Child Health ALERT

Volume 14 A Survey of Current Developments Affecting Child Health Care September 1996

Does Bullying Cause Common Health Symptoms?

As young children grow and develop, virtually all will have some experience with bullying. Parents and child care professionals know that bullying causes children a great deal of psychological and behavioral distress, but researchers haven't given much attention to whether bullying might also be related to various health symptoms in children.

To see whether this might be the case, scientists from London, England, asked school nurses to interview almost 3,000 children between the ages of 8 and 9 years in a large number of schools. The nurses inquired about common health problems (e.g.. headaches, stomachaches) and also asked the children whether they had been bullied. Overall, 22% of the children in school: the most common complaints were "being hurt" (36% ). "bad words" (30%). or both (18%).

It was not surprising to find that almost one-quarter of the schoolchildren reported being bullied; what was of particular interest, however, was that children who were bullied were more likely to report that they didn't sleep well, felt sad, had bedwetting, and had relatively frequent headaches and stomachaches. The more bullying the children experienced, the more likely they were to report having these health symptoms.

The researchers are careful to point out that even though they found a relationship between bullying and health symptoms, it doesn't mean that bullying caused those symptoms; for example, it is possible that some children, when they are interviewed, are simply more likely to answer "yes", whether correct or not, in response to most questions they are asked.

Still, these authors encourage child health professionals to keep in mind the possibility that bullying may be related to certain health symptoms in children; when children have these kinds of symptoms, they should be asked whether they are being bullied, and if they are, it is important to consider whether the bullying may indeed be related to that child's symptoms. (Williams K et al: British Medical Journal, pp. 17-19, July 6, 1996)

DR. BARRY ZUCKERMAN COMMENTS: Child care professionals can easily recognize powerful effect that bullying can have on children. Though we tend to think of these effects being psychological and behavioral, suggests that bullying might also lead to a variety of physical symptoms. The authors are right to caution that the association between bullying and reporting of symptoms could be due to something other than a cause-and-effect relationship--for example, children who have psychosomatic symptoms (such as frequent stomachaches) might also have behaviors that make them more likely to be targets of bullying.

Whatever the study's limitations, I agree with the authors' conclusion that when bullying is reported or identified in a child with symptoms such as headache, stomachache, feeling sad, bed wetting, or not sleeping well, it should be taken seriously and addressed by child health professionals and parents alike. Those who want more information about how to deal with such situations might want to read the following reference (cited by the authors): Olweus D: Bullying at School. What We Know and What We Can Do. Oxford: Blackwell Publishers, 1993. (Dr. Zuckerman is a member of the CHILD HEALTH ALERT Editorial Advisory Board)

CHILD CARE ISSUES ~

Mary Ucci: Using "Time-Out" Properly

Disciplining a child has different meanings for different people, but I view discipline not as a punishment but rather as a means to help the child develop ways to discipline himself. Using "time-out" has become a very common approach among parents and child care providers alike. Time-out is actually a current term for an age-old concept--taking a break from the action, finding a time and space to regroup and regain a better sense of self control. However, if time-out is used too frequently or inappropriately, it can be both ineffective and potentially harmful.

I have seen a tremendous variation in the way time-outs are used, but there are certain key elements that are necessary for it to work effectively. First, it is important to understand that when a child misbehaves, he or she needs adult support. For this reason, a time-out for a preschooler means that the child is not simply removed from the situation and placed alone; rather, that child needs to be removed from the situation, but also needs an adult to be with him/her.

Second, it's good to have a "script" to convey a supportive message, so the child understands that although he may not be in complete control of himself at the moment, there is an adult who is taking charge. For example. "I can see you're having a problem waiting to use the crayons" tells the child what the problem is. "I can help you" indicates who's in charge, and when the child is taken away from the situation, "We can be here for awhile and talk" lets the child know that there is a purpose to the time out. It's also important to avoid lecturing the child and use very short sentences.

Keep in mind that it's difficult for a child to talk about the problem in the middle of the disruption; once he or she has calmed down, the adult can tell him what happened ("You were taking Tommy's crayons"), and say "It's not OK to take crayons away when Tommy is using them." It is equally important to tell the child what would be an acceptable thing to do, such as "You may tell Tommy that you'd like to use the crayons when he's done."

Third, the amount of time for a timeout shouldn't be too long--perhaps one to two minutes--and it's better to err on the side of making it too short rather than too long, since the whole point of time-out is to be supportive rather than punitive.

Finally, however time-out is used, it has to be tailored to the situation and, most importantly, to the child's stage of development. For example, it may be helpful to explain the problem and solution to a preschooler, but for a younger child who can't articulate very well, it may be more appropriate to remove him from the problem and provide him the support of a caring adult. Knowing a child's developmental needs and keeping in mind the purpose of time-out will go a long way toward making the most effective use of this valuable approach. (Mary Ucci is a member of the CHILD HEALTH ALERT Editorial Advisory Board)

Editor's Note: Because of the importance of this subject to parents as well as child-care providers. subscribers are encouraged to post. copy, and distribute this page.

Mary Ucci, who is Educational Director of the Child Study Center of Wellesley College, writes this periodic column on early childhood development; she welcomes questions from readers, which she will answer as space permits. Questions should be sent to her c/o Child Health Alert, P 0. Box 610228, Newton Highlands, MA 02461.

ASTHMA/ALLERGY

Peanut and Nut Allergies On The Increase

Most people who care for children understand and appreciate that peanuts and nuts can cause serious allergic reactions in some children. Noticing how common reactions to nuts and peanuts were, an allergy specialist from England described the patients seen in one year. Most were children, and the most common reasons for being seen were allergenic reactions to peanuts, Brazil nuts, almonds, and hazelnuts. The most frequent reaction was facial swelling. Because children with peanut allergy often have been exposed to these foods early in life, the author suggests that young children who have other kinds of allergies should avoid peanuts and nuts to reduce their risk of developing allergic reactions to these foods. (Ewan PS: British Medical Journal, April 27,1996, pp. 1074-1078)

In an editorial commenting on the study above, Dr. Hugh Sampson, an international allergy specialist, points out that as the American lifestyle has become more hectic. Infants and young children are increasingly being exposed to peanut products (especially peanut butter) earlier in life. He points out that "today peanuts are believed to be one of the leading causes of food allergic reactions in the U.S. and. together with tree nuts (such as Brazil nuts), are probably the leading cause of serious allergic reactions to foods".

To reduce the risk of developing these allergies, he echoes Dr. Ewan's advice that children who have allergic dispositions should be identified early in life, and parents of these children should try to avoid giving them peanut products for the first three years of life (and mothers who are breast feeding should eliminate peanuts from their own diets, since the allergic component of peanuts can pass to the infant through breast milk).

A problem in managing children with peanut allergy, notes Dr. Sampson, is that perhaps one-quarter of them have reactions because they have been accidentally exposed to peanuts. "The patient, parent, and any care providers should be given detailed information about the allergy, how to recognize anaphylaxis (serious allergic reactions), how to administer adrenaline and antihistamine, and a detailed emergency plan for transporting the patient to a medical facility."

He also reinforces the need to carefully monitor the diet of children with such allergies. Many foods may contain peanuts without listing them on the label. They may be in breakfast cereals, trail mixes, chili and spaghetti sauces, gravies, oriental cooking (including egg rolls), pastries, sweets, ice creams, desserts, and as garnishes for many foods. Also, removing peanuts from a dish doesn't remove the risk, and foods can be contaminated even by utensils used to cook peanut-containing foods. Dr. Sampson concludes that "If there is any doubt about a food's ingredients, peanut and nut allergic individuals must not eat it." (Sampson HA: British Medical Journal, April 27, 1996, pp, 1050-1051)

COMMENT: Readers should not be unnecessarily alarmed about peanut and nut allergy. since the vast majority of children eat these foods without having any problems. As both experts point out, the children who seem to be at greatest risk for developing allergies to these foods, are those who have other allergies for this reason. it is important to consult with an infant's and child's medical provider to determine whether peanuts and nuts ought to be avoided.

On the other hand, when a child has a true allergy to nuts or peanuts, Dr. Sampson's advice about avoiding these foods cannot be overemphasized-when in doubt, leave it out.

Another Alert About Nuts

On the subject of foods that may contain nuts that are not identified on the product label, readers should be aware that some packages of Pillsbury Banana Quick Bread Mix may contain walnuts and almonds. Only 14 oz. packages with codes beginning with B6MO7 are being recalled (the ten character code is located on the top of the box). Consumers with questions or concerns should call 1-800-775-0625 for further information. (Asthma and Allergy Advance, May/June, 1996, p. 8)

READER'S MAIL BAG

Safety And Effectiveness Of "Tylenol" And "Children's Motrin"

Q: I work at a day care facility and issues of CHILD HEALTH ALERT hang in our staff room. Employees are required to read and sign the top of each issue. Each issue is very informative and educational to the staff. enabling us to pass on any new and helpful information to the parents, to better educate them as well.

Someone mentioned an article in a local newspaper about Tylenol and the possible effects of it on children, such as liver damage I was informed that Children's Motrin was safer and more effective when it comes to teething, fever, and pain. I would appreciate if you could provide us any information you might have.

-- Danna Wilkinson Chino Hills Children's Center Chino Hills, CA

A: many years ago, there were two products available without prescription to treat fever and pain in children--aspirin and acetaminophen (sold under brand names such as Tylenol, Datril, and many generic products). When aspirin was linked to a very rare but very serious condition called Reye syndrome, parents were warned not to use it, leaving acetaminophen as the major children's pain and fever reliever. A few years ago, ibuprofen (Children's Motrin, Children's Advil) became available to treat pain and fever in children, but it could only be obtained through a doctor's prescription. About a year ago, that situation changed when the U.S. Food and Drug Administration made Children's Motrin available without prescription, giving parents an alternative to acetaminophen.

Both acetaminophen and ibuprofen are effective in treating children's fevers and pains. Though most studies have found them to be roughly similar in their effectiveness, many parents will report that one medication works better for their child than the other. Ibuprofen may work better when it comes to treating problems that involve inflammation. such as a sprained ankle. and this medication also tend, to last longer (6-8 hours) than acetaminophen (4 hours).

The safety of the two drugs has been a matter of great controversy. mainly because of some poorly-done studies in adults, alarming stories in -the media. and competing ad% advertising campaigns by the drugs manufacturers The studies in adults focused on what happens when people who use either drug also drink alcohol, and it is these studies that raised concern about acetaminophen causing liver problems and ibuprofen causing intestinal bleeding; these suggestions are still very much under debate, but it is important to remember that they were focused on adults.

When it comes to children, there's very little reason for concern about the safety of either medication. Acetaminophen can cause severe liver damage if it is taken in large overdoses, but there is no evidence, even after decades of use in children, that acetaminophen would harm a child's liver when taken in recommended doses. Ibuprofen doesn't have the track record of acetaminophen because it hasn't been used for as many years; however ever, an unusually large study of over 80,000 children compared the safety of ibuprofen and acetaminophen in children with fever, and the results were reassuring enough for the Food and Drug Administration to make ibuprofen available without prescription.

So the "bottom line" is that both drugs are considered safe and effective for use in children, and parents can feel comfortable making their choices based on what the product label says, the price, and how they feel the medication works for their child.

PRODUCT RECALLS

-Warning On Chillers Sticks...

Kraft Foods, Inc.. of Northfield, I1, is conducting an in-store recall and issuing a safety advisory for about 678,000 sets of Chillers Sticks distributed in connection with a Jell-O instant pudding promotion. The plastic sticks may break, presenting a choking hazard to young children. The red or purple Chillers Sticks measure 3 inches long, come in packs of 6, and are used to make frozen Jell-O pudding treats. They were distributed nationwide from early June through mid-July, 1996. Kraft has recalled them from store shelves and urges consumers to discard the Chillers Sticks. For more information, call Kraft at (800) 433-9363.

... Playskool Baby Fold N'Travel Infant Carrier...

Playskool Baby, Inc.. of Northvale. NJ. is recalling about 38,000 "Fold N' Travel" infant carriers because infants may fall out of them I at least - instances of crippling, head injuries have been reported). The lightweight plastic :arriver, about I - inches Ion,-, when folded and about 26 inches when fully extended; they were available in blue or teal with either a fabric or vinyl I pad (model numbers, 100, 101, 102, and 103). It can be adjusted to any of three positions--rocker, feeder, or sleeper--by pushing the buttons located on each side of the handle near where the handle attaches to the carrier. This product sold nationwide from April 1991 through 1993 for about $35. The carriers should be returned to the store where purchased for a full refund. To receive pre-paid shipping materials and for more information on how to return the carrier, consumers should call Playskool at (800) 447-7707.

... Winnie The Pooh Pull Toys...

About 12,000 Classic Winnie the Pooh pull toys are being recalled by the Charpente Division of Michel & Co. of Culver City, CA, because children might choke on the small wooden ball at the end of the toy's pull cord, or strangle on the cord. Those involved in the recall are: Pooh, No. 65301; Eeyore, No. 65302; Pooh with Honey Pot and Piglet, No. 65303; Pooh and Piglet in Wagon, No. 65304; and Christopher, Pooh and Gang, No. 65305. These toys sold nationwide for $30 to $35 since early 1994 in department stores, gift shops, and upscale specialty shops. For more information, call Michel & Co. Inc. at (800) 533-7263, or write the company at P.O. Box 3625, Culver City, CA 90231-3625.

... Wooden Armadillos And Turtles

The Americas Co. of San Francisco is recalling about 42,000 wooden armadillos and turtles because they are covered with lead paint that is dangerous if consumed by children. The creatures, with bodies measuring up to 4 inches, are made of dried gourds painted in various colors and patterns. Heads , are movable, as are the tails of the larger armadillos. They sold for $4 to $14 nationwide from May 1995 to February 1996 at various retail stores, including The Nature Co. The animals should be returned to the store where purchased for a refund or exchange they also can be returned, with proof of purchase, to The Americas Co., 1977 Union St., San Francisco, CA 94123; returned items will be exchanged for a new product that meets federal standards. For more information, call The Americas Co. at (800) 278-4329

And Engineering Truck

Christmas Tree Shops Inc., of Yarmouth, MA, is recalling about 12,000 wooden "Engineering Truck" toys (item 00011-34416) because small parts can break off and present a choking hazard to young children. The truck is about 6 inches long and 2 inches wide, with a front cab section that has a small, peg-shaped "driver" figure about 1 inch high. The truck's flat bed features a hauler, a cement mixer an asphalt roller, a crane, or an extension ladder. The toys have no labels, but were packaged in blue and white cardboard boxes with photographs of the toys and labels that read, in part, Engineering Truck Educational Toy... Made in China"; the box also has SKU number "000011 34416 2." The toys were sold in New England from April 1994 through March 1996 for $1 each. Consumers should return the trucks to the nearest Christmas. Tree Shop for a refund. For more information, call the store at (800) 876-9677

(All notices from Consumer Product Safety Commission, Washington, D.C.)

Healthy Handwashing" Coloring Packet Now Available

"Healthy Handwashing" Poster so useful that we have now developed a companion "Healthy Handwashing" Coloring Packet.

This packet includes the same delightful animals from the poster; each of the 10 pages (measuring 8.5x I I inches) illustrates an important handwashing principle. Children will, love to color them and teachers will use them to reinforce the, importance and value of proper handwashing.