Ring in the New Year with a bounty of Clinical Tips

January 1, 2007
Howard J. Bennett, MD

Get off to a good start with these helpful hints for your practice.

DR. BENNETT is a clinical professor of pediatrics at George Washington University Medical Center, Washington, D.C. He is the author of Waking up Dry: A Guide to Help Children Overcome Bedwetting, published by the American Academy of Pediatrics, and Lions Aren't Scared of Shots, published by Magination Press.

1 A clearer look at double vision

Diplopia is considered a serious symptom in children who have headache, unexplained vomiting, or a gait disturbance because it may signal increased intracranial pressure affecting the cranial nerves. The technique most often used to assess diplopia is to hold up an index finger and ask the child whether she (he) sees one or two fingers. This must be done across the patient's entire visual field because diplopia can be missed if the patient is examined only when looking straight ahead.

2 Bedwetting: Think bowels as well as bladder

Constipation is an under-recognized cause of bedwetting. Because most parents pay little attention to the frequency or consistency of their child's stools once the child is toilet trained, it is important to get a good bowel history when treating enuresis: Does the child have large, infrequent, or hard stools? Does he (she) have a history of recurrent abdominal pain, anal fissures or "blocking up" the toilet? Does he get tummy aches after meals?

To get accurate answers to these questions, I put parents on "poop patrol" (a term coined by Preston Smith, MD, founder of http://PottyMD.com/) for one week. During this time, I ask them to record the size and frequency of their child's stools and to judge the effort used to pass them. Treating constipation can sometimes reduce or cure bedwetting without additional intervention (Loening-Baucke V: Urinary incontinence and urinary tract infection and their relationship with treatment of chronic constipation of childhood. Pediatrics 1997;100:228).

3 Making the transition to preschool as easy as child's play

Many children have difficulty separating from their parents when they begin preschool at 3 or 4 years of age. One of the mothers in my practice came up with a terrific idea to help her son adjust. She asked the director for a class list two months before school began, then called all the parents on the list and invited them to bring their children to a Sunday morning play session on the school playground. She told the parents that she would be there with her son every week and encouraged them to come by whenever they could.

By the time school began, her son had met everyone in his class and knew half the children well. His transition proved much easier than his mother would ever have predicted.

4 New twist on cerumen removal

Several techniques can be used to remove wax from the ear canal. If a child has hard or flaky wax, I irrigate the ear with water or docusate sodium (Colace), as described in a previous Clinical Tip ("If it can soften stool...," November 1992). If a child has soft wax, however, I prefer to remove it with a calcium alginate swab. To avoid inadvertently pushing the wax deeper into the ear canal during removal, I insert the swab gently with a twirling motion. As the swab comes in contact with the wax, the cerumen wraps around the tip, which prevents the cerumen from moving deeper into the canal. When the swab is removed, the wax is attached to the end like cotton candy on a paper tube.