There is no effective treatment for nail-biting in children. The use of gloves or mittens, threats or punishment, or bitter nail polishes or solutions to paint onto the fingers have not been shown to work, and may cause considerable embarrassment and distress to child and parents alike.

Some advocate the use of chewing gum, arguing that it is difficult to bite one’s nails when one has a mouthful of gum. However, leaving aside concerns about teeth, it is clearly not practical to have gum in the mouth for 24 hours every day. In older children, especially girls, teaching them to take pride in the appearance of their nails is often effective. This can be reinforced by the purchase of a nail file or manicure set.

Where children are visibly anxious or stressed, you should look for contributing factors, and try to deal with them. Sometimes relaxation techniques and similar strategies may be helpful, as may referral to a counsellor if you are deeply concerned about the possibility of underlying psychological problems, but this applies only to a small minority of these children. In older children who are embarrassed by the habit and are clearly motivated to give it up, behaviour modification techniques may be helpful. This should be organised with the help of a psychologist or other professional with experience in the area.

There is usually little reason to seek medical advice for nail-biting in children. If the nailbed or surrounding skin becomes infected, the doctor will treat it appropriately, although it may recur as long as the child continues to be a nail-biter. Sometimes the family doctor may uncover underlying stresses or emotional issues, especially in adolescents, that may contribute to the nail-biting. Issues of confidentiality then need to be taken into account, and this needs to be carefully negotiated between the doctor and family members.

Prevention

No strategies to prevent nail-biting are known. Theoretically, it might be considered that minimisation or reduction in stress levels may lessen the chances of nail-biting beginning or continuing, but this has not been demonstrated to be the case. It goes without saying that good and open communication with children is desirable and can serve to minimise stress.

*193\90\8*

As with ordinary X-rays, CT scanning does expose your child to small amounts of radiation, but this is well within all safety limits.

The machinery itself can look quite frightening to children, as they have to lie still within a large cylindrical tube. It always helps if you stay close to your child during the procedure, and remain calm and reassuring. It may be necessary to give a younger child a light general anaesthetic to ensure that he lies perfectly still for the test.

*26\9\8*

*107\94\8*

*232/40/1*

The muscle layers of the abdominal wall are then repaired and tightened so as to prevent recurrence. The muscles are pulled tightly together with stitches. Sometimes a layer of stitches or wire is placed between the muscle layers so as to add strength.

The usual stay in hospital is about five days. Most workers are given six weeks off work to recover but the self-employed and those who can be found suitable alternative work involving minimal lifting of restricted weights can return to work within four weeks.

Unfortunately, despite the skill of the surgeon, the hernia may recur and require another operation. This second attempt is always more difficult than the first repair because of the scarring and the difficulty in separating the various muscle layers.

*420/71/1*

An Rh negative woman can be sensitised and develop antibodies if she receives a blood transfusion of Rh positive blood.

In the past, Rhesus iso-immunisation was a great worry to every doctor who delivered babies. With modern treatment, it should no longer be seen. Unfortunately, that is not yet the case.

Where an Rh negative woman becomes pregnant to an Rh positive man, in most, but not all, cases the child will be Rhesus positive.

It is rare for the woman to be sensitised in her first pregnancy but one in 10 are sensitised by the second and the percentage becomes higher with each pregnancy. Previously, in six out of every 1000 deliveries, the child would be affected by Rhesus iso-immunisation.

Once the mother has formed these antibodies, they readily cross the placenta to enter the baby’s circulation and can destroy the baby’s red cells.

*166/71/1*

*16\44\4*

A recent study which compared people eating a diet of three meals a day with those who had three meals and three snacks showed that snacking stimulated the body to use up more energy for metabolism compared to concentrating the same amount of food into three meals. It’s as if the more fuel you give your body the more it will burn. Frequent small meals stimulate the metabolic rate.

The problem with grazing is that most snacks turn out to be high fat foods like cakes, chocolate, snack bars, crisps or pastries. Another criticism of grazing has been that for people who eat too much, increasing the number of times that they face food is tempting disaster. Overeating is less likely to occur if the foods eaten are carbohydrate rich and have a low G.I. factor. Using these foods, you will feel satisfied before you have overconsumed!

*148\33\4*

I tried repeating the word to myself — ENDOMETRIOSIS. I drifted back to sleep, happy that at last a name had been given to the cause of my debilitating period pain.

The doctor’s voice roused me once again: ‘You’ll probably never have children’.

I wondered who the doctor was talking to. I knew it was not me because I had not even tried to get pregnant.

The truth dawned the next day when once again the doctor described the severity of the endometriosis and repeated that pregnancy looked very doubtful.

He told me that I was to take 400 milligrams of Danazol a day for three months and then he would perform major surgery including the removal of my diseased ovary.

As the endometriosis was so extensive, he felt the Danazol would only marginally improve my condition and he could not guarantee the success of surgery.

I was devastated. One day I was in hospital with a suspected ovarian cyst. The next I was told I had a disease that I could not even pronounce, I had to take male hormones, I had little prospect of ever having a baby and I was to have major surgery in the near future.

I knew very little about Danazol as it was then a relatively new drug in Australia and I asked my doctor about any side effects. He tried to assure me that I need not worry about little details and that he would look after me. I did not feel at all reassured.

The week after being diagnosed as having endometriosis, my husband’s firm transferred him interstate. I was in turmoil, life was caving in around me.

Once settled in our new home, I decided to seek a second opinion. The news about the endometriosis had been so shattering I did not want to believe it. I wanted to hear something positive, something encouraging.

My new doctor had received a letter from my first doctor giving details of the disease. The new doctor asked me if I had any questions. Did I have any questions!

For the next half an hour he quietly explained in detail all I wanted to know, including drawing some diagrams so that I understood more clearly. He felt it was essential that I knew all the possible side effects of Danazol.

After I had exhausted my list of questions, he told me that he wanted to change the dosage of my treatment. I was to increase the dosage of Danazol to 600 milligrams daily and take it for six months. He hoped he would not have to perform major surgery. At the end of six months I had a laparoscopy to see how effective the Danazol had been. Much to my doctor’s surprise there was no visible endometriosis. There were certainly signs where the disease had been, but everything appeared normal.

My doctor suggested I continue taking Danazol for another three months just to make absolutely sure the endometriosis had been completely eradicated.

A few weeks after finishing the Danazol tablets I discovered to my delight that I was pregnant.

I often wonder how my story would have ended if I had not decided to have a second opinion. Would the smaller dosage of Danazol have cleared my endometriosis? Would the major surgery have eradicated the endometriosis? Would I have been left with painful adhesions? Would I have lost an ovary? Would I ever have become pregnant?

Of course, I do not know the answers to these questions but I am grateful I decided to seek a second opinion as the outcome was more than I ever hoped for.

*117\83\2*

The GnRH agonists are modified versions of a naturally occurring hormone, gonadotropin releasing hormone (usually abbreviated to GnRH), which helps to control the menstrual cycle.

Initially, it was drought that the GnRH agonists would not be suitable for the treatment of endometriosis as it was assumed that they would stimulate the production of oestrogen. However, it was discovered that prolonged use of the GnRH agonists actually suppressed the production of oestrogen and caused the oestrogen levels in most women to decrease to the levels found in women following the menopause. Consequently, researchers began to investigate their use for the treatment of endometriosis.

How GnRH agonists work

The GnRH agonists eradicate endometrial implants by suppressing ovulation and oestrogen secretion. The resulting low levels of oestrogen in the body mean that the endometrial implants are no longer stimulated to grow and breakdown each month so they gradually degenerate and waste away.

Most women stop ovulating and menstruating during treatment and resume ovulation and menstruation again within one to two months of completing their treatment.

Dosages of GnRH agonists generally used

Since 1971 more than 2,000 GnRH agonists have been developed by various pharmaceutical companies. Some of them are still being developed and tested while others have been released for use in some countries. At present none of them are available in Australia for the treatment of endometriosis, except under special circumstances.

Some of the more well known GnRH agonists are Buserelin (Superfact), Naferelin (Synarel), Leuprolide (Lupron), and Goserelin (Zoladex).

None of the current GnRH agonists are effective when taken by mouth because they are broken down in the digestive system. Other methods of administering the drugs have been developed, including nasal sprays, daily injections and monthly injections.

Side effects GnRH agonists

The side effects experienced by most women are usually a result of low oestrogen levels. The majority of women experience hot flushes and some also experience other menopausal-type symptoms, including vaginal dryness, decreased libido, headaches and depression. The side effects usually disappear soon after the cessation of treatment.

The GnRH agonists appear to have no adverse effects on the levels of fats and cholesterol in the blood.

One possible long-term side effect of GnRH agonist therapy is osteoporosis (loss of bone density). In trials conducted so far some women have shown a decrease in the density of the bones in their spines; it appears that this effect is reversed and the bone density usually returns to normal within six months of ceasing treatment.

At present it seems that this loss of bone density is not likely to be a significant long-term problem if the treatment lasts only six to nine months but considerable further research is needed before the complete picture is known.

How effective are the GnRH agonists

The results of the clinical trials indicate that the GnRH agonists are effective in eradicating endometriosis and relieving its symptoms but, like all the other hormonal drugs, they have no significant effect on adhesions or endometriomas and they are not a permanent cure. Overall, the GnRH agonists appear to be as effective as Danazol. When they have been approved for use in Australia they will probably assume an important place in the hormonal treatment of endometriosis.

*60\83\2*