxia
Huntington’s chorea
Lawrence-Moon Beidel syndrome
Myotonic dystrophy
Porphyria
Prader-Willi syndrome
Others
Gestational diabetes mellitus
 

——————————————————————————–

*–Patients with any form of diabetes may require insulin treatment at some stage of the disease. Use of insulin does not, of itself, classify the patient.

†–Vacor is an acute rodenticide that was released in 1975 but withdrawn as a general-use pesticide in 1979 because of severe toxicity. Exposure produces destruction of the beta cells of the pancreas, causing diabetes mellitus in survivors.

Adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-97.
 
 

The definition and diagnosis of gestational diabetes mellitus was not altered in these new recommendations.2 Gestational diabetes mellitus is an operational classification (rather than a pathophysiologic condition) identifying women who develop diabetes mellitus during gestation.7 (Women with diabetes mellitus before pregnancy are said to have “pregestational diabetes” and are not included in this group.) Women who develop type 1 diabetes mellitus during pregnancy and women with undiagnosed asymptomatic type 2 diabetes mellitus that is discovered during pregnancy are classified with gestational diabetes mellitus. However, most women classified with gestational diabetes mellitus have normal glucose homeostasis during the first half of the pregnancy and develop a relative insulin deficiency during the last half of the pregnancy, leading to hyperglycemia. The hyperglycemia resolves in most women after delivery but places them at increased risk of developing type 2 diabetes mellitus later in life.

TABLE 2
Criteria for the Diagnosis of Diabetes Mellitus and Impaired Glucose Homeostasis 
 
Diabetes mellitus–positive findings from any two of the following tests on different days:
Symptoms of diabetes mellitus* plus casual† plasma glucose concentration >=200 mg per dL (11.1 mmol per L)
or
FPG >=126 mg per dL (7.0 mmol per L)
or
2hrPPG >=200 mg per dL (11.1 mmol per L) after a 75-g glucose load
Impaired glucose homeostasis
Impaired fasting glucose: FPG from 110 to <126 (6.1 to 7.0 mmol per L)
Impaired glucose tolerance: 2hrPPG from 140 to <200 (7.75 to <11.1 mmol per L)
Normal
FPG <110 mg per dL (6.1 mmol per L)
2hrPPG <140 mg per dL (7.75 mmol per L)

——————————————————————————–

Adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997; 20:1183-97.

†–Casual is defined as any time of day without regard to time since last meal.

*–Symptoms include polyuria, polydipsia or unexplained weight loss.

FPG=fasting plasma glucose; 2hrPPG=two-hour postprandial glucose.
 
 

New Diagnostic Criteria for Diabetes Mellitus

The new diagnostic criteria for diabetes mellitus have been greatly simplified (Table 2).2

The oral glucose tolerance test previously recommended by the National Diabetes Data Group has been replaced with the recommendation that the diagnosis of diabetes mellitus be based on two fasting plasma glucose levels of 126 mg per dL (7.0 mmol per L) or higher. Other options for diagnosis include two two-hour postprandial plasma glucose (2hrPPG) readings of 200 mg per dL (11.1 mmol per L) or higher after a glucose load of 75 g (essentially, the criterion recommended by WHO) or two casual glucose readings of 200 mg per dL (11.1 mmol per L) or higher. Measurement of the fasting plasma glucose level is the preferred diagnostic test, but any combination of two abnormal test results can be used. Fasting plasma glucose was selected as the primary diagnostic test because it predicts adverse outcomes (e.g., retinopathy) as well as the 2hrPPG test but is much more reproducible than the oral glucose tolerance test or the 2hrPPG test and easier to perform in a clinical setting.

The choice of the new cutoff point for fasting plasma glucose levels is based on strong evidence from a number of populations linking the risk of various complications to the glycemic status of the patient. Figure 1 shows the risk of diabetic retinopathy based on the glycemic status of 40- to 74-year-old participants in the National Health and Nutritional Epidemiologic Survey (NHANES III).2 The risk of retinopathy greatly increases when the patient’s fasting plasma glucose level is higher than 109 to 116 mg per dL (6.05 to 6.45 mmol per L) or when the result of a 2hrPPG test is higher than 150 to 180 mg per dL (8.3 to 10.0 mmol per L). However, the committee decided to maintain the cutoff point for the 2hrPPG test at 200 mg per dL (11.1 mmol per L) because so much literature has already been published using this criterion. They selected a cutoff point for fasting plasma glucose of 126 mg per dL (7.0 mmol per L) or higher. This point corresponded best with the 2hrPPG level of 200 mg per dL (11.1 mmol per L). The risk of other complications also increases dramatically at the same cutoff points.

A normal fasting plasma glucose level is less than 110 mg per dL (6.1 mmol per L) and normal 2hrPPG levels are less than 140 mg per dL (7.75 mmol per L). Blood glucose levels above the normal level but below the criterion established for diabetes mellitus indicate impaired glucose homeostasis. Persons with fasting plasma glucose levels ranging from 110 to 126 mg per dL (6.1 to 7.0 mmol per L) are said to have impaired fasting glucose, while those with a 2hrPPG level between 140 mg per dL (7.75 mmol per L) and 200 mg per dL (11.1 mmol per L) are said to have impaired glucose tolerance. Both impaired fasting glucose and impaired glucose tolerance are associated with an increased risk of developing type 2 diabetes mellitus. Lifestyle changes, such as weight loss and exercise, are warranted in these patients.

FIGURE 1
Prevalence of retinopathy by deciles of the distribution of FPG, 2hrPPG and HbAlc in 40- to 74-year-old participants in the National Health and Nutritional Epidemiologic Survey (NHANES III). The x-axis labels indicate the lower limit of each decile group. (FPG=fasting plasma glucose; 2hrPG=two-hour postprandial plasma glucose; HbA1c=glycosylated hemoglobin) 
 
 
 

The committee chose not to address the current controversies surrounding the diagnosis of gestational diabetes mellitus and did not alter the diagnostic criteria in this area. Screening for gestational diabetes mellitus is generally accomplished with administration of a 50-g glucose load one hour before determining a plasma glucose level. A positive screen (defined as a plasma glucose level of 140 mg per dL [7.75 mmol per L] or higher) should prompt a diagnostic test: fasting plasma glucose levels should be measured after a 100-g glucose load at baseline and at one, two and three hours after the glucose load. Two of the four values must be abnormal (105 mg per dL [5.8 mmol per L] or higher; 190 mg per dL [10.5 mmol per L] or higher; 165 mg per dL [9.15 mmol per L] or higher; and 145 mg per dL [8.05 mmol per L] or higher) for a patient to be diagnosed with gestational diabetes mellitus. The WHO criteria use a glucose load of 75 g with a test two hours after the glucose load, using the same criterion for the diagnosis of gestational diabetes mellitus.

Glycated Hemoglobin

 
Glycated hemoglobin (also known as glycohemoglobin, glycosylated hemoglobin or HbA1c) is used to monitor treatment in patients with diabetes mellitus; however, it is not recommended for routine diagnosis of this condition because of a lack of standardization of tests and results.
 
 

Measurements of glycated hemoglobin have commonly been used to monitor the glycemic control of persons already diagnosed with diabetes mellitus. Measurements of this hemoglobin, also called glycosylated hemoglobin, glycohemoglobin, hemoglobin A1c or hemoglobin A1, aid in the evaluation of the stable linkage of glucose to minor hemoglobin components. There is currently no agreement on standardization, so a variety of measurement methods and normal ranges are being used.

Some experts argue that a glycated hemoglobin test could be used for the diagnosis of diabetes mellitus.8,9 Glycated hemoglobin levels are as highly correlated to adverse clinical outcomes (e.g., retinopathy) as are fasting plasma glucose or postprandial plasma glucose levels and are as reproducible as fasting plasma glucose levels. The major advantage of measuring glycated hemoglobin is that the specimen can be collected without regard to when the patient last ate.

The expert committee, however, did not include glycated hemoglobin measurement in the recommendations for international standards for the diagnosis of diabetes mellitus.2 They noted the lack of standardization and normal ranges among the various tests, making it difficult to dictate a standard cutoff point. The test for measuring glycated hemoglobin is not widely available in developing countries; consequently, it was not favored for use as an international criterion. There is also some overlap in the levels of glycated hemoglobin in patients with diabetes mellitus and those without it.

Although it was not specifically recommended by the National Diabetes Data Group as a diagnostic test for diabetes mellitus, glycated hemoglobin may, in some cases, be used to diagnose diabetes mellitus. The diagnosis of diabetes mellitus is made in the following fashion.8,9 A glycated hemoglobin level of 1 percent above the reference laboratory’s upper range of normal is consistent with diabetes mellitus and has a specificity of 98 percent.8 People with normal glycated hemoglobin levels (i.e., within the laboratory’s published normal range) either do not have diabetes mellitus or have well-controlled diabetes mellitus (i.e., a false-negative test). However, incorrectly diagnosing these persons as normal would not alter their treatment because exercise and diet are adequately controlling their blood glucose levels. People who are not diagnosed with diabetes mellitus and who have near-normal glycated hemoglobin levels (less than 1 percent above the normal range) may be advised of the high probability that they have diabetes mellitus and may be offered the same treatment as a person with mild diabetes mellitus (i.e., dietary and exercise counseling), followed by repeat testing of glycated hemoglobin several months later. This method of screening and counseling high-risk persons is easier for many patients and clinicians because the blood specimen can be drawn at the time of the patient visit.

Impact of the New Diagnostic Criteria

Physicians may be concerned that the new diagnostic criteria for diabetes mellitus, including the lower cutoff for fasting plasma glucose levels, may greatly increase the number of people who are diagnosed with diabetes mellitus in their practices. Concerns about overdiagnosis include the harm created by anxiety, the risks and costs of unnecessary treatment, and possible insurance discrimination, especially if the condition that is being diagnosed is relatively benign or if no effective treatment is available. On the other hand, underdiagnosing a condition is harmful if early treatment can make a difference in patient outcome, especially if the treatment is relatively benign and inexpensive.

It is true that a rigorous screening program will increase the number of persons who are diagnosed with diabetes mellitus. However, currently one half of the people who have diabetes mellitus according to the old criteria have not been diagnosed and may remain undiagnosed for up to 10 years.10 People who are asymptomatic and undiagnosed continue to develop the complications of diabetes mellitus.1

TABLE 3
Recommendations for Diabetes Screening of Asymptomatic Persons 
 
Timing of first test and repeat tests

Test at age 45; repeat every three years:Patients 45 years of age or older

Test before age 45; repeat more frequently than every three years if patient has one or more of the following risk factors:

Obesity: >=120% of desirable body weight or BMI >=27 kg per m2
First-degree relative with diabetes mellitus
Member of high risk-ethnic group (black, Hispanic, Native American, Asian)
History of gestational diabetes mellitus or delivering a baby weighing more than 4,032 g (9 lb)
Hypertensive (>=140/90 mm Hg)
HDL cholesterol level ¾35 mg per dL (0.90 mmol per L) and/or triglyceride level >=250 mg per dL (2.83 mmol per L)
History of IGT or IFG on prior testing 

——————————————————————————–

BMI=body mass index; HDL=high density lipoprotein; IGT=impaired glucose tolerance; IFG=impaired fasting glucose.

Adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-97.
 
 

Screening Recommendations

The expert committee provided guidelines governing the selection of patients to be tested for diabetes and the frequency of that testing (Table 3).2 Testing should be considered for all persons who are 45 years or older and should be repeated at three-year intervals.

Testing should be considered at a younger age and be performed more frequently in persons who are obese (120 percent of desirable body weight or greater or a body mass index of 27 kg per m2 or greater); who have a first-degree relative with diabetes mellitus; who are black, Hispanic or Native American; who have delivered a baby weighing more than 4,032 g (9 lb), or who were diagnosed with gestational diabetes mellitus during pregnancy; are hypertensive; or have a high-density lipoprotein level of 35 mg per dL (0.90 mmol per L) or lower and/or a triglyceride level of 250 mg per dL (2.83 mmol per L) or higher. In addition, any patient with impaired glucohomeostasis should be reevaluated on a more frequent basis.

The expert committee recommended that screening for gestational diabetes mellitus be reserved for use in women who meet one or more of the following criteria: 25 years of age or older, obese (defined as more than 120 percent above their desirable body weight), a family history of a first-degree relative with diabetes mellitus, and belong to a high-risk ethnic population.

Final Comment

The changes recommended by the expert committee for the diagnosis of diabetes mellitus should prove beneficial to patients. Measurement of fasting plasma glucose levels should be more acceptable to patients than the oral glucose tolerance test and can be readily incorporated with fasting lipid determinations. Identifying asymptomatic persons earlier in the disease process will allow earlier institution of lifestyle changes and medical therapy that may decrease the complications of hyperglycemia. The National Diabetes Data Group emphasizes that these changes in diagnostic criteria have not changed the treatment goals in patients with diabetes mellitus. These goals include maintaining a fasting plasma glucose level of less than 120 mg per dL (6.65 mmol per L) and a glucose hemoglobin measurement of less than 7.0 percent.

Figure 1 adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20: 1183-97.
——————————————————————————–

The Author

JENNIFER MAYFIELD, M.D., M.P.H.,
is associate professor of family medicine at Bowen Research Center, Indiana University, Indianapolis. She received a medical degree from Loma Linda (Calif.) School of Medicine and completed a residency in family medicine at the University of Minnesota Medical School, Minneapolis. Dr. Mayfield has served as chair of the Council on Foot Care for the American Diabetes Association for the past two years and was previously the epidemiologist for the Indian Health Service Diabetes Program.

Address correspondence to Jennifer Mayfield, M.D., M.P.H., Bowen Research Center, Department of Family Practice, Indiana University, 1110 West Michigan St., Long Hospital Room 200, Indianapolis, IN 46202. Reprints are not available from the author.

Everyone knows what it’s like to witness a child’s temper tantrum. Even before you had kids of your own, you may remember standing in a grocery store line behind some woman who may have uttered that two-letter word no 2-year-old wants to hear – N-O – only to be met by wailing and whining from the child.

Temper tantrums can be hard on parents and kids. Parents get frustrated and embarrassed, particularly if their little darling is acting up in a public place. When children have tantrums, they, too, may be expressing frustration, anger or disappointment.

Why do children have tantrums?

Temper tantrums are a normal part of a child’s development as he learns self-control. Emotions are hard for young children to hold inside, and hard for them to express in words. So, when they are frustrated, angry, or disappointed, they often cry, scream, stomp up and down, and may even throw themselves on the floor kicking and screaming. Children have temper tantrums when they aren’t getting their own way, to get a grownup’s attention, or when they are tired, hungry or feeling helpless.

Nearly all children have tantrums between the ages of 1 and 3. Some people call them “the terrible twos.” After age 3, temper tantrums taper off as children learn to express their feelings. Children who cannot express their feelings well with words are more apt to continue having tantrums. Temper tantrums may also continue, even when a child is older, if there have been unusual changes or stresses in the child’s life.

Don’t be surprised if your child has tantrums only in front of you. For one thing, this is one way he can test your rules and limits. For another, children feel safer showing their feelings to the people they trust.

Can temper tantrums be prevented?

You can’t prevent all tantrums, but you can reduce the odds of your child having one if you follow these suggestions:

• Make sure your child is well rested, especially before a busy day or before a lot of activity.
• Keep a daily routine as much as possible, so your child knows what to expect.
• Avoid long outings or keeping a child out late beyond her bedtime. If you have a trip, bring along your child’s favorite books or toys for entertainment.
• Encourage your child to use his words to describe feelings. You might suggest words that can help your child express feelings, such as “I’m really angry.”
• Let your child make choices when possible. If your child resists taking a bath, you can be firm about the bath, but you might ask which toys he would like to pick to bring in the bath.
• Allow transition time when changing activities. If your child is having fun, he will need some time to switch gears when he must change to another activity. For example, if he’s playing as dinnertime approaches, give him a five-minute notice that you will be eating soon.

How do I deal with a tantrum?

You see it coming, but it’s too late. The tantrum has begun, and now what do you do?

Here are some suggestions that can help you both get through it:

• Distract your child by calling his attention to something else, such as a new activity, book, or toy. Or interrupt his behavior with a comment like, “Do you see what that kitty is doing?” Changing your location may work. Try something like, “let’s go outside and look at the flowers.” Humor, or making a silly face, can work, too, sometimes.
• Try to remain calm. Shouting or becoming angry is only likely to make matters worse. The general rule is the more attention you give a tantrum, the more likely it is to happen again.
• Ignore it, if it’s minor. Either stand quietly and wait until it’s over, or silently pick him up and leave the scene. This might mean leaving a store or a checkout line and taking your child to your car to calm down. If you are unable to leave the child alone for safety reasons or because you’re in a situation where you can’t leave (such as on an airplane), holding her may comfort her.

Some temper tantrums cannot be ignored. The following behaviors should not be ignored and are not acceptable:

• Hitting or kicking parents or others
• Throwing things in a dangerous way
• Prolonged screaming or yelling

Use a cooling-off period or a “time-out” to remove your child from the situation. For children old enough to understand, a good rule of thumb for a time-out is one minute of time for every year of your child’s age. For example, a 3-year-old would get a three-minute time-out.

What shouldn’t you do during a tantrum?

• Never punish your child for a temper tantrum. He may start to bottle up his anger or frustration, which can be unhealthy. Try to respond calmly, with understanding. As your child grows he will learn to deal better with his emotions.
• Do not reward your child for stopping a tantrum. Rewards may teach your child that a temper tantrum will help her get her way.
• Don’t try to reason with your child during a tantrum. Logical explanations are unlikely to be heard through the crying and yelling.

• Don’t change your “no” to a “yes” just to get your child to be quiet. Letting your child have his way may solve the problem that instant, but if he learns that throwing a tantrum will help him get his way, he’ll surely try it again.

For  More   Information:  Please  consult  your   physician  on  your  next  visit.

ANKYLOSING SPONDYLITIS (AS) is a form of chronic inflammation of the spine and the sacroiliac joints. Chronic inflammation in these areas causes pain and stiffness in and around the spine. Over time, chronic spinal inflammation can lead to a complete cementing together (fusion) of the vertebrae, a process referred to as ankylosis. Ankylosis leads to loss of mobility of the spine and the condition known as bamboo spine. It is important to note that the course of ankylosing spondylitis varies greatly from person to person. So too can the onset of symptoms. Although symptoms usually start to appear in late adolescence or early adulthood (ages 17-35), the symptoms can occur in children or much later. Typically, the first symptoms of AS are frequent pain and stiffness in the lower back and buttocks, which comes on gradually over the course of a few weeks or months. At first, discomfort may only be felt on one side, or alternate sides. The pain is usually dull and diffuse, rather than localized. This pain and stiffness is usually worse in the mornings and during the night, but may be improved by a warm shower or light exercise. Also, in the early stages of AS, there may be mild fever, loss of appetite and general discomfort. The pain normally becomes persistent (chronic) and is felt on both sides, usually persisting for at least three months. Over the course of months or years, the stiffness and pain can spread up the spine and into the neck. Pain and tenderness spreading to the ribs, shoulder blades, hips, thighs and heels is possible as well. Men are affected more than women by a ratio about of 3:1. AS can also be associated with ulcerative colitis, Crohn’s disease, psoriasis, and Reiter’s disease. Ayurveda offers excellent therapies for treating Ankylosing spondylitis. The strength of Ayurveda in the area of spine and joint treatments is globally appreciated. Since it addresses the root cause of the issue, the results are fantastic. Ayurveda has in-depth knowledge of causative factors of AS and clearly explained the pathogenesis and line of treatment to be followed. At CHARAKA, we are completely dedicated for treatment of AS. With our deep understanding and research, we are providing a very effective treatment methodology based on the classical texts of Ayurveda. The treatment comprises of Detoxification, rejuvenation through Ayurvedic Panchakarma therapy along with the administration of researched medicines internally. Initial treatment requires around 45 – 60 days of Panchakarma therapy along with internal medicines and diet & life style modification. After this phase only internal medicines are continued. If patient can come for the treatment in early stages, even total cure is also possible.

For those who suffer have knee pain from arthritis, wearing flatter and more flexible shoes may reduce the complications associated with osteoarthritis in the joints and keep them much more comfortable, says a new research.

The scientists at Rush University in Illinois came to the conclusion that flat shoes, such as flip flops, provide better support and help to the knee, when compared to walking shoes, clogs or the shoes with heels. According to the experts, footwear that provide arch support can take pressure away from joints like the ankles, but add more pressure to the knees. In turn, footwear with flat and flexible soles restore the pressure to the bottom of the foot, and over time reduce the damage to the knee and, as a result, can help stop the development of osteoarthritis.

Osteoarthritis is the most common form of arthritis and a significant source of disability and impaired quality of life. A higher-than-normal pressure of a person’s weight onto the knee joint is a key factor that is associated with the development of the condition. That is why the type of shoes a person wears especially during walking needs to be chosen very carefully, Dr. Najia Shakoor a principal author of the study said.

For the purposes of their study, Dr. Shakoor and her team analyzed the gait of 31 individuals with symptoms of osteoarthritis in the Rush Motion Analysis Laboratory. All the participants were split into several groups and were asked to walk either barefoot or to wear four popular shoe types, including Dansko clogs, which are usually worn by healthcare professionals who are on their feet most time of the day; Brooks Addiction stability shoes, which are often prescribed for the comfort of the feet; Puma H-Street shoes, a flat athletic footwear with flexible soles; and flip-flops.

The results revealed that, when it came to the clogs and stability shoes, the pressure on the knee joints was up to 15 per cent higher when compared to the flat walking shoes, flip-flops or walking barefoot. Pressure on the knees was roughly the same whether participants wore flips-flops or walked without any footwear.

Previous studies have demonstrated that barefoot walking is linked to lower knee pressure and is much more beneficial than walking wearing the conventional footwear. The experts further explained that it may be that the flexible movement of the bare foot is mechanically advantageous. It could be that the natural flex of the foot when it touches the ground, decreases the impact on the joint, compared to the artificial stomping movement created by a stiff-soled shoe.

The findings are reported online in the journal Arthritis Care and Research. The study was funded by the National Institutes of Health.

Pregnant women should take 4,000 IU of vitamin D every day – 10 times more than doctors currently recommend – to decrease their risk of preterm birth and infections, according to a new study that appears to be the first to investigate the safety of high doses of vitamin D during pregnancy.

Current recommendations for daily intake of vitamin D during pregnancy range from 200 IU (international units) a day to 400 IU, the amount that can be found in the majority of prenatal vitamins. For many years, pregnancy specialists were concerned that too much consumption of vitamin D in pregnancy could result in birth defects, and under current guidelines anything that is more than 2,000 IU a day is still believed to be potentially dangerous for any person, not just future moms.

According to the researchers at Medical University of South Carolina in Charleston, 2,000 IU of vitamin D is not only safe during pregnancy, but making this dosage double may actually decrease the risk of developing undesirable complications. To come up with this conclusion, researchers studied 494 women who were between 12 and 16 weeks into pregnancy, and assigned them into three different groups. The first group of women received 400 IU of vitamin D per day until labor; women in the second group were given 2,000 IU of the vitamin; and, finally, the participants in the third group received 4,000 IU of vitamin D.

All future moms were tested on a monthly basis, including calcium levels in their blood, to ensure that there were not experiencing any negative side effects from any of the prescribed doses. Their levels of vitamin D before the trial were the same. Neither the participants nor the investigators were aware of what dose of vitamin D they were taking during an experiment, which makes it a “blinded,” randomized controlled study whose methodology is considered the gold standard of medical science.

The results revealed that the women who were given the highest dose of vitamin D were 50 per cent less likely to experience any problems including premature birth, gestational diabetes, infections and pre-eclampsia (a sudden increase in blood pressure and protein in urine that can be dangerous for both mothers and their babies), when compared to the ladies who were taking the lowest dose of the vitamin.

Future mothers need to take 4,000 IU of vitamin D every day, said one of the authors of the study, Dr. Bruce Hollis, Ph.D., the director of pediatric nutritional sciences at the Medical University of South Carolina. “We did not see a single adverse effect. It was absolutely safe, and we saw a lot of improved outcomes. The risk of preterm labor was vastly decreased and so was the risk of other complications of pregnancy,” Dr.Hollis concluded.

The results of the new study were presented last week at the annual meeting of the Pediatric Academic Societies in Vancouver, British Columbia.

If you are interested in the topic “get pregnant fertility”, you might find some useful information in the following paragraphs.

If a woman wants to get pregnant, male sperms have to fertilize the female egg cell which is only possible during her fertile days. With a regular cycle of 28 days, the ovulation should take place on the 14th day after the first day of the last period. The egg cell normally can be fertilized over a period of 12 to max. 24 hours. The male sperms do have a life expectancy of 2-3 days (sometimes up to 5 days). Therefore, the fertile days are normally between the 10th and 16th days after the beginning of the period, i.e. these are the days of the “get pregnant fertility”.

The fertility of a woman is dependent on a lot of factors:

1.) Age
With the increasing age of a woman, her fertility decreases. Whereas a healthy woman at the age of 20 normally only has to wait 2 1/2 months to get pregnant, a 40-year old woman sometimes has to wait up to 2 years to conceive. However, a decreasing quantity and quality of their sperms can also be observed in older men.

2.) Health and nutrition
The health of the woman who would like to get pregnant is also a decisive factor for “get pregnant fertility”. If a woman, for example, is suffering from an illness and has to take a special type of medication, this may prevent the woman from being fertile for a period of time. Furthermore, a healthy nutrition is also essential for the fertility of a woman. A woman who would like to get pregnant should also take care that she is neither overweight nor underweight

Serious complications may develop as a sequelae of STDs if appropriate treatment is not given.The complications include:

1.Complications of pregnancy
a.congenital syphilis.Its an important cause of stillbirth.
b.congenital cytomegalovirus infection-It leads to birth defect.
c.prematurity-It is responsible for many neonatal deaths.

2.Complications in infants
a.Infections by N.gonorrhoea could rapidly lead to blindness.
b.C.trachomatis can cause conjunctivitis and fatal pneumonia in infants from 1-4months of age,typically presenting as an afebrile,interstitial pneumonia.
c.Pelvic inflammatory disease caused by gonorrhoea,Chlamydia and other STD
agents may result in infertility or ectopic pregnancy
d.Urethritis may result in stricture
e.Cancers related to STD which include hepatocellular carcinoma caused by hepatitis B ,and kaposi’s sarcoma, B-cell lymphomas and primary lymphoma of CNS in patients with AIDS.

Pregnancy is a critical time. A mother’s chemical exposures can adversely affect her baby in many ways. Here are some simple but important steps you can take to reduce the risks during pregnancy – and beyond.

1. Don’t smoke
Cigarettes contain thousands of chemicals that have been proven to cause harm, including raising the risk of low birth weight and size, reduced lung capacity and impaired brain function. Babies born to mothers who smoked during pregnancy are at higher risk of asthma, sudden infant death syndrome (SIDS), learning disabilities, diminished IQ and behavioral problems.

2. Get your iodine
Use iodized salt, especially while pregnant and nursing, and take iodine-containing vitamins. Iodine buffers against chemicals such as perchlorate that can disrupt your thyroid system and affect your baby’s brain development during pregnancy and infancy.

3. Eat good fats
Omega-3 fatty acids can offset the toxic effects of lead and mercury. Omega-3’s are plentiful in fish, eggs, nuts, oils and produce. Choose low-mercury fish such as salmon, tilapia and pollock, rather than high-mercury tuna and swordfish. Breast milk is the best source of good fats (and other benefits) for babies and protects them from toxic chemicals.

4. Go organic and eat fresh foods
Opt for organic fruits and veggies, or use FoodNews.org to find conventionally grown produce with the least pesticide residue. Choose milk and meat produced without added growth hormones. Limit canned food, since can linings usually contain bisphenol-A (BPA).

5. Drink safer water
It’s important for pregnant women to drink plenty of water. Use a reverse osmosis system or carbon filter pitcher to reduce your exposure to impurities such as chlorine, perchlorate and lead. Don’t drink bottled water, which costs more and isn’t necessarily better. If you’re out and about, use a stainless steel, glass or BPA-free plastic reusable container. Mix infant formula with fluoride-free water.

6. Choose better body care products
Just because the label says “gentle” or “natural” doesn’t mean a product is kid-safe. Look it up on CosmeticsDatabase.com. Read the ingredients and avoid triclosan, BHA, fragrance and oxybenzone.

7. Identify lead sources & avoid them
Have your tap water tested for lead from pipes and avoid any home remodeling if your house was built before 1978, when lead house paint was banned. Dust from sanding or blasting old paint is a common source of exposure.

8. Clean greener
Household cleaners, bug killers, pet treatments and air fresheners can irritate kids’ and babies’ lungs – especially if they have asthma. Check out less toxic alternatives. Some ideas: vinegar in place of bleach, baking soda to scrub your tiles, hydrogen peroxide to remove stains. Use a wet mop/rag and a HEPA-filter vacuum to get rid of dust – which can contain contaminants. Leave shoes – and the pollutants they track inside — at the door. Get EWG’s Tips for Greener Home Cleaning.

9. Pick plastics carefully
Some plastics contain toxic chemicals, including BPA, PVC and phthalates. Don’t reuse single-use containers or microwave food in plastic containers. Avoid PVC by hanging a natural-fabric shower curtain. When remodeling, go with PVC-free flooring and pipes.

10. Think ahead to baby.

* Breast milk is best, but if you use formula, choose a powdered product and mix it with filtered water (without fluoride). See EWG’s Babysafe Guide.
* Choose glass or BPA-free plastic baby bottles.
* Use organic baby food and milk when the time comes.
* Avoid fire retardants in nursing pillows, furniture, and electronics.
* Choose fewer and safer body care products, including diaper cream, wipes and soap.
* When you outfit the nursery, choose an organic crib mattress or use a wool cover.

Breastfeeding is the natural, physiologic way of feeding infants and young children milk, and human milk is the milk made specifically for human infants. Formulas made from cow’s milk or soybeans (most formulas) are only superficially similar, and advertising which states otherwise is misleading. Breastfeeding should be easy and trouble free for most mothers. A good start helps to assure breastfeeding is a happy experience for both mother and baby.

The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for four to six months. In fact, most mothers produce more than enough milk. Unfortunately, outdated hospital routines based on bottle feeding still predominate in too many health care institutions and make breastfeeding difficult, even impossible, for some mothers and babies. For breastfeeding to be well and properly established, a good early few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage.

The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well, gets milk well. A baby who latches on poorly has difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole which is too small-the bottle is full of milk, but the baby will not get much. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Unfortunately anyone can say that the baby is latched on well, even if he isn’t. Too many people who should know better just don’t know what a good latch is. Here are a few ways breastfeeding can be made easy:

1. The baby should be at the breast immediately after birth. The vast majority of newborns can be at the breast within minutes of birth. Indeed, research has shown that, given the chance, many babies only minutes old will crawl up to the breast from the mother’s abdomen, latch on and start breastfeeding all by themselves. This process may take up to an hour or longer, but the mother and baby should be given this time together to start learning about each other. Babies who “self-attach” run into far fewer breastfeeding problems. This process does not take any effort on the mother’s part, and the excuse that it cannot be done because the mother is tired after labour is nonsense, pure and simple. Incidentally, studies have also shown that skin to skin contact between mothers and babies keeps the baby as warm as an incubator.

2. The mother and baby should room in together. There is absolutely no medial reason for healthy mothers and babies to be separated from each other, even for short periods. Health facilities which have routine separations of mothers and babies after birth are years behind the times, and the reasons for the separation often have to do with letting parents know who is in control (the hospital) and who is not (the parents). Often, bogus reasons are given for separations. One example is the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours’ “observation”.

There is no evidence that mothers who are separated from their babies are better rested. On the contrary, they are more rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up.

The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to nurse. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not tiring.

3. Artificial nipples should not be given to the baby. There seems to be some controversy about whether “nipple confusion” exists. Babies will take whatever gives them a rapid flow of fluid and may refuse others that do not. Thus, in the first few days, when the mother is producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, he will tend to prefer the rapid flow method. You don’t have to be a rocket scientist to figure that one out, though many health professionals, who are supposed to be helping you, don’t seem to be able to manage it. Nipple confusion includes a range of problems, including the baby not taking the breast as well as he could and thus not getting milk well and/or the mother getting sore nipples. Just because a baby will “take both” does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see Using a Lactation Aid, and Finger Feeding) why use an artificial nipple?

4. No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time. Thus, if he is, it is usually because he is not latching on well and not getting the milk that is available. Get help to fix the baby’s latch, and use compression to get the baby more milk (see Breast Compression). This, not a pacifier, not a bottle, not taking the baby to the nursery, will help.

5. Supplements of water, sugar water, or formula are rarely needed. Most supplements could be avoided by getting the baby to take the breast properly and get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but usually supplements are suggested for the convenience of the hospital staff. If supplements are required, they should be given by lactation aid, not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with sugar water if you are not able to express much at first. Formula is hardly ever necessary in the first few days.

6. A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being “helped” by people who don’t know what a proper latch is. If you are being told your two day old’s latch is good despite your having very sore nipples, be skeptical, and ask for help from someone who knows. Before you leave the hospital, you should be shown that your baby is latched on properly, and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open-pause-close type of suck). If you and the baby are leaving hospital not knowing this, get experienced help quickly.

7. Free formula samples and formula company literature are not gifts. There is only one purpose for these “gifts” and that is to get you to use formula. It is very effective, and very unethical, marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. “But I need formula because the baby is not getting enough!”. Maybe, but, more likely, you weren’t given good help and the baby is simply not getting the milk that is available. Even if you need formula, nobody should be suggesting a particular brand and giving you free samples. Get good help. Formula samples are not help.

Under some circumstances, it may be impossible to start breastfeeding early. However, most medical reasons (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. Get good help. Premature babies can start breastfeeding much, much earlier than they do in many health facilities. In fact, studies are now quite definite that it is less stressful for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this.