Pilomatricoma

Pilomatricoma also called pilomatrixoma and sometimes known as calcifying epithelioma of Malherbe, is an uncommon, harmless, hair follicle tumor derived from hair matrix cells (from the cells at the base of hair follicles) ¹⁾. Pilomatricomas are typically found in the head and neck region, but also occur in the upper extremities and are rarely reported in other sites ²⁾. The largest case series in the literature includes 346 pilomatrixomas of which 15.3 percent were observed in the upper extremities ³⁾.

A pilomatricoma normally appears as a single pink or purplish lump containing white areas. The white areas are due to calcium (chalky) deposits and makes the lump feel hard as a bone.

Pilomatricomas are usually less than 3 cm in diameter, although rarely can be larger. They are most common on the head and neck or the upper body in children and teenagers, but can develop anywhere on the body at any age.

Pilomatricoma is most often diagnosed in young children but may also affect adults. Pilomatricoma appears to be slightly more common in females than males.

Your doctor may suspect the diagnosis on examining the skin and may refer you for an ultrasound scan. The diagnosis is confirmed by specialist examination of a small tissue sample (a biopsy – when a tiny piece of skin is removed under local anesthetic).

Figure 1. Pilomatricoma

Can a pilomatricoma be cured?

Yes, if a pilomatricoma is completely removed surgically (cut out or excised), it is considered to be cured. It is very unlikely that they will grow back after being removed. They do not tend to go away by themselves and will either stay the same size or slowly grow over the years.

Pilomatricoma causes

The cause of pilomatricoma is now known to be due to a localized mutation in a hair matrix cell. An overactive proto-oncogene called BCL-2 suggests the normal process of cell death is suppressed, and mutations in CTNNB1 in most cases suggest loss of regulation of a protein complex called beta-catenin or LEF-1.

Are pilomatricomas hereditary?

Most pilomatricomas do not run in families, but very rarely (less than 1 in 100,000) there may be a link to rare (less than 1 in 10,000) genetic disorders.

Pilomatricoma signs and symptoms

A pilomatricoma does not normally cause any symptoms unless it becomes inflamed or infected; when it becomes red and sore. Occasionally the growth may burst and release white and yellow chalky fluid. Pilomatricomas can sometimes be uncomfortable.

Pilomatricoma presents as a single skin-colored or purplish lesion:

• They are usually found on the head and neck, but they may occur on any site.
• They don’t usually cause any symptoms, but they may be tender.
• They may be skin coloured, white or red.
• They may be regular or irregular in shape.
• Most pilomatricomas are 5–10 mm in diameter.
• They may remain stable for years or slowly grow in size up to several centimeters in diameter.

Pilomatricoma is characterized by calcification within the lesion, which makes it feel hard and bony, and often results in an angulated shape (the ‘tent’ sign).

Pilomatricoma complications

Complications of pilomatricoma are rare. However, occasionally they grow to giant size several centimeters in diameter and pilomatrix carcinoma (cancer) has been very rarely reported. Pilomatrix carcinoma is locally aggressive and can recur and approximately 90 cases have been reported in the literature. In several cases, it has demonstrated metastases. Many key features are similar between these benign and malignant counterparts; the primary differentiating characteristics include a high mitotic rate with atypical mitoses, central necrosis, infiltration of the skin and soft tissue, and invasion of blood and lymphatic vessels ⁴⁾.

A few cases have been reported of multiple pilomatricomas in association with the rare neurological condition myotonic dystrophy. Individual cases have also been reported of pilomatricomas arising in patients with a variety of other genetic disorders. The vast majority are not associated with any other abnormality.

Pilomatricoma diagnosis

If pilomatricoma is suspected, dermoscopy may be helpful, showing a central whitish or grayish-blue structureless area. Erythema and telangiectasia are sometimes observed.

If the nature of the skin lesions is uncertain, ultrasound scan may be recommended. The scan of pilomatricoma is described as a doughnut within the dermis (mid layer of the skin) with a tail (the tail denotes calcification). Alternatively, the calcification may be detected by X-ray.

A biopsy will help to establish the cause of the lesion. Alternatively the whole lesion can be removed, providing both diagnosis and treatment. The histology of pilomatricoma is striking. It may show a sharply demarcated tumor surrounded by a fibrous capsule or a poorly demarcated tumor without capsule. There are darkly stained ‘basophilic’ cells and ‘shadow’ cells with missing nuclei. Calcium deposits are found in most lesions.

Pilomatricoma treatment

Pilomatricomas are usually surgically excised. They do not disappear by themselves, and if incompletely removed, they may recur. The recurrence rate is low, ranging from 0 to 3 percent ⁵⁾. If a lesion recurs after excision or rapidly enlarges, it should be excised due to malignant potential or possible misdiagnosis.

Thumb hypoplasia

Thumb hypoplasia also commonly called hypoplastic thumb, is the medical term for missing or underdeveloped thumbs. Thumb aplasia means that your child’s thumb is missing altogether. Thumb hypoplasia is a congenital condition, which means your child is born with this condition. Thumb hypoplasia is a rare congenital deformity that constitutes 3.5% of all upper limb congenital deformities ¹⁾. Thumb hypoplasia is a rare condition and occurs in about 1 in 100,000 infants. It is equally common in males and females. In approximately 60 percent of patients with thumb hypoplasia, both thumbs are affected. In some cases, a child’s other fingers may also be missing or underdeveloped.

The degree to which your child’s thumb is underdeveloped can vary; it may only be slightly smaller in size than normal, or missing entirely (a condition known as thumb aplasia).

Thumb hypoplasia key points:

• Your child’s thumb is slightly smaller than normal, but all of its structures — the bones, tendons, ligaments, muscles, and joints — are normal.
• Your child’s thumb is small and there are often minor abnormalities in the tendons and muscles within the thumb.
  • The middle joint of the thumb is unstable, causing the thumb to wobble. The web space between the thumb and index finger is tight and restricts movement.
  • The bones of your child’s thumb are abnormally small.
• There are abnormalities in many of the thumb’s muscles along with a range of problems in the joints of the thumb and an abnormal tight web space between the thumb and index finger.
• Your child’s thumb is “floating” with no bony support and is attached to the hand by only skin and soft tissue.
• Your child’s thumb is missing.
• Thumb hypoplasia is rare, occurring in about 1 out of every 100,000 babies.
• Thumb hypoplasia can occur by itself or may be associated with other conditions where the radial side (thumb side) of the forearm does not develop properly. These include Holt-Oram and Fanconi syndromes. And also routinely seen with radial longitudinal deficiency.

Thumb hypoplasia classification

Thumb hypoplasia was originally classified by Blauth ²⁾ and subsequently modified by Buck-Gramko ³⁾ and Manske et al ⁴⁾ (see Table 1 below) and finally by Tonkin in 2013 (Figure 1) who added subgrades such as 2C ⁵⁾. Thumb hypoplasia classification system is dependent on the degree of hypoplasia, ranging from a slightly smaller thumb to a completely absent thumb. The modification proposed by Manske et al ⁶⁾ divides grade 3 based on the stability of the thumb carpometacarpal (CMC) joint. The modified classification provides surgeons guidance with regards to treatment of these underdeveloped thumbs. While some surgeons may choose to reconstruct all forms of hypoplastic thumbs, most Western surgeons utilize the classification and reconstruct thumbs type 2 and 3A, and choose pollicization for grades 3B, 4, and 5 thumbs.

Figure 1. Thumb hypoplasia classification (Tonkin classification)

Table 1. Thumb hypoplasia classification of Blauth as modified by Manske

Thumb hypoplasia classification
Type 1	Slightly small thumb
Type 2	Small thumb with Narrow first web space Unstable carpometacarpal joint Deficient thenar musculature
Type 3a	Type 2 with Extrinsic tendon abnormalities Metacarpal hypoplasia Stable carpometacarpal joint
Type 3b	Type 2 with Extrinsic tendon abnormalities Absent metacarpal base/ carpometacarpal instability
Type 4	Floating thumb
Type 5	Absent thumb

Thumb hypoplasia causes

The cause of thumb hypoplasia is unknown, but the condition has been associated with several genetic syndromes and conditions including:

• VATER syndrome, a group of birth defects that affect five different areas in which a child may have abnormalities: vertebrae, anus, trachea, esophagus and renal (kidneys)
• TAR syndrome, which is characterized by the absence of the radius bone in the forearm and extremely reduced platelet count
• Holt-Oram syndrome, often called hand-heart syndrome, which includes abnormalities of hands and arms, as well as cardiac defects
• Fanconi’s anemia, which is a rare blood disorder that affects many parts of the body.

Thumb hypoplasia symptoms

Because of the reduced functionality of your child’s thumb, they may have some problems with using their hand.

Children will adapt and can function without a missing finger. Children who have no use of a thumb will learn to rely on a lateral pinch between the long and index fingers. However, they may have problems with fine motor activities such as pinching and grasping. It is these children who may require surgery to correct the problem.

Thumb hypoplasia diagnosis

In most cases, thumb hypoplasia is identified after birth. In some cases, thumb hypoplasia is diagnosed before birth during an ultrasound.

In order to determine the best course of treatment for your child’s thumb hypoplasia, doctors may:

• Conduct a thorough physical exam of your child and take a family medical history
• Use imaging techniques like X-rays to look at the underlying structure of your child’s hands
• Recommend genetic testing and imaging of other parts of the body to identify related genetic syndromes and conditions
• Recommend a cardiac echocardiogram if a heart murmur is detected
• Recommend a renal ultrasound if a genetic anomaly is suspected

Thumb hypoplasia treatment

The thumb is a very important part of the hand: it accounts for about 40 percent of the hand’s function. This is why surgery to reconstruct a small thumb or create a thumb if one is missing entirely is usually the recommended treatment for thumb hypoplasia.

Your child will be examined by one of our pediatric hand and arm specialists to determine which surgery is best suited to her condition.

Thumb hypoplasia surgery

Surgical treatment is required for grade 2 to 5 deformities.

When considering reconstruction for types 2 and 3A, there are 3 specific components to be considered:

1. There is hypoplasia of the thumb muscles, intrinsics only in type II and extrinsic with intrinsic muscles in type 3.
2. There is instability of the thumb metacarpophalangeal joint. The metacarpophalangeal joint instability must be addressed in order to provide stability for use and function of the thumb specifically with regards to pinch and grasp. This can be isolated to laxity of the ulnar collateral ligament or can be a global instability.
3. The first webspace may be narrowed, requiring widening with a Z-plasty or dorsal transposition flap. This can be challenging to recognize in small hands and as a guide, in a normal hand the distance between the thumb and index metacarpal head should be the same as that of the index to small metacarpal head.

There are two commonly utilized tendon transfers to augment thumb function and strength in opposition, the Huber opposition transfer ⁷⁾ and the flexor digitorum superficialis opposition transfer ⁸⁾. Both techniques are effective in improving thumb function and each has specific advantages.

The Huber opposition transfer involves transfer of the abductor digiti minimi muscle from the ulnar border of the hand to the thumb. This muscle is a reliable transfer candidate; it is always present in radial longitudinal deficiency and there is little (if any) notable deficit once transferred. The abductor digiti minimi is rotated across the palm and augments thumb opposition and increases bulk in the thenar region, improving cosmesis of the hand. Also the transfer does not require the use of a pulley, which the flexor digitorum superficialis transfer necessitates. Unfortunately the muscle is short and has a very small tendon insertion. As a result, this muscle cannot be used to help stabilize the thumb metacarpophalangeal joint. Additional steps, such as imbrication of the ulnar collateral ligament and capsule of the metacarpophalangeal joint, must be performed to create stability of this joint. This is important because the pull of the Huber transfer on the abductor pollicis brevis insertion adds a further deforming force to the UCL and can worsen UCL instability if this is not addressed.

The flexor digitorum superficialis opposition transfer is the alternative to the Huber to improve hypoplastic thumb strength and function. This technique utilizes a flexor tendon from one of the ulnar digits, typically the ring finger or long finger, as a transfer to augment thumb strength. As with the abductor digiti minimi, the flexor digitorum superficialis is present in the ring finger and can be reliably harvested. There has been no documentation of decreased strength in the hand with this transfer. The flexor digitorum superficialis passes across the palm to the thumb. This technique does not augment the thenar eminence cosmetically, but the tendon length is beneficial because it allows for simultaneous reconstruction of the collateral ligament of the thumb metacarpophalangeal joint.

Reconstructive surgery for hypoplastic thumb

If your child’s hand has a carpometacarpal joint, which stabilizes the base of the thumb, your child may benefit from a surgery to rebuild the ligaments and fix the tendons of the thumb. This will allow the reconstructed thumb to function more normally.

Thumb reconstruction is typically performed as an outpatient procedure when your child is about a year old. Your child will go home the same day as the procedure. She will have a long arm cast for two weeks after surgery, then be in a splint for another two weeks. She may need to work with one of our hand therapists to maximize functionality of the reconstructed thumb.

Pollicization

If your child does not have a carpometacarpal joint, a surgeon will perform a pollicization. This surgery includes the amputation of the non-functional, unstable thumb and the construction of a useable thumb by moving the index finger to the thumb position.

This procedure is typically performed as an inpatient procedure when your child is about a year old. Your child will be spend one night in the hospital after this surgery and will be in a long arm cast for two weeks following the surgery.

After the cast is removed, your child’s hand will be placed in a splint and hand therapy will be started. In most cases, your child will need several months of hand therapy after surgery. The newly constructed thumb will never be as strong or have as much range of motion as a normal thumb, but this surgery will significantly increase the functionality of your child’s hand.

Pollicization may be followed by subsequent procedures to deepen the web space between the fingers or improve motion.

Figure 2. Thumb hypoplasia treated with pollicization

Footnote: Thumb hypoplasia before (left) and after (right) being treated with pollicization.

Follow-up care

Your child will need to be examined by the hand surgeon two weeks after surgery, and again at six weeks and three months postoperatively.

Your child will need hand therapy after surgery. The duration of therapy will depend on which surgery was performed and how much normal hand function your child has.

You can also expect to return to the hand surgeon for several annual visits throughout early childhood to ensure that your child is developing appropriate hand function as she develops skills such as writing and playing sports.

Ataxic cerebral palsy

Cerebral palsy (CP) is a group of disorders that affect a person’s ability to move and maintain balance and posture. People with ataxic cerebral palsy have problems with balance and coordination. They might be unsteady when they walk. They may walk with their legs farther apart than other kids. They might have a hard time with quick movements or movements that need a lot of control, like writing. They might have a hard time controlling their hands or arms when they reach for something. They can have trouble knowing exactly where something is. They might think it is closer or farther than it actually is.

Ataxic cerebral palsy is the least common form of cerebral palsy. Ataxia means ‘without order’ or ‘incoordination’. Ataxic movements are characterized by clumsiness, imprecision, or instability. Movements are not smooth and may appear disorganized or jerky. The incoordination seen with ataxia occurs when a person attempts to perform voluntary movements such as walking or picking up objects. Ataxia causes an interruption of muscle control in the arms and legs, resulting in a lack of balance and coordination.

Other types of cerebral palsy can lead to muscle stiffness (spastic cerebral palsy) or writhing movements (dyskinetic cerebral palsy). Some kids have more than one kind of cerebral palsy. Some people have symptoms of more than one type of cerebral palsy. The most common type of mixed cerebral palsy is spastic-dyskinetic cerebral palsy. And sometimes, the type of cerebral palsy a child has can change over time.

Figure 1. Human brain

Figure 2. Cerebellum

Ataxic cerebral palsy causes

Cerebral palsy is usually the result of a brain injury or problem. In ataxic cerebral palsy, the brain injury or problem is in a part of the brain called the cerebellum. The cerebellum is the balance center of the brain. The cerebellum fine-tunes movement commands and coordinates movements in order to compensate for whatever posture is being used. The cerebellum also accounts for the various forces being generated by different parts of the body.

A child might be born with cerebral palsy or develop it later. The brain injury or problem doesn’t get worse, but someone with cerebral palsy may have different needs over time.

Cerebral palsy can be caused by:

• infections during pregnancy
• stroke either in the womb or after birth
• untreated jaundice (a yellowing of the skin and whites of eyes)
• genetic disorders
• medical problems in the mom during pregnancy
• being shaken as a baby (shaken baby syndrome)
• injury during delivery
• injury from an accident (such as a car accident)

Premature babies (babies born early) are at higher risk for cerebral palsy than babies born at full-term. So are low-birthweight babies (even if carried to term) and multiple births, such as twins and triplets.

Ataxic cerebral palsy symptoms

Ataxia means that someone has trouble coordinating muscles to do something. Ataxia can affect any part of the body and impact upon the movements required to do many day-to-day activities. Ataxia can affect a person’s legs, arms, hands, fingers, speech, eye movements and even muscles involved in swallowing. Kids with ataxic cerebral palsy may walk with their feet spread apart, and their walk may look unbalanced or jerky. They might not be able to get their muscles to do other things too, like reach for a fork.

People with ataxic cerebral palsy may have:

• Unsteady, shaky movements or tremor
• Difficulties maintaining balance
• People with ataxia appear very unsteady and shaky because their sense of balance and depth perception is affected.

Kids with all types of cerebral palsy can have vision, hearing, speech, eating, behavior, and learning problems. Some kids have seizures.

Effect on the upper limbs (arms and hands)

When ataxia affects the arms and hands it may cause a tremor or shakiness due to the over-correction of inaccurate movements – this means that when a person reaches for an object, they overshoot the target. It also results in difficulty performing tasks requiring precise finger movements such as handwriting or using cutlery, or movements that require regular repetition such as clapping.

Effect on the lower limbs (legs)

When ataxia affects walking, a person is unstable and likely to fall. As a result, the person usually walks with the feet spread further apart than the hips, which is known as a ‘wide-base gait’. This is done to try to compensate for their instability and poor balance. This way of walking can sometimes give the mistaken impression that the person is under the influence of alcohol or drugs. Because their balance is affected, the person may also fall without reason, or be unable to compensate for being accidentally bumped or for variations in the ground surfaces or an accidental mild bump from the side.

Effect on speech and swallowing

Ataxia may have an effect on speech and swallowing. When ataxia affects speech, it is sometimes called ‘scanning’ speech – the person uses a monotone voice with a breathy sound; sometimes there are unusual accelerations or pauses between their syllables.

Effect on the eyes

Ataxia may sometimes cause slow eye movements. When the person attempts to change their eye-gaze quickly, their eyes may miss the target. The eyes overshoot or underestimate their mark and then have to make ‘catch-up’ movements.

Ataxic cerebral palsy life diagnosis

Most children with ataxic cerebral palsy are diagnosed in the first 2 years of life. If a baby is premature or has another health problem that can be associated with cerebral palsy, this will alert health care providers to start looking for signs of cerebral palsy.

No single test can diagnose ataxic cerebral palsy. So health care professionals look at many things, including a child’s:

• development
• growth
• reflexes
• movement
• muscle tone
• interactions with others

Testing may include:

• brain MRI, CT scan, or ultrasound
• blood and urine (pee) tests to check for other medical conditions, including genetic conditions
• electroencephalography (EEG) to look at electrical activity in the brain
• electromyography (EMG) to check for muscle weakness
• evaluation of how a child walks and moves
• speech, hearing, and vision testing

Ataxic cerebral palsy life treatment

There is no cure for cerebral palsy. The health care team works with the child and family to make a treatment plan. The health care team includes a:

• pediatrician
• developmental behavioral pediatrician
• occupational therapist
• physical therapist
• speech therapist
• dietitian
• neurologist (nervous system doctor)
• ophthalmologist (eye doctor)
• orthopedic surgeon (bone doctor)
• otolaryngologist (ear, nose, and throat doctor)

The treatment plan may include:

• physical therapy and occupational therapy. Physical therapy and occupational therapy are among some of the main treatments for ataxic cerebral palsy. These treatments can help children with ataxic cerebral palsy become more independent later in life.
• leg braces, a walker, and/or a wheelchair
• medicine for muscle pain or stiffness
• special nutrition to help the child grow
• surgery to improve movement in the legs, ankles, feet, hips, wrists, and arms

Living with cerebral palsy is different for every child. To help your child move and learn as much as possible, work closely with your care team to develop a treatment plan. Then, as your child grows and his or her needs change, adjust the plan as necessary.

Physical therapy

Often the first step of treatment, physical therapy combines strength and flexibility exercises with massage therapy and orthotic devices, such as splints and casts. Orthotic devices are helpful when it comes to walking and posture by providing children with balance and stability.

The overall goal of physical therapy is to help children manage their movement problems and become more independent. In children with ataxic cerebral palsy, it may be difficult to balance or control reflexes. Physical therapists use various exercises when working with children who have this type of cerebral palsy to prevent muscles that are not used regularly from growing weak or shrinking.

Occupational therapy

Occupational therapy can help improve problems with balance or coordination in children with ataxic cerebral palsy while increasing their upper body strength. A main goal of occupational therapy is to provide a child with ataxic cerebral palsy with the skills they need to perform daily tasks on their own and decrease the use of assistive devices.

An occupational therapist will typically use various exercises to evaluate a child’s ability to perform daily tasks and age-appropriate activities. These exercises may also improve issues with strength, hand-eye coordination, sensory processing skills and playing with children their age.

Speech therapy

Children with ataxic cerebral palsy often struggle with expressing thoughts or emotions through speech, as well as having trouble swallowing. Speech therapy entails the use of articulation therapy, breathing exercises and word association to help a child with ataxic cerebral palsy to better communicate.

Speech-language pathologists (SLPs) will evaluate a child’s communication skills by conducting a series of auditory or listening training tests. Speech-language pathologists will also use language intervention activities that incorporates books, objects and pictures to stimulate language development. Swallowing and tongue exercises will allow children with conditions such as dysphagia to strengthen the muscles in their mouth and face.

Medication

Many children with ataxic cerebral palsy are prescribed medication as a supplement to physical therapy. Muscle relaxants and anti-anxiety medication, such as Valium, can calm shakiness and tremors.

Medications can also be used to treat co-occurring conditions, such as epilepsy, attention deficit hyperactivity disorder (ADHD) and incontinence. Physicians will typically evaluate the level of tremors a child with ataxic cerebral palsy experiences and prescribe medication based on the severity and frequency.

Ataxic cerebral palsy life expectancy

With appropriate therapeutic services, people with cerebral palsy may be able to fully integrate academically and socially.

Patients with severe forms of cerebral palsy may have a significantly reduced life span, although this continues to improve with improved health care and gastrostomy tubes ¹⁾. Patients with milder forms of this disorder have a life expectancy close to the general population, although it is still somewhat reduced ²⁾.

The morbidity and mortality of cerebral palsy relate to the severity of this condition and concomitant medical complications, such as respiratory and gastrointestinal difficulties. In patients with quadriplegia, the likelihood of epilepsy, extrapyramidal abnormalities, and severe cognitive impairment is greater than in those with diplegia or hemiplegia.

Cognitive impairment occurs more frequently in persons with cerebral palsy than in the general population. The overall rate of mental retardation in affected persons is thought to be 30–50%. Some form of learning disability (including mental retardation) has been estimated to occur in perhaps 75% of patients. However, standardized cognitive testing primarily evaluates verbal skills and may result in the underestimation of cognitive abilities in some individuals.

In some studies, 25% of patients with cerebral palsy are unable to walk. However, many patients with this disorder (particularly those with spastic diplegia and spastic hemiplegia types) can ambulate independently or with assistive equipment. Thus, approximately 25% of children with cerebral palsy have mild involvement with minimal or no functional limitation in ambulation, self-care, and other activities. Approximately half are moderately impaired to the extent that complete independence is unlikely but function is satisfactory. Only 25% are so severely disabled that they require extensive care and are nonambulatory.

A prospective study of children has suggested that being able to sit by age 2 years is a good predictive sign of eventual ambulation. The suppression of obligatory primitive reflex activity by age 18–24 months was a sensitive indicator for distinguishing children who ultimately walked from those who were not expected to walk. Children who did not sit by age 4 years did not ambulate.

In patients with spastic quadriplegia, a less favorable prognosis correlated with a longer delay in the resolution of extensor tone. At times, hypertonicity and spasticity may improve or resolve over time in patients with cerebral palsy. Spasticity in patients with spastic quadriplegia can be more resistant even with services and orthopedic and rehabilitative intervention.

Complications

Cerebral palsy complications may affect multiple systems. For example, skin complications include decubitus ulcers and sores; orthopedic complications may include contractures, hip dislocation, and/or scoliosis.

Maintaining weight close to idea body weight is important for wheelchair-bound patients or those with ambulatory dysfunction. Nutrition consultation should be done early and periodically to ensure proper growth. Parents and medical professionals must keep on top of the potential nutritional difficulties in children with cerebral palsy. These patients are especially at risk of developing osteoporosis because of decreased weight bearing, so following their calcium intake and vitamin D levels is important ³⁾.

Gastrointestinal and nutritional complications include the following:

• Failure to thrive due to feeding and swallowing difficulties secondary to poor oromotor control; patients may require a gastrostomy tube (G-tube) or a jejunostomy tube (J-tube) to augment nutrition.
• Obesity, less frequently than failure to thrive
• Gastroesophageal reflux and associated aspiration pneumonia
• Constipation
• Dental caries

Dental problems also include enamel dysgenesis, malocclusion, and gingival hyperplasia. Malocclusion is twice as prevalent as in the normal population. The increased incidence of dental problems is often secondary to the use of medications, especially drugs administered to premature infants and antiepileptic agents.

Respiratory complications include the following:

• Increased risk of aspiration pneumonia because of oromotor dysfunction
• Chronic lung disease/bronchopulmonary dysplasia
• Bronchiolitis/asthma

Neurologic complications include the following:

• Epilepsy
• Hearing loss (particularly in patients who had acute bilirubin encephalopathy (also known as kernicterus); also seen in patients who were born prematurely or who were exposed to ototoxic drugs)
• Vision
• Visual-field abnormalities due to cortical injury
• Strabismus

Epilepsy occurs in 15-60% of children with cerebral palsy and is more common in patients with spastic quadriplegia or mental retardation. When compared with controls, children with cerebral palsy have a higher incidence of epilepsy with onset within the first year of life and are more likely to have a history of neonatal seizures, status epilepticus, polytherapy, and treatment with second-line anticonvulsants. Factors associated with a seizure-free period of at least 1 year include normal intelligence, single seizure type, monotherapy, and spastic diplegia.

Visual acuity decreases in premature infants because of retinopathy of prematurity with hypervascularization and possible retinal detachment.

Cognitive/psychologic/behavioral complications include the following:

• Mental retardation (30-50%), most commonly associated with spastic quadriplegia
• Attention-deficit/hyperactivity disorder
• Learning disabilities
• Impact on academic performance and self-esteem
• Increased prevalence of depression
• Sensory integration difficulties
• Increased prevalence of pervasive developmental disorder or autism associated with concurrent diagnosis of cerebral palsy.

Childhood fears

It’s normal for children to feel afraid at times. Fear is an emotion that can help kids be cautious. Things that are new, big, loud, or different can seem scary at first. Parents can help kids feel safe and learn to feel at ease.

It’s normal for children to show signs of anxiety, worries and fears sometimes. In most cases, anxiety in children and fears in childhood come and go and don’t last long.

In fact, different anxieties often develop at different stages. For example:

• Babies and toddlers often fear loud noises, heights, strangers and separation.
• Preschoolers might start to show fear of being on their own and of the dark.
• School-age children might be afraid of supernatural things (like ghosts), social situations, failure, criticism or tests, and physical harm or threat.

Babies and young children don’t tend to worry about things. For children to be worried, they have to imagine the future and bad things that might happen in it. This is why worries become more common in children over eight years of age.

Children also worry about different things as they get older. In early childhood, they might worry about getting sick or hurt. In older childhood and adolescence, the focus becomes less concrete. For example, they might think a lot about war, economic and political fears, family relationships and so on.

Worry and fear are different forms of anxiety. Fear usually happens in the present. Worry usually happens when a child thinks about past or future situations. For example, a child might be fearful when she sees a dog and also worry about visiting a friend with a pet dog.

Is my child’s fear normal, or does my child need help?

Most kids cope with normal fears with gentle support from their parent. As they grow, they get over fears they had at a younger age.

Some kids have a harder time, and need more help with fears. If fears are extreme or keep a child from doing normal things, it might be a sign of an anxiety disorder.

Talk to your doctor if your child’s fears:

• seem extreme or last past the normal age
• cause your child to be very upset or have tantrums
• keep your child from doing things — like going to school, sleeping alone, or being apart from you
• cause physical symptoms (like stomachaches, headaches, or a racing heart) or your child feels breathless, dizzy, or sick.

Common childhood fears

What children feel afraid of changes as they grow. Some fears are common and normal at certain ages.

For example:

• Infants feel stranger anxiety. When babies are about 8–9 months old, they can recognize the faces of people they know. That’s why new faces can seem scary to them — even a new babysitter or relative. They may cry or cling to a parent to feel safe.
• Toddlers feel separation anxiety. At some time between 10 months and 2 years, many toddlers start to fear being apart from a parent. They don’t want a parent to leave them at daycare, or at bedtime. They may cry, cling, and try to stay near their parent.
• Young kids fear “pretend” things. Kids ages 4 through 6 can imagine and pretend. But they can’t always tell what’s real and what’s not. To them, the scary monsters they imagine seem real. They fear what might be under their bed or in the closet. Many are afraid of the dark and at bedtime. Some are afraid of scary dreams. Young kids may also be afraid of loud noises, like thunder or fireworks.
• Older kids fear real-life dangers. When kids are 7 or older, monsters under the bed can’t scare them (much) because they know they’re not real. At this age, some kids begin to fear things that could happen in real life. They may have a fear that a “bad guy” is in the house. They may feel afraid about natural disasters they hear about. They may fear getting hurt or that a loved one could die. School age kids may also feel anxious about schoolwork, grades, or fitting in with friends.
• Preteens and teens may have social fears. They might feel anxious about how they look or whether they will fit in. They may feel anxious or afraid before they give a report in class, start a new school, take a big exam, or play in a big game.

Types of anxiety in children

Children experience several types of anxiety. A child might have only one type of anxiety, or she might show features of several of them.

Social anxiety in children

Social anxiety is fear and worry in situations where children have to interact with other people, or be the focus of attention. Children with social anxiety might:

• believe that others will think badly of or laugh at them
• be shy or withdrawn
• have difficulty meeting other children or joining in groups
• have only a few friends
• avoid social situations where they might be the focus of attention or stand out from others – for example, talking on the telephone and asking or answering questions in class.

Separation anxiety in children

Separation anxiety is the fear and worry children experience when they can’t be with their parents or carers. Children with separation anxiety might:

• protest, cry or struggle when being separated from their parents or carers
• worry about getting hurt or having an accident (they might worry about their parents or themselves)
• refuse to go to or stay at day care, preschool or school by themselves
• refuse to sleep at other people’s homes without their parents or carers
• feel sick when separated from their parents or carers.

Generalized anxiety in children

Children with generalized anxiety tend to worry about many areas of life – anything from friends at playgroup to world events. Children with generalized anxiety might:

• worry about things like health, schoolwork, school or sporting achievements, money, safety, world events and so on
• feel the need to get everything perfect
• feel scared of asking or answering questions in class
• find it hard to perform in tests
• be afraid of new or unfamiliar situations
• seek constant reassurance
• feel sick when worried.

When to be concerned about anxiety in children?

Most children have fears or worries of some kind. But if you’re concerned about your child’s fears, worries or anxiety, it’s a good idea to seek professional help.

You might consider seeing your doctor or another health professional if:

• your child’s anxiety is stopping him from doing things he wants to do or interfering with his friendships, schoolwork or family life
• your child’s behavior is very different from children the same age – for example, it’s common for most children to have separation fears when going to preschool for the first time, but far less common over the age of eight years
• your child’s reactions seem unusually severe – for example, your child might show extreme distress or be very hard to settle when you leave him.

Severe anxiety can impact on children’s health and happiness. Some anxious children will grow out of their fears, but others will keep having trouble with anxiety unless they get professional help.

What is specific phobias?

Specific phobias are an overwhelming and unreasonable fear of objects or situations that pose little real danger but provoke anxiety and avoidance. Unlike the brief anxiety you may feel when giving a speech or taking a test, specific phobias are long lasting, cause intense physical and psychological reactions, and can affect your ability to function normally at work, at school or in social settings.

Specific phobias are among the most common anxiety disorders, and not all phobias need treatment. But if a specific phobia affects your daily life, several therapies are available that can help you work through and overcome your fears — often permanently.

If you have a specific phobia, consider getting psychological help, especially if you have children. Although genetics likely plays a role in the development of specific phobias, repeatedly seeing someone else’s phobic reaction can trigger a specific phobia in children.

By dealing with your own fears, you’ll be teaching your child excellent resiliency skills and encouraging him or her to take brave actions just like you did.

Professional treatment can help you overcome your specific phobia or manage it effectively so you don’t become a prisoner to your fears. You can also take some steps on your own:

• Try not to avoid feared situations. Practice staying near feared situations as frequently as you can rather than avoiding them completely. Family, friends and your therapist can help you work on this. Practice the techniques you learn in therapy and work with your therapist to develop a plan if symptoms get worse.
• Reach out. Consider joining a self-help or support group where you can connect with others who understand what you’re going through.
• Take care of yourself. Get enough rest, eat healthy and try to be physically active every day. Avoid caffeine, as it can make anxiety worse. And don’t forget to celebrate successes as things get better.

What causes specific phobia?

Much is still unknown about the actual cause of specific phobias. Causes may include:

• Negative experiences. Many phobias develop as a result of having a negative experience or panic attack related to a specific object or situation.
• Genetics and environment. There may be a link between your own specific phobia and the phobia or anxiety of your parents — this could be due to genetics or learned behavior.
• Brain function. Changes in brain functioning also may play a role in developing specific phobias.

These factors may increase your risk of specific phobias:

• Your age. Specific phobias can first appear in childhood, usually by age 10, but can occur later in life.
• Your relatives. If someone in your family has a specific phobia or anxiety, you’re more likely to develop it, too. This could be an inherited tendency, or children may learn specific phobias by observing a family member’s phobic reaction to an object or a situation.
• Your temperament. Your risk may increase if you’re more sensitive, more inhibited or more negative than the norm.
• A negative experience. Experiencing a frightening traumatic event, such as being trapped in an elevator or attacked by an animal, may trigger the development of a specific phobia.
• Learning about negative experiences. Hearing about negative information or experiences, such as plane crashes, can lead to the development of a specific phobia.

Specific phobia symptoms

A specific phobia involves an intense, persistent fear of a specific object or situation that’s out of proportion to the actual risk. There are many types of phobias, and it’s not unusual to experience a specific phobia about more than one object or situation. Specific phobias can also occur along with other types of anxiety disorders.

Common categories of specific phobias are a fear of:

• Situations, such as airplanes, enclosed spaces or going to school
• Nature, such as thunderstorms or heights
• Animals or insects, such as dogs or spiders
• Blood, injection or injury, such as needles, accidents or medical procedures
• Others, such as choking, vomiting, loud noises or clowns

Each specific phobia is referred to by its own term. Examples of more common terms include acrophobia for the fear of heights and claustrophobia for the fear of confined spaces.

No matter what specific phobia you have, it’s likely to produce these types of reactions:

• An immediate feeling of intense fear, anxiety and panic when exposed to or even thinking about the source of your fear
• Awareness that your fears are unreasonable or exaggerated but feeling powerless to control them
• Worsening anxiety as the situation or object gets closer to you in time or physical proximity
• Doing everything possible to avoid the object or situation or enduring it with intense anxiety or fear
• Difficulty functioning normally because of your fear
• Physical reactions and sensations, including sweating, rapid heartbeat, tight chest or difficulty breathing
• Feeling nauseated, dizzy or fainting around blood or injuries
• In children, possibly tantrums, clinging, crying, or refusing to leave a parent’s side or approach their fear

Specific phobias complications

Although specific phobias may seem silly to others, they can be devastating to the people who have them, causing problems that affect many aspects of life.

• Social isolation. Avoiding places and things you fear can cause academic, professional and relationship problems. Children with these disorders are at risk of academic problems and loneliness, and they may have trouble with social skills if their behaviors significantly differ from their peers.
• Mood disorders. Many people with specific phobias have depression as well as other anxiety disorders.
• Substance abuse. The stress of living with a severe specific phobia may lead to abuse of drugs or alcohol.
• Suicide. Some individuals with specific phobias may be at risk of suicide.

Specific phobias diagnosis

Diagnosis of specific phobias is based on a thorough clinical interview and diagnostic guidelines. Your doctor will ask questions about your symptoms and take a medical, psychiatric and social history. He or she may use the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Specific phobias treatment

The best treatment for specific phobias is a form of psychotherapy called exposure therapy. Sometimes your doctor may also recommend other therapies or medication. Understanding the cause of a phobia is actually less important than focusing on how to treat the avoidance behavior that has developed over time.

The goal of treatment is to improve quality of life so that you’re no longer limited by your phobias. As you learn how to better manage and relate to your reactions, thoughts and feelings, you’ll find that your anxiety and fear are reduced and no longer in control of your life. Treatment is usually directed at one specific phobia at a time.

Psychotherapy

Talking with a mental health professional can help you manage your specific phobia. Exposure therapy and cognitive behavioral therapy are the most effective treatments.

• Exposure therapy focuses on changing your response to the object or situation that you fear. Gradual, repeated exposure to the source of your specific phobia and the related thoughts, feelings and sensations may help you learn to manage your anxiety. For example, if you’re afraid of elevators, your therapy may progress from simply thinking about getting into an elevator, to looking at pictures of elevators, to going near an elevator, to stepping into an elevator. Next, you may take a one-floor ride, then ride several floors, and then ride in a crowded elevator.
• Cognitive behavioral therapy (CBT) involves exposure combined with other techniques to learn ways to view and cope with the feared object or situation differently. You learn alternative beliefs about your fears and bodily sensations and the impact they’ve had on your life. CBT emphasizes learning to develop a sense of mastery and confidence with your thoughts and feelings rather than feeling overwhelmed by them.

Medications

Generally psychotherapy using exposure therapy is successful in treating specific phobias. However, sometimes medications can help reduce the anxiety and panic symptoms you experience from thinking about or being exposed to the object or situation you fear.

Medications may be used during initial treatment or for short-term use in specific, infrequently encountered situations, such as flying on an airplane, public speaking or going through an MRI procedure.

• Beta blockers. These drugs block the stimulating effects of adrenaline, such as increased heart rate, elevated blood pressure, pounding heart, and shaking voice and limbs that are caused by anxiety.
• Sedatives. Medications called benzodiazepines help you relax by reducing the amount of anxiety you feel. Sedatives are used with caution because they can be addictive and should be avoided if you have a history of alcohol or drug dependence.

Lifestyle and home remedies

Ask your doctor or other health care professional to suggest lifestyle and other strategies to help you manage the anxiety that accompanies specific phobias. For example:

• Mindfulness strategies may be helpful in learning how to tolerate anxiety and reduce avoidance behaviors.
• Relaxation techniques, such as deep breathing, progressive muscle relaxation or yoga, may help cope with anxiety and stress.
• Physical activity and exercise may be helpful in managing anxiety associated with specific phobias.

Helping your child cope with fears

When your child is afraid, you can help by doing these things to help your child cope with fears:

• Comfort your infant, toddler, or very young child by saying, “It’s OK, you’re safe, I’m here.” Let your child know you’re there to protect them. Give hugs and soothing words to help your child feel safe.
• As your child grows, talk and listen. Be calm and soothing. Help your child put feelings into words. Help kids try new things.
• Talk openly about fears. Let your child know that everyone has scary thoughts and feelings sometimes, but some do more than others. Don’t trivialize the problem or belittle your child for being afraid. Instead, talk to your child about his or her thoughts and feelings and let your child know that you’re there to listen and to help.
• Help your baby get used to a new person while you hold him and let him feel safe. Soon, the new person won’t seem like a stranger anymore.
• Let your toddler be apart from you for short times at first. When you need to part from your child, say you’ll be back, give a hug and a smile, and go. Let your child learn that you always come back.
• For your young child who’s afraid of the dark, have a soothing bedtime routine. Read or sing to your child. Let your child feel safe and loved.
• Help your child slowly face fears. For example, check together for under-bed monsters. With you there to support her, let your child see for herself there’s nothing to fear. Help her feel her courage.
• Limit the scary images, movies, or shows kids see. These can cause fears.
• Don’t reinforce specific phobias. Take advantage of opportunities to help children overcome their fears. If your child is afraid of the neighbor’s friendly dog, for example, don’t go out of your way to avoid the animal. Instead, help your child cope when confronted with the dog and show ways to be brave. For example, you might offer to be your child’s home base, waiting and offering support while your child steps a little closer to the dog and then returns to you for safety. Over time, encourage your child to keep closing the distance.
• Model positive behavior. Because children learn by watching, you can demonstrate how to respond when confronted by something your child fears or that you fear. You can first demonstrate fear and then show how to work through the fear.
• Help kids and teens learn to prepare for challenges, like tests or class reports. Let them know you believe in them.

If your child’s fears seem to be excessive, persistent and interfere with daily life, talk with your child’s doctor for advice on whether professional diagnosis and treatment are indicated.

Vegetarian children

Teenagers who are vegetarians need to work harder to get the nutrients they need for growth and development. Vegetarian teenagers need to make sure they get enough protein, omega-3 fatty acids, iron and vitamin B12 in their diets. All teenagers need nutrients like protein, omega-3 fatty acids, iron and vitamin B12 to fuel the physical changes of puberty. These nutrients are also important for general health and development. Teenagers who choose vegetarian diets need to work a bit harder to get these nutrients, which non-vegetarians get in foods like red meat, chicken and fish. If your child is thinking about trying a vegetarian diet, it might be a good idea for him to speak with his doctor or a dietitian. These health professionals can help him make sure his diet is well-balanced and gives him all the nutrients he needs.

More and more people are choosing to follow a vegetarian diet for many different reasons. It’s estimated that two per cent of the population now don’t eat meat or fish.

Reasons for switching to a vegetarian diet include:

• the health benefits
• ethical and moral reasons
• religious or cultural reasons
• concern for animal welfare
• concern about the environment and sustainability
• taste – some people just don’t like the taste of meat or fish.

A vegetarian diet, based on unprocessed foods, can provide many health benefits. Vegetarian diets can be healthful and nutritionally sound if they’re carefully planned to include essential nutrients. However, a vegetarian diet can be unhealthy if it contains too many calories and/or saturated fat and not enough important nutrients.

Research has shown that the foods you eat influence your health. Eating certain foods, such as fruits and nuts, has been associated with reduced death rates, while other foods, such as red meat and processed meat, have been linked to increased mortality. Studies comparing overall eating patterns and mortality rates, however, have had mixed results.

For advice and help with what to eat and including vegetarian recipes go to the Vegetarian Society (https://www.vegsoc.org).

Below are the key nutrients to consider with a vegetarian diet.

• Protein: You don’t need to eat foods from animals to have enough protein in your diet. Plant proteins alone can provide enough of the essential and non-essential amino acids, as long as sources of dietary protein are varied and caloric intake is high enough to meet energy needs.
• Whole grains, legumes, vegetables, seeds and nuts all contain both essential and non-essential amino acids. You don’t need to consciously combine these foods (“complementary proteins”) within a given meal.
• Soy protein has been shown to be equal to proteins of animal origin. It can be your sole protein source if you choose.
• Iron: Vegetarians may have a greater risk of iron deficiency than nonvegetarians. The richest sources of iron are red meat, liver and egg yolk — all high in cholesterol. However, dried beans, spinach, enriched products, brewer’s yeast and dried fruits are all good plant sources of iron.
• Vitamin B-12: This comes naturally only from animal sources. Vegans need a reliable source of vitamin B-12. It can be found in some fortified (not enriched) breakfast cereals, fortified soy beverages, some brands of nutritional (brewer’s) yeast and other foods (check the labels), as well as vitamin supplements.
• Vitamin D: Vegans should have a reliable source of vitamin D. Vegans who don’t get much sunlight may need a supplement.
• Calcium: Studies show that vegetarians absorb and retain more calcium from foods than nonvegetarians do. Vegetable greens such as spinach, kale and broccoli, and some legumes and soybean products, are good sources of calcium from plants.
• Zinc: Zinc is needed for growth and development. Good plant sources include grains, nuts and legumes. Shellfish are an excellent source of zinc. Take care to select supplements containing no more than 15-18 mg zinc. Supplements containing 50 mg or more may lower HDL (“good”) cholesterol in some people.

Depending on the type of vegetarian diet chosen, kids may miss out on some of these important nutrients if the diet isn’t monitored by your doctor or a registered dietitian. The less restrictive the vegetarian diet, the easier it will be for your child to get enough of the necessary nutrients. In some cases, fortified foods or supplements can help meet nutritional needs.

A well-planned vegetarian diet can meet kids’ nutritional needs and has some health benefits. For example, a diet rich in fruits and veggies will be high in fiber and low in fat, factors known to improve cardiovascular health by reducing blood cholesterol and maintaining a healthy weight. However, kids and teens on a vegetarian diet may need to be careful that they get an adequate amount of certain vitamins and minerals.

Vegetables are categorized into five subgroups ¹⁾:

1. dark-green,
2. red and orange,
3. beans and peas (legumes),
4. starchy,
5. and other vegetables. Cruciferous vegetables fall into the “dark-green vegetables” category and the “other vegetables” category.

The amount of vegetables you need to eat depends on your age, sex, and level of physical activity. Recommended total daily amounts and recommended weekly amounts from each vegetable subgroup are shown in the two tables below.

Table 1: Daily Vegetables Recommendation
Children	2-3 years old 4-8 years old	1 cup 1 ½ cups
Girls	9-13 years old 14-18 years old	2 cups 2 ½ cups
Boys	9-13 years old 14-18 years old	2 ½ cups 3 cups
Women	19-30 years old 31-50 years old 51+ years old	2 ½ cups 2 ½ cups 2 cups
Men	19-30 years old 31-50 years old 51+ years old	3 cups 3 cups 2 ½ cups

Note: These amounts are appropriate for individuals who get less than 30 minutes per day of moderate physical activity, beyond normal daily activities. Those who are more physically active may be able to consume more while staying within calorie needs.

[Source ²⁾ ]

Table 2: Weekly Vegetables Recommendation
	Dark green vegetables	Red and orange vegetables	Beans and peas	Starchy vegetables	Other vegetables
	Amount per Week
Children 2-3 yrs old 4-8 yrs old	½ cup 1 cup	2 ½ cups 3 cups	½ cup ½ cup	2 cups 3 ½ cups	1 ½ cups 2 ½ cups
Girls 9-13 yrs old 14-18 yrs old	1 ½ cups 1 ½ cups	4 cups 5 ½ cups	1 cup 1 ½ cups	4 cups 5 cups	3 ½ cups 4 cups
Boys 9-13 yrs old 14-18 yrs old	1 ½ cups 2 cups	5 ½ cups 6 cups	1 ½ cups 2 cups	5 cups 6 cups	4 cups 5 cups
Women 19-30 yrs old 31-50 yrs old 51+ yrs old	1 ½ cups 1 ½ cups 1 ½ cups	5 ½ cups 5 ½ cups 4 cups	1 ½ cups 1 ½ cups 1 cup	5 cups 5 cups 4 cups	4 cups 4 cups 3 ½ cups
Men 19-30 yrs old 31-50 yrs old 51+ yrs old	2 cups 2 cups 1 ½ cups	6 cups 6 cups 5 ½ cups	2 cups 2 cups 1 ½ cups	6 cups 6 cups 5 cups	5 cups 5 cups 4 cups

Note: Vegetable subgroup recommendations are given as amounts to eat WEEKLY. It is not necessary to eat vegetables from each subgroup daily. However, over a week, try to consume the amounts listed from each subgroup as a way to reach your daily intake recommendation.

1 Cup of Vegetable: In general, 1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw leafy greens can be considered as 1 cup from the Vegetable Group.

[Source ³⁾ ]

Vegetarian infants

The main sources of protein and nutrients for infants are breast milk and formula (soy formula for vegan infants), especially in the first 6 months of life. Breastfed infant vegans should receive a source of vitamin B12 if the mother’s diet isn’t supplemented, and breastfed infants and infants drinking less than 32 ounces (1 liter) formula should get vitamin D supplements.

Guidelines for the introduction of solid foods are the same for vegetarian and nonvegetarian infants. Breastfed infants 6 months and older should receive iron from complementary foods, such as iron-fortified infant cereal.

Once an infant is introduced to solids, protein-rich vegetarian foods can include pureed tofu, cottage cheese, yogurt or soy yogurt, and pureed and strained legumes (legumes include beans, peas, chickpeas, and lentils).

Vegetarian toddlers

Toddlers are already a challenge when it comes to eating. As they come off of breast milk or formula, kids are at risk for nutritional deficiencies. After the age of 1, strict vegan diets may not offer growing toddlers enough essential vitamins and minerals, such as vitamin D, vitamin B12, iron, calcium, and zinc.

So it’s important to serve fortified cereals and nutrient-dense foods. Vitamin supplementation is recommended for young children whose diets may not provide adequate nutrients.

Toddlers are typically picky about which foods they’ll eat and, as a result, some may not get enough calories from a vegetarian diet to thrive. For vegan toddlers, the amount of vegetables needed for proper nutrition and calories may be too bulky for their tiny stomachs.

During the picky toddler stage, it’s important for vegetarian parents to make sure their young child eats enough calories. You can get enough fat and calories in a vegan child’s diet, but you have to plan carefully.

Older vegetarian kids and teens

Preteens and teens often voice their independence through the foods they choose to eat. One strong statement is the decision to stop eating meat. This is common among teens, who may decide to embrace vegetarianism in support of animal rights, for health reasons, or because friends are doing it.

If it’s done right, a meat-free diet can actually be a good choice for adolescents, especially considering that vegetarians often eat more of the foods that most teens don’t get enough of — fruits and vegetables.

A vegetarian diet that includes dairy products and eggs (lacto-ovo) is the best choice for growing teens. A more strict vegetarian diet may fail to meet a teen’s need for certain nutrients, such as iron, zinc, calcium, and vitamins D and B12. If you’re concerned that your child is not getting enough of these important nutrients, talk to your doctor, who may recommend a vitamin and mineral supplement.

The good news for young vegetarians — and their parents — is that many schools are offering vegetarian fare, including salad bars and other healthy vegetarian choices. Schools publish lists of upcoming lunch menus; be sure to scan them to see if your child will have a vegetarian choice. If not, you can pack lunch.

If your vegetarian preteen or teen would rather make his or her own school lunch or opts to buy lunch, keep in mind that your child’s idea of a healthy vegetarian meal may be much different from yours (e.g., french fries and a soda). Talk to your child about the importance of eating right, especially when following a vegetarian diet.

Also be wary if your child has self-imposed a very restrictive diet. A teen with an eating disorder may drastically reduce calories or cut out all fat or carbohydrates and call it “vegetarianism” because it’s considered socially acceptable and healthy.

Even if preteens or teens are approaching vegetarianism in a healthy way, it’s still important for them to understand which nutrients might be missing in their diet. To support your child’s dietary decision and promote awareness of the kinds of foods your preteen or teen should be eating, consider having the whole family eat a vegetarian meal at least one night a week.

Nutrients for vegetarian teenagers

Protein

For protein, your vegetarian child can include beans, lentils, chickpeas, tofu and nuts in her diet.

Omega-3 fatty acids

Flaxseed and walnuts are good vegetarian sources of omega-3 fatty acids.

Iron

Good sources of iron for vegetarian teenagers include:

• dark green leafy vegetables like spinach
• legumes like beans and lentils
• wholegrains and fortified cereals.

If your child is a vegetarian, encourage him to eat foods high in vitamin C at the same time as he eats foods high in iron. This will help him absorb iron better. For example, he could try lentils with tomato sauce at dinner, or wholegrain cereal with an orange at breakfast.

Vitamin B12

Your child can get vitamin B12 from eggs and milk if she eats a vegetarian diet that includes these animal products. Fortified breakfast cereals can be a great source of vitamin B12 if your child avoids all animal products. Not all cereals have added B12 so be sure to read food labels.

What is a vegetarian?

According to the Vegetarian Society (https://www.vegsoc.org), a vegetarian is:

• “Someone who lives on a diet of grains, pulses, legumes, nuts, seeds, vegetables, fruits, fungi, algae, yeast and/or some other non-animal-based foods (e.g. salt) with, or without, dairy products, honey and/or eggs. A vegetarian does not eat foods that consist of, or have been produced with the aid of products consisting of or created from, any part of the body of a living or dead animal. This includes meat, poultry, fish, shellfish*, insects, by-products of slaughter** or any food made with processing aids created from these.”
• * Shellfish are typically ‘a sea animal covered with a shell’. We take shellfish to mean; Crustaceans (hard external shell) e.g. lobsters, crayfish, crabs, prawns, shrimps; Molluscs (most are protected by a shell) e.g. mussels, oysters, winkles, limpets, clams, etc. Also includes cephalopods such as cuttlefish, squid, octopus.
• ** By-products of slaughter includes gelatine, is in glass and animal rennet.
• Eggs: Many lacto-ovo vegetarians will only eat free-range eggs. This is because of welfare objections to the intensive farming of hens. Through its Vegetarian Society Approved trademark scheme, the Vegetarian Society will only license its trademark to products containing free-range eggs where eggs are used.

There are different types of vegetarians:

• Lacto-ovo-vegetarians eat both dairy products and eggs (usually free range). This is the most common type of vegetarian diet ⁴⁾.
• Lacto-vegetarians eat dairy products, but avoid eggs.
• Ovo-vegetarian. Eats eggs but not dairy products.
• Vegans do not any products derived from animals – no meat, fish, dairy or eggs.

The principles of planning a vegetarian diet are the same as planning any healthy diet — provide a variety of foods and include foods from all of the food groups. A balanced diet will provide the right combinations to meet nutritional needs. But be aware of potential nutrient deficiencies in your child’s diet and figure out how you’ll account for them. With a little exploration, you may find more vegetarian options than you realized.

If you aren’t sure your child is getting all necessary nutrients or if you have any questions about vegetarian diets, check in with your family doctor, pediatrician, or a registered dietitian.

For advice and help with what to eat and including vegetarian recipes go to the Vegetarian Society (https://www.vegsoc.org).

In general, vegetarians had significantly lower intakes of protein, saturated fat and cholesterol and significantly higher intakes of dietary fiber and vitamin C than omnivorous diets ⁵⁾.

Vegetarian diet potential health benefits

Vegetarian diets can be healthful and nutritionally sound if they’re carefully planned to include essential nutrients. Specifically, Johnson lays out several potential benefits of a vegetarian diet:

• Healthier weight. Vegetarians may be more likely to be at a healthy weight compared to meat eaters.
• Lower incidence of heart disease. Vegetarians seem to have a lower incidence of heart disease than meat eaters. The unsaturated fats found in soybeans, seeds, avocados, nuts, olives and other foods of plant origin tend to reduce the risk of heart disease. Plant-based diets tend to be higher in fiber and are associated with healthy blood lipids.
• Lower blood pressure and less hypertension. Vegetarians tend to have lower blood pressure and lower rates of hypertension than nonvegetarians. This may be related to vegetarians being at a healthy body weight, which helps maintain a healthy blood pressure.

Vegetarian diet potential risks

• Lack of nutrients. There can be risks linked to vegetarian diets associated with a lack of nutrients. If you are not careful to get the nutrients you need, you could experience a lack of protein, iron, zinc, calcium, vitamin B12, vitamin D and omega-3 fatty acids.
• Unhealthy if contains too many calories. It is important to note a vegetarian diet can be unhealthy if it contains too many calories and/or saturated fat and not enough important nutrients.

It would be helpful for you following a vegetarian diet to see a registered dietitian to assure that all your nutrient needs are being met.

What is Vegan diet?

A vegan diet is a total vegetarian diet. Besides not eating meat, vegans don’t eat food that comes from animals in any way. That includes milk (dairy) products, eggs, fish, honey, and gelatin (which comes from bones and other animal tissue).

In a small Swedish study involving 30 teenagers (average age 17.5 years) who are eating the vegan diet ⁶⁾. The study found that the dietary habits of the vegans varied considerably and did not comply with the average requirements for some essential nutrients. Vegans had dietary intakes lower than the average requirements of riboflavin (vitamin B2), vitamin B-12, vitamin D, calcium, and selenium. Intakes of calcium and selenium remained low even with the inclusion of dietary supplements ⁷⁾. This study result is consistent with another study showing the health effects of vegan diets ⁸⁾.

If I switch to a vegan diet, will I lose weight?

A vegan diet is not inherently a weight-loss diet, but rather a lifestyle choice.

It is true, that adults and children who follow a vegan diet are generally leaner than those who follow a non-vegan diet. This may be because a vegan diet typically emphasizes more fruits and vegetables and includes whole grains and plant-based proteins — foods that are more filling, less calorie dense and lower in fat. Vegan diets can contain a lot of fiber. Fiber is great because it fills you up without adding a lot of calories.

A study looking at the health effects of people on the vegetarian diets and vegan diets ⁹⁾ found that vegan diets when compared to vegetarian diets vegan diets tend to contain less saturated fat and cholesterol and more dietary fiber. Vegans tend to be thinner, have lower serum cholesterol, and lower blood pressure, reducing their risk of heart disease. However, eliminating all animal products from the diet increases the risk of certain nutritional deficiencies. Micronutrients of special concern for the vegan include vitamins B-12 and D, calcium, and long-chain n-3 (omega-3) fatty acids. Unless vegans regularly consume foods that are fortified with these nutrients, appropriate supplements should be consumed. In some cases, iron and zinc status of vegans may also be of concern because of the limited bioavailability of these minerals ¹⁰⁾. On the other hand, vegetarian diets contain higher content for vitamins A, C, and E, thiamin, riboflavin, folate, calcium, magnesium, and iron, suggesting that vegetarian diets are nutrient dense, consistent with dietary guidelines, and could be recommended for weight management without compromising diet quality ¹¹⁾.

The study of Appleby and colleagues ¹²⁾ with 34,696 participants (7947 men and 26,749 women aged 20-89 years, including 19,249 meat eaters, 4901 fish eaters, 9420 vegetarians and 1126 vegans) points to the increased fracture risk in vegans compared to omnivorous, pesco-vegetarians and vegetarians. The higher fracture risk in the vegans appeared to be a consequence of their considerably lower mean calcium intake. An adequate calcium intake is essential for bone health, irrespective of dietary preferences ¹³⁾.

So going back to the question whether you will lose weight by going on a vegan diet, the answer is not necessarily true that you will lose weight. Because a vegan diet isn’t automatically low calorie diet. You can gain weight even on a vegan diet if your portion sizes are too big or if you eat too many high-calorie foods, such as sweetened beverages, fried items, snack foods and desserts.

Even some foods marketed as vegan can be high in calories, salt, sugar and fat, such as soy hot dogs, fried beans and snack bars.

Whether you avoid or eat meat or animal products, the basics of achieving and maintaining a healthy weight are the same for all people. Eat a healthy diet and balance calories eaten with calories burned.

If properly planned, a vegan diet can provide all the nutrients you need. In general, people who don’t eat meat:

• Weigh less than people who eat meat.
• Are less likely to die of heart disease.
• Have lower cholesterol levels.
• Are less likely to get: High blood pressure, prostate cancer, colon cancer and type 2 diabetes.

There are many reasons why some people choose a vegan diet:

• It can be healthier than other diets.
• Some people think it’s wrong to use animals for food.
• Some religions forbid eating meat.
• A vegan diet can cost less than a diet that includes meat.
• Eating less meat can be better for the environment, because most meat is commercially farmed.
• Some people don’t like the taste of meat.

While there is no research on vegan diet and mortality, there are research that gives support that those on a vegetarian diet tended to have a lower rate of death due to cardiovascular disease, diabetes, and renal disorders such as kidney failure. And there was no association was detected in this study between diet and deaths due to cancer. The researchers also found that the beneficial associations between a vegetarian diet and mortality tended to be stronger in men than in women.

Good health could be related to a diet of mostly fruits, vegetables, and whole grains.

How can vegans eat a balanced diet ?

You may be worried that you won’t get all the nutrients you need with a vegan diet. But as long as you eat a variety of foods, there are only a few things you need to pay special attention to.

• Calcium for people who don’t eat milk products. If you don’t get your calcium from milk products, you need to eat a lot of other calcium-rich foods. Calcium-fortified breakfast cereals, soy milk, and orange juice are good choices. Calcium-fortified means that the manufacturer has added calcium to the food. Other foods that have calcium include certain legumes, certain leafy green vegetables, nuts, seeds, and tofu. If you don’t use calcium-fortified foods, ask your doctor if you should take a daily calcium supplement.
• Vitamin D for people who don’t eat milk products. Getting enough calcium and vitamin D is important to keep bones strong. People who don’t eat milk products can use fortified soy milk and breakfast cereals.
• Iron. Getting enough iron is not a problem for vegans who take care to eat a wide variety of food. Our bodies don’t absorb iron from plant foods as well as they absorb iron from meats. So it’s important for vegans to regularly eat iron-rich foods. Vegan iron sources include cooked dried beans, peas, and lentils; leafy green vegetables; and iron-fortified grain products. And eating foods rich in vitamin C will help your body absorb iron.
• Vitamin B12. Vitamin B12 comes from animal sources only. If you are a vegan, you’ll need to rely on food that is fortified with this vitamin (for example, soy milk and breakfast cereals) or take supplements. This is especially important for vegan women who are pregnant or breastfeeding.

Vegans also need to make sure they get the following nutrients:

• Protein. When considering a vegan diet, many people worry that they will not get enough protein. But eating a wide variety of protein-rich foods such as soy products, legumes, lentils, grains, nuts, whole grains and seeds will give you the protein you need.
• Omega-3 fatty acids. Without fish and eggs in your diet, you need to find other good sources of omega-3 fatty acids, such as hemp seeds, flaxseeds, pumpkin seeds, walnuts, certain leafy green vegetables, soybean oil, canola oil, and sea vegetables (such as arame, dulse, nori, kelp, kombu or wakame).
• Zinc. Your body absorbs zinc better when it comes from meat than when it comes from plants. But vegans don’t usually have a problem getting enough zinc if they eat lots of other foods that are good sources of zinc, including whole-grain breads, cooked dried beans and lentils, soy foods, and vegetables.
• Iodine. Iodine is a component in thyroid hormones, which help regulate metabolism, growth and function of key organs. Vegans may not get enough iodine and may be at risk of deficiency and possibly even a goiter. In addition, foods such as soybeans, cruciferous vegetables and sweet potatoes may promote a goiter. However, just 1/4 teaspoon of iodized salt a day provides a significant amount of iodine.

If you’re contemplating to give vegan diet a go, talk to a registered dietitian or nutrionist to learn how to plan a healthy vegan diet. A vegan diet excludes all animal products, including dairy. So it’s easy to miss certain key nutrients that are crucial to health. Protein, calcium, vitamins D and B12, omega-3 fatty acids, iron, zinc, and Iodine — they are all harder to get when you are vegan.

In most cases, you can get them from plants. But you may need to take a daily supplement for some nutrients like B12 or calcium because it’s hard to get enough from plant sources. And certain nutrients, like iron and zinc, are harder to absorb from plant-based foods. Good news is, a lot of foods, like cereal, are fortified to include these nutrients, which can make it easier to get them into your meal plan.

Comparison of Nutritional Quality of the Vegan, Vegetarian, Semi-Vegetarian, Pesco-Vegetarian and Omnivorous Diet

A study was performed to analyze and compare the nutrient intake and the diet quality of vegans, vegetarians, semi-vegetarians, pesco-vegetarians and omnivorous subjects (total 1475 participants) ¹⁴⁾. Three out of four were females and almost 50% were less than 30 years of age. Hundred and four persons were following a vegan diet (7.1%), 573 (38.8%) were vegetarians, 498 (33.8%) declared to be semi-vegetarians, 145 (9.8%) were pesco-vegetarians and 155 (10.5%) were omnivores. The percentages of participants with normal weights varied from 78.8% for vegans to 67.7% for omnivores; 8.7% of vegans were underweight, which was comparable with vegetarians and pesco-vegetarians. The prevalence of overweight and obesity was the highest for the omnivores, respectively 20.6% and 8.4%, and lowest for vegans (respectively 10.6% and 1.9%). Almost 80% of the sample had a university or university college level of education.

Except for the omnivores, all diet groups had a comparable number of underweight subjects (ranging from 6.2% to 8.9%), whilst this was only 3.2% for the omnivores. These percentages were reversed for overweight and obesity, with a higher prevalence of overweight and obese subjects amongst the omnivores compared to the other diet groups. These findings are in agreement with published literature, where pesco-vegetarians, vegetarians and especially vegans had lower BMI than meat-eaters ¹⁵⁾.

Nutritional intake of vegans compared to an omnivorous diet is in line with earlier research on vegans. Indeed, the most restricted diet had lowest total energy intake, better fat intake profile (i.e., lower cholesterol, total and saturated fat and higher poly-unsaturated fat), lowest protein and highest dietary fiber intake in contrast to the omnivorous diet ¹⁶⁾. The intakes of the prudent diets were in between the vegan and omnivorous values. Absolute carbohydrate and sugar intakes were of the same magnitude across all diets, whilst relative intakes were highest in the vegan and lowest in the omnivorous diet. The higher carbohydrate intake as a function of the restriction results in a better macronutrient distribution for the more restrictive diets, which is in line with the literature ¹⁷⁾.

It is well known that fruit is an important contributor of carbohydrates and sugars, especially in the more restricted diets, where fruit consumption is generally high ¹⁸⁾. Moreover, other common and less healthy sources of sugar (i.e., candy, chocolate, cake and cookies) often contain animal products allowing only limited availability of these sugar sources for vegans ¹⁹⁾. Sodium intake in vegans is less than half of the omnivorous intake. Although not of the same magnitude, lower sodium intakes have been reported when comparing respectively vegetarian ²⁰⁾ and vegan diets ²¹⁾ with omnivorous diets. The restrictive diets allowing dairy consumption had the highest calcium intakes with the vegans only reaching half of these values. Indeed, in Western countries, dairy products are a major source of calcium in most diets ²²⁾. The study of Appleby and colleagues ²³⁾ points to the increased fracture risk in vegans compared to omnivorous, pesco-vegetarians and vegetarians. The higher fracture risk in the vegans appeared to be a consequence of their considerably lower mean calcium intake. An adequate calcium intake is essential for bone health, irrespective of dietary preferences ²⁴⁾. In agreement with the EPIC-Oxford study, a certain similarity was detected for the calcium intakes for omnivores, vegetarians, semi-vegetarians and pesco-vegetarians ²⁵⁾. The iron intake, with the most favorable values for the vegans, will not automatically result in an optimal iron status, since absorption of non-haem iron is less efficient ²⁶⁾, ²⁷⁾. Analysis of the different components of the Healthy Eating Index 2010 and the Mediterranean Diet Score indicate that vegans obtained the better scores for vegetables and legumes. The study of Ball & Bartlett demonstrated the importance of the vegetables component when comparing the iron intake of vegetarian versus omnivorous women ²⁸⁾. The results are in line with those of the comparative study of Larsson & Johansson on vegan adolescents versus omnivores where vegan iron intake in females was significantly higher compared to their omnivorous counterparts ²⁹⁾. The uneven gender distribution in this study vegan sample (70% females) may partly explain these high iron intakes since dietary practices in women are generally better than those in men ³⁰⁾.

Vegetarian Diets Linked to Lower Mortality

Adults who eat a more plant-based diet may be boosting their chance of living longer, according to a large analysis.

Researchers studied more than 73,000 Seventh-day Adventist men and women ages 25 and older ³¹⁾. The participants were categorized into dietary groups at the time of recruitment based on their reported food intake during the previous year. Nearly half of the participants were nonvegetarian, eating red meat, poultry, fish, milk and eggs more than once a week. Of the remaining, 8% were vegan (eating red meat, fish, poultry, dairy or eggs less than once a month); 29% were lacto-ovo vegetarians (eating eggs and/or dairy products, but red meat, fish or poultry less than once per month); 10% were pesco-vegetarians (eating fish, milk and eggs but rarely red meat or poultry); and 5% were semi-vegetarian (eating red meat, poultry and fish less than once per week).

Over about 6 years, there were 2,570 deaths among the participants. The researchers found that vegetarians (those with vegan, and lacto-ovo-, pesco-, and semi-vegetarian diets) were 12% less likely to die from all causes combined compared to nonvegetarians. The death rates for subgroups of vegans, lacto-ovo–vegetarians, and pesco-vegetarians were all significantly lower than those of nonvegetarians.

Those on a vegetarian diet tended to have a lower rate of death due to cardiovascular disease, diabetes, and renal disorders such as kidney failure. No association was detected in this study between diet and deaths due to cancer. The researchers also found that the beneficial associations between a vegetarian diet and mortality tended to be stronger in men than in women.

The researchers note several limitations to the study. Participants only reported their diet at the beginning of the study, and their eating patterns might have changed over time. In addition, they were only followed for an average of 6 years; it may take longer for dietary patterns to influence mortality ³²⁾.

Vegetarian Diet and Mortality from Cardiovascular Disease

A study involving 11,000 vegetarians and health conscious people over 17 years ³³⁾, the results were: 2064 (19%) subjects smoked, 4627 (43%) were vegetarian, 6699 (62%) ate wholemeal bread daily, 2948 (27%) ate bran cereals daily, 4091 (38%) ate nuts or dried fruit daily, 8304 (77%) ate fresh fruit daily, and 4105 (38%) ate raw salad daily. After a mean of 16.8 years follow up there were 1343 deaths before age 80. Overall the cohort had a mortality about half that of the general population. Within the cohort, daily consumption of fresh fruit was associated with significantly reduced mortality from ischaemic heart disease (heart attack), cerebrovascular disease (stroke), and for all causes combined. The conclusion from that study ³⁴⁾: in health conscious individuals, daily consumption of fresh fruit is associated with a reduced mortality from ischaemic heart disease, cerebrovascular disease, and all causes combined.

Cruciferous Vegetables and Cancer Prevention

Cruciferous vegetables are part of the Brassica genus of plants ³⁵⁾. They include the following vegetables, among others:

Arugula Bok choy Broccoli Brussels sprouts Cabbage Cauliflower Collard greens

Horseradish Kale Radishes Rutabaga Turnips Watercress Wasabi

Researchers have investigated possible associations between intake of cruciferous vegetables and the risk of cancer. Studies in humans, however, have shown mixed results.

A few studies have shown that the bioactive components of cruciferous vegetables can have beneficial effects on biomarkers of cancer-related processes in people. For example, one study found that indole-3-carbinol was more effective than placebo in reducing the growth of abnormal cells on the surface of the cervix ³⁶⁾.

In addition, several case-control studies have shown that specific forms of the gene that encodes glutathione S-transferase, which is the enzyme that metabolizes and helps eliminate isothiocyanates from the body, may influence the association between cruciferous vegetable intake and human lung and colorectal cancer risk ³⁷⁾, ³⁸⁾, ³⁹⁾.

Higher consumption of vegetables in general may protect against some diseases, including some types of cancer. However, when researchers try to distinguish cruciferous vegetables from other foods in the diet, it can be challenging to get clear results because study participants may have trouble remembering precisely what they ate. Also, people who eat cruciferous vegetables may be more likely than people who don’t to have other healthy behaviors that reduce disease risk. It is also possible that some people, because of their genetic background, metabolize dietary isothiocyanates differently. However, research has not yet revealed a specific group of people who, because of their genetics, benefit more than other people from eating cruciferous vegetables.

The evidence has been reviewed by various experts ⁴⁰⁾. Key studies regarding four common forms of cancer are described briefly below.

• Prostate cancer: Cohort studies in the Netherlands ⁴¹⁾, United States ⁴²⁾, and Europe ⁴³⁾ have examined a wide range of daily cruciferous vegetable intakes and found little or no association with prostate cancer risk. However, some case-control studies have found that people who ate greater amounts of cruciferous vegetables had a lower risk of prostate cancer ⁴⁴⁾, ⁴⁵⁾.

• Colorectal cancer: Cohort studies in the United States and the Netherlands have generally found no association between cruciferous vegetable intake and colorectal cancer risk ⁴⁶⁾, ⁴⁷⁾, ⁴⁸⁾. The exception is one study in the Netherlands—the Netherlands Cohort Study on Diet and Cancer—in which women (but not men) who had a high intake of cruciferous vegetables had a reduced risk of colon (but not rectal) cancer ⁴⁹⁾.

• Lung cancer: Cohort studies in Europe, the Netherlands, and the United States have had varying results ⁵⁰⁾, ⁵¹⁾, ⁵²⁾. Most studies have reported little association, but one U.S. analysis—using data from the Nurses’ Health Study and the Health Professionals’ Follow-up Study—showed that women who ate more than 5 servings of cruciferous vegetables per week had a lower risk of lung cancer ⁵³⁾.

• Breast cancer: One case-control study found that women who ate greater amounts of cruciferous vegetables had a lower risk of breast cancer ⁵⁴⁾. A meta-analysis of studies conducted in the United States, Canada, Sweden, and the Netherlands found no association between cruciferous vegetable intake and breast cancer risk ⁵⁵⁾. An additional cohort study of women in the United States similarly showed only a weak association with breast cancer risk ⁵⁶⁾.

Exercises for teens

Experts recommend that teens do 60 minutes or more of physical activity every day. Most of that should be moderate to vigorous aerobic activity. Aerobic activity is anything that gets your heart going — like biking, dancing, or running. Then take a few minutes for some strength training. Exercises like the ones below help build muscle and boost metabolism. Flexibility is the third component of well-rounded exercise. Check out yoga as one way to stay flexible.

A balanced exercise routine includes aerobic (cardio) activity, stretching, and strength training. Walking, running, and swimming are examples of aerobic activity. Aerobic activity strengthens your heart and lungs. Stretching improves your flexibility. Strength training uses resistance, like free weights, weight machines, resistance bands, or a person’s own weight, to build muscles and strength. Teens may want to strength train to improve sports performance, treat or prevent injuries, or improve appearance.

Teens should always be supervised by a qualified adult, who can help them and demonstrate the proper technique. For that reason, it’s safer to work out at school or at a health club than on home exercise equipment. Other precautions to take include the following:

• See your doctor or pediatrician for a physical and medical checkup before your youngster starts training.
• Remember that resistance training is a small part of a well-rounded fitness program. Experts generally recommend that adolescents exercise with weights no more than three times a week.
• Don’t overdo it: Excessive physical activity can lead to injuries and cause menstrual abnormalities. Your teenager may be exercising too much if her weight falls below normal or her muscles ache. Complaints of pain warrant a phone call to your pediatrician.
• Don’t overdo it: Teens should be reminded not to step up the weight resistance and number of repetitions before they’re physically ready. Getting in shape takes time.
• Drink plenty of fluids when exercising. Young people are more susceptible to the effects of heat and humidity than adults. Teens’ ability to dissipate heat through sweating is not as efficient as adults. The Centers for Disease Control and Prevention recommends that teens drink at least two six-ounce glasses of water before, during and after working out in steamy conditions.
• Always warm up and cool down with stretching exercises before and after training. Stretching the muscles increases their flexibility: the ability to move joints and stretch muscles through a full range of motion, and the fourth component of physical fitness. It also helps safeguard against injury.

NOTE: Exercises should not be painful. When pain develops, exercises may need to be modified or exercises even may need to be stopped. In some cases, it may be necessary to obtain further professional consultation if symptoms persist.

Ab workout for teens

• Sit on floor, legs bent
• Arms straight in front
• Lean back gradually
• Keep arms straight and tummy tight
• Take it as far back as comfortable
• Slowly return to sitting position
• Repeat

Is there such thing as exercising too much?

Yes, and it is called compulsive exercise. Because teenagers’ bodies are still developing, they need enough calories to support that process. Exercising too much burns all the calories necessary to develop and function properly. Too much exercise is also a sign of a possible eating disorder. It is also possible to train too much for a certain sport. High school athletes should not train more than five days a week, and should have two or three months of rest per year. It is not recommended that you exercise with an injury – it will only delay the healing process.

What are the symptoms of compulsive exercise?

• Upset because you missed a workout
• Exercising even when you do not feel well
• Exercising instead of hanging out with friends
• Hate sitting still because you are not burning calories
• Feel that you will gain weight from going a day without exercise

Aerobic Exercise

A teen’s fitness program should include aerobic exercise such as brisk walking, basketball, bicycling, swimming, in-line skating, soccer, jogging—any continuous activity that increases heart rate and breathing. Regular workouts improve the efficiency of the cardiorespiratory system, so that the heart and lungs don’t have to work as hard to meet the body’s increased demands for freshly oxygenated blood.

Aerobic exercise also affects body weight composition, by burning excess calories that would otherwise get converted to fat. In general, the more aerobic an activity, the more calories are expended. For instance, if a teenager weighing 132 pounds walks at a moderate pace for ten minutes, he burns forty-three calories. Running instead of walking more than doubles the amount of energy spent, to ninety calories.

Low-intensity workouts burn a higher percentage of calories from fat than high-intensity workouts do. However, the more taxing aerobic exercises ultimately burn more fat calories overall. One study compared the burn rates for a thirty-minute walk at three and a half miles per hour and a thirty-minute run at seven miles per hour. The walking group expended an average of 240 calories. Two-fifths came from fat, and three-fifths came from carbohydrates, for a total of ninety-six fat calories. In the running group, the ratio of fat energy burned versus carbohydrate energy burned was significantly less: one to four. Yet overall, the runners consumed 450 calories. Total number of fat calories burned: 108.

Strength training

Under the guidance of well-trained adults, children aged eight or older can safely incorporate weight training also called strength training and resistance training into their workouts to increase muscle strength and muscle endurance. Muscle strength refers to the ability to displace a given load or resistance, while muscle endurance is the ability to sustain less-intense force over an extended period of time. Males will not be able to develop large muscles until after puberty. Females generally are not able to develop large muscle mass. They do not have to worry about getting too muscular.

Teens who work out with weights can use:

• free weights. Free weights (including barbells, dumbbells, and hand weights) are portable and inexpensive. It may take some practice to learn good technique.
• weight machines. Weight machines make it easier to follow good technique, but you will probably have to go to a gym or weight room.

People can also use resistance bands and even their own body weight (as in push-ups, sit-ups, planks, and squats) for strength training.

You can do these three strength-building exercises at home. There’s no need for special equipment, expensive gym fees, or lots of time. Just check with your doctor, PE teacher, or coach first to be sure these exercises are OK for you.

If you haven’t started puberty, strength training will help you get stronger but your muscles won’t get bigger. After puberty, the male hormone, testosterone , helps build muscle in response to weight training. Because guys have more testosterone than girls do, they get bigger muscles.

Multiple studies show that young people gain strength and endurance faster by lifting moderately heavy weights many times rather than straining to hoist unwieldy loads for just a few repetitions.

Getting started

Before you start strength training, visit your doctor to make sure it’s safe for you to lift weights.

When you get the OK from your doctor, get some guidance and expert advice. Trainers who work at schools, gyms, and in weight rooms know about strength training. But look for someone who is a certified strength-training expert and experienced working with teens.

The best way to learn proper technique is to do the exercises without any weight. After you’ve mastered the technique, you can gradually add weight as long as you can comfortably do the exercise for 8 to 15 repetitions.

When lifting weights — either free weights or on a machine — make sure that there’s always someone nearby to supervise.

Having a spotter nearby is particularly important when using free weights. Even someone in great shape sometimes just can’t make that last rep. It’s no big deal if you’re doing biceps curls; all you’ll have to do is drop the weight onto the floor. But if you’re in the middle of a bench press — a chest exercise where you’re lying on a bench and pushing a loaded barbell away from your chest — it’s easy to get hurt if you drop the weight. A spotter can keep you from dropping the barbell onto your chest.

Many schools offer weight or circuit training in their gym classes. Or check out your local gym to see if you can sign up for a strength training class.

Basic rules to follow in strength training

Here are some basic rules to follow in strength training:

1. Warm up for 5–10 minutes before each session.
2. If you are new to strength training, start with body weight exercises for a few weeks (such as sit-ups, push-ups, and squats) and work on technique without using weights.
3. Work out with resistance (weights, resistance bands, or body weight) about three times a week. Avoid weight training on back-to-back days.
4. Do 2–3 sets of higher repetitions (8–15); No maximum lifts. A certified trainer, coach, or teacher can help put together a program that is right for you.
5. Learn correct technique and always train with supervision
6. Cool down for 5–10 minutes after each session, stretching the muscles you worked out.

For best results, do strength exercises for at least 20–30 minutes 2 or 3 days per week. Take at least a day off between sessions. Work the major muscle groups of your arms, legs, and core (abdominal muscles, back, and buttocks).

Doctors recommend at least an hour a day of moderate to vigorous physical activity. So on days when you’re not lifting weights, aim for more aerobic activity. Also, drink plenty of liquids and eat a healthy diet for better performance and recovery.

What are the benefits of strength training?

Besides building stronger muscles, strength training can:

• improve overall fitness
• increase lean body mass (more muscle, less fat)
• burn more calories
• make bones stronger
• improve mental health

Is strength training safe?

Strength-training programs are generally safe. When done properly, strength training won’t damage growing bones. Kids and teens with some medical conditions — such as uncontrolled high blood pressure, seizures, or heart problems — will need to be cleared by their doctors before starting a strength-training program.

When you’re in the middle of a strength-training session and something doesn’t feel right to you, you feel pain, or if you hear or feel a “pop” during a workout, stop what you’re doing. Have a doctor check it out before you go back to training. You may need to change your training or even stop lifting weights for a while to allow the injury to heal.

Many people tend to lump all types of weightlifting together. But there’s a big difference between strength training, powerlifting, and bodybuilding. Powerlifting concentrates on how much weight a person can lift at one time. The goal of competitive bodybuilding is to build muscle size and definition.

Powerlifting, maximal lifts, and bodybuilding are not recommended for teens who are still maturing. That’s because these types of activity increase the chance of injuries.

Some people looking for big muscles may turn to anabolic steroids or other performance-enhancing drugs. These substances are risky and can cause problems like acne, balding, and high blood pressure. They also increase the chances of getting cancer, heart disease, and sterility.

Yoga

The word yoga is Sanskrit (one of the ancient languages of the East). It means to “yoke,” or unite, the mind, body, and spirit.

Yoga includes physical exercise, but it’s also about life balance. Training your mind, body, and breath — as well as connecting with your spirituality — are the main goals of the yoga lifestyle.

Yoga has tons of benefits. It can improve flexibility, strength, balance, and stamina. In addition, many people who practice yoga say that it reduces anxiety and stress, improves mental clarity, and even helps them sleep better.

The physical part of the yoga lifestyle is called hatha yoga. Hatha yoga focuses on asanas, or poses. A person who practices yoga goes through a series of specific poses while controlling his or her breathing. Some types of yoga also involve meditation and chanting.

There are many different types of hatha yoga, including:

• Ashtanga yoga: Ashtanga yoga is a vigorous, fast-paced form of yoga that helps to build flexibility, strength, concentration, and stamina. When doing Ashtanga yoga, a person moves quickly through a set of predetermined poses while remaining focused on deep breathing.
• Bikram yoga: Bikram yoga is also known as “hot yoga.” It is practiced in rooms that may be heated to more than 100°F (37.8°C) and focuses on stamina and purification.
• Gentle yoga: Gentle yoga focuses on slow stretches, flexibility, and deep breathing.
• Kundalini yoga: Kundalini yoga uses different poses, breathing techniques, chanting, and meditation to awaken life energy.
• Iyengar yoga: This type of yoga focuses on precise alignment of the poses. Participants use “props” like blankets, straps, mats, blocks, and chairs.
• Restorative yoga: This practice allows the body to fully relax by holding simple postures passively for extended periods of time.
• Vinyasa/power yoga: Similar to Ashtanga yoga, these are also very active forms of yoga that improve strength, flexibility, and stamina. This type of yoga is popular in the United States.

Getting started

Many gyms, community centers, and YMCAs offer yoga classes. Your neighborhood may also have a specialized yoga studio. Some yoga instructors offer private or semi-private classes for students who want more personalized training.

Before taking a class, check whether the instructor is registered with the Yoga Alliance, a certification that requires at least 200 hours of training in yoga techniques and teaching. You may also want to sit in and observe the class that interests you.

You could also try using a yoga DVD. Websites, DVDs, and books can’t compare to learning yoga poses from a teacher, but they can help you find out more. They can be especially helpful if you have already taken yoga classes and want to practice at home. And also can try one of the many yoga apps available for smartphones and other devices.

Dress comfortably for your first yoga session in clothing that allows you to move your body fully. Stretchy shorts or pants and a T-shirt or tank top are best. Yoga is practiced barefoot, so you don’t have to worry about special shoes.

If you’re doing your yoga workout on a carpeted floor, you probably don’t need any equipment, although many people like to use a yoga mat or “sticky” mat. This special type of mat provides cushioning and grip while you do your poses. Yoga mats are sold in sporting goods stores, major retailers, and, possibly, at your yoga class location.

What can you expect at a yoga class or when you watch a yoga video? To begin the class, the instructor may lead you through a series of poses like Sun Salutations to warm up your arms, legs, and spine. After that, you’ll concentrate on specific poses that work different areas of your body. Most yoga sessions end with some type of relaxation exercise.

Before you begin any type of exercise program, it’s a good idea to talk to your doctor, especially if you have a health problem. Be sure to let your instructor know about any orthopedic problems or special needs you may have before the class begins. A good instructor will be able to provide modified poses for students who are just beginning or who have special needs.

Staying on track

Your schedule’s already packed, so how are you supposed to fit in time for yoga? Here are a few tips:

• Break it down. If you can’t do a half hour of yoga in one sitting, try doing it in chunks. How about 15 minutes after you get up and 15 minutes before bed? Or try three 10-minute workouts to break up a long study session.
• Do what works for you. Some people have more success working out in the morning before the day’s activities sidetrack them; others find that an after-school workout is the perfect way to unwind. Experiment with working out at different times of the day and find the time that fits your schedule and energy level best.
• Find a workout buddy. Doing your yoga routines with a friend is a great way to stay motivated. You’ll be less likely to miss your workout if you have an appointment with a friend. You and your buddy can compare tips on healthy eating and exercise habits, evaluate each other’s poses for form, and keep each other on track.
• Consistency is key. If you want to reap the benefits that yoga provides, you’ll have to do it consistently. A once-a-month yoga workout may relieve some stress, but for benefits like increased flexibility and stamina, you should aim to practice yoga three or four times a week.
• Set some goals. The same routine every week may become monotonous, so set some goals to help you stay focused. Perhaps you’d like to incorporate power yoga into your routine so you get a better cardiovascular workout. Maybe you’ve always gone to yoga class and your goal is to start practicing on your own at home. Whatever you choose as your goal, make sure you reward yourself when you accomplish it.

The great thing about yoga is it can be as vigorous or as gentle as you want it to be. That makes it a good choice for anybody.

Testicular self examination

Most testicular cancers can be found at an early stage, when they’re small and haven’t spread. Most of the time a lump on the testicle is the first symptom, or the testicle might be swollen or larger than normal. But some testicular cancers might not cause symptoms until they’ve reached an advanced stage. Testicular cancer is usually found as a result of symptoms that a person is having. It can also be found when tests are done for another condition.

No studies have been done to find out if testicular self-exams, regular exams by a doctor, or other screening tests in men with no symptoms would decrease the risk of dying from testicular cancer. However, routine screening probably would not decrease the risk of dying from testicular cancer. This is partly because testicular cancer can usually be cured at any stage. Finding testicular cancer early may make it easier to treat. Patients who are diagnosed with testicular cancer that has not spread to other parts of the body may need less chemotherapy and surgery, resulting in fewer side effects.

Most doctors agree that examining a man’s testicles should be part of a general physical exam during a routine check-up. This can help find cancer at an early stage. When abnormal tissue or cancer is found early, it may be easier to treat. By the time symptoms appear, cancer may have begun to spread.

Some doctors recommend that all men examine their testicles monthly after puberty. Each man has to decide for himself whether or not to do this. If you have certain risk factors that increase your chance of developing testicular cancer such as an undescended testicle, previous germ cell tumor in one testicle, or a family history, you should seriously consider monthly self-exams and talk about it with your doctor.

Testicular cancer key points

• Testicular cancer is a disease in which malignant (cancer) cells form in the tissues of one or both testicles.
• Testicular cancer is the most common cancer in men aged 15 to 34 years. Testicular cancer is very rare, but it is the most common cancer found in men between the ages of 15 and 34. White men are four times more likely than black men to have testicular cancer
• Testicular cancer can usually be cured. Although the number of new cases of testicular cancer has doubled in the last 40 years, the number of deaths caused by testicular cancer has decreased greatly because of better treatments. Testicular cancer can usually be cured, even in late stages of the disease.
• A condition called cryptorchidism (an undescended testicle) is a risk factor for testicular cancer. Anything that increases the chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk. Risk factors for testicular cancer include the following:
  • Having cryptorchidism (an undescended testicle).
  • Having a testicle that is not normal, such as a small testicle that does not work the way it should.
  • Having testicular carcinoma in situ.
  • Being white.
  • Having a personal or family history of testicular cancer.
  • Having Klinefelter syndrome.
  • Men who have cryptorchidism, a testicle that is not normal, or testicular carcinoma in situ have an increased risk of testicular cancer in one or both testicles, and need to be followed closely.

Testicle anatomy

The testicles are 2 egg-shaped glands inside the scrotum (a sac of loose skin that lies directly below the penis). The testicles are held within the scrotum by the spermatic cord. The spermatic cord also contains the vas deferens and vessels and nerves of the testicles.

The testicles are the male sex glands and make testosterone and sperm. Germ cells in the testicles make immature sperm. These sperm travel through a network of tubules (tiny tubes) and larger tubes into the epididymis (a long coiled tube next to the testicles). This is where the sperm mature and are stored.

Almost all testicular cancers start in the germ cells. The two main types of testicular germ cell tumors are seminomas and nonseminomas.

Figure 1. Male reproductive system

Figure 2. Testis anatomy

Figure 3. Testicular cancer

How does testicular cancer present itself?

Testicular cancer can present in two ways, it can be an isolated lump that will not spread and can be removed along with one testicle or it can be the type of cancer that can spread to the lymph nodes. The latter is more aggressive and may lead to removal of the testicle, some lymph nodes and a period of chemotherapy and radiotherapies to prevent any risk of cancer spreading. Fortunately, the chances of cancer recurring in most cases is very low. The best diagnostic tool for both types is a scan, which is the most comprehensive way to determine if a person has testicular cancer. A blood test can also be an indicator of cancer as high hCG (human chorionic gonadotropin) levels can also be a symptom.

Signs and symptoms of testicular cancer

Many of these symptoms are more likely to be caused by something other than testicular cancer. A number of non-cancerous conditions, such as testicle injury or inflammation, can cause symptoms a lot like those of testicular cancer. Inflammation of the testicle (known as orchitis) and inflammation of the epididymis (epididymitis) can cause swelling and pain of the testicle. Both of these also can be caused by viral or bacterial infections.

Some men with testicular cancer have no symptoms at all, and their cancer is found during medical testing for other conditions. For instance, sometimes imaging tests done to find the cause of infertility can uncover a small testicular cancer.

But if you have any of these signs or symptoms, see your doctor right away.

Lump or swelling in the testicle

Most often, the first symptom of testicular cancer is a lump on the testicle, or the testicle becomes swollen or larger. It’s normal for one testicle to be slightly larger than the other, and for one to hang lower than the other. Some testicular tumors might cause pain, but most of the time they don’t. Men with testicular cancer can also have a feeling of heaviness or aching in the lower belly (abdomen) or scrotum.

Breast growth or soreness

In rare cases, germ cell tumors can make breasts grow or become sore. This happens because certain types of germ cell tumors secrete high levels of a hormone called human chorionic gonadotropin (HCG), which stimulates breast development.

Some Leydig cell tumors can make estrogens (female sex hormones), which can cause breast growth or loss of sexual desire.

Early puberty in boys

Some Leydig cell tumors can make androgens (male sex hormones). Androgen-producing tumors may not cause any symptoms in men, but in boys they can cause signs of puberty at an abnormally early age, such as a deepening voice and the growth of facial and body hair.

Symptoms of advanced testicular cancer

Even if testicular cancer has spread to other parts of the body, many men might not have symptoms right away. But some men might have some of the following:

• Low back pain, from cancer spread to the lymph nodes (bean-sized collections of immune cells) in back of the belly.
• Shortness of breath, chest pain, or a cough (even coughing up blood) may develop from cancer spread in the lungs.
• Belly pain, either from enlarged lymph nodes or because the cancer has spread to the liver.
• Headaches or confusion, from cancer spread in the brain.

Testicular cancer diagnosis

The next step is an exam by a doctor. Your doctor will feel the testicles for swelling or tenderness and for the size and location of any lumps. The doctor will also examine your belly (abdomen), lymph nodes, and other parts of your body carefully to look for signs of cancer spread. Often the results of the exam are normal other than the changes in the testicles. If a lump or other sign of testicular cancer is found, testing will be needed to look for the cause.

Ultrasound of the testicles

An ultrasound is often the first test done if the doctor thinks you might have testicular cancer. It uses sound waves to produce images of the inside of your body. It can be used to see if a change is a certain benign condition (like a hydrocele or varicocele) or a solid tumor that could be a cancer. If the lump is solid, it’s more likely to be a cancer. In this case, the doctor might recommend other tests or even surgery to remove the testicle.

Blood tests for tumor markers

Some blood tests can help diagnose testicular tumors. Many testicular cancers make high levels of certain proteins called tumor markers, such as alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). When these tumor markers are in the blood, it suggests that there’s a testicular tumor.

Rises in levels of AFP (alpha-fetoprotein) or human chorionic gonadotropin (HCG) can also help doctors tell which type of testicular cancer it might be.

• Non-seminomas often raise alpha-fetoprotein (AFP) and/or human chorionic gonadotropin (HCG) levels.
• Pure seminomas occasionally raise HCG levels but never AFP levels.

This means any increase in AFP is a sign that the tumor has a non-seminoma component. (Tumors can be mixed and have areas of seminoma and non-seminoma.) Sertoli and Leydig cell tumors don’t make these substances. It’s important to note that some cancers are too small to elevate tumor markers levels.

A testicular tumor might also increase the levels of an enzyme called lactate dehydrogenase (LDH). A high LDH (lactate dehydrogenase) level often (but not always) indicates widespread disease. But, LDH levels can also be increased with some non-cancerous conditions.

Tumor marker tests sometimes are also used for other reasons, such as to help estimate how much cancer is present to see how well treatment is working, or to look for signs the cancer might have come back.

Surgery to diagnose testicular cancer

Most types of cancer are diagnosed by removing a small piece of the tumor and looking at it under a microscope for cancer cells. This is known as a biopsy. But a biopsy is rarely done for a testicular tumor because it might risk spreading the cancer. The doctor can often get a good idea of whether it’s testicular cancer based on the ultrasound and blood tumor marker tests, so instead of a biopsy the doctor will very likely recommend surgery (a radical inguinal orchiectomy) to remove the tumor as soon as possible.

The entire testicle is sent to the lab, where a pathologist (a doctor specializing in laboratory diagnosis of diseases) looks at pieces of the tumor with a microscope. If cancer cells are found, the pathologist sends back a report describing the type and extent of the cancer.

In very rare cases, when a diagnosis of testicular cancer is uncertain, the doctor may biopsy the testicle before removing it. This is done in the operating room. The surgeon makes a cut above the pubic area, takes the testicle out of the scrotum, and examines it without cutting the spermatic cord. If a suspicious area is seen, a piece of it is removed and looked at right away by the pathologist. If cancer is found, the testicle and spermatic cord are then removed. If the tissue is not cancer, the testicle can often be returned to the scrotum.

If testicular cancer is found, your doctor will order imaging tests of other parts of your body to check for spread outside the testicle. These tests may also be done before the diagnosis is confirmed by surgery.

Imaging tests

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Ultrasound of the testicles, described above, is a type of imaging test. Other imaging tests may be done for a number of reasons after a testicular cancer diagnosis, including:

• To learn if and how far the cancer might have spread
• To help determine if treatment worked
• To look for possible signs of cancer coming back after treatment

Chest x-ray

• Your chest may be x-rayed to see if cancer has spread to your lungs.

Computed tomography (CT) scan

• CT scans can be used to help determine the stage (extent) of the cancer by showing if it has spread to the lymph nodes, lungs, liver, or other organs.

Magnetic resonance imaging (MRI) scan

• MRI scans are very good for looking at the brain and spinal cord. They are only done in patients with testicular cancer if the doctor has reason to think the cancer might have spread to those areas.

Positron emission tomography (PET) scan

• A PET scan can help spot small collections of cancer cells in the body. It’s sometimes useful to see if lymph nodes that are still enlarged after chemotherapy contain cancer or are just scar tissue. PET scans are often more useful for seminomas than for non-seminomas, so they are less often used in patients with non-seminoma. Many centers have special machines that can do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET with the more detailed images of the CT.

Bone scan

• A bone scan can help show if a cancer has spread to the bones. It might be done if there is reason to think the cancer might have spread to the bones (because of symptoms such as bone pain) and if other test results aren’t clear.

How to perform testicular self exam

The best time for you to examine your testicles is during or after a bath or shower, when the skin of the scrotum is relaxed.

1. Hold your penis out of the way and examine each testicle separately.
2. Hold your testicle between your thumbs and fingers with both hands and roll it gently between your fingers.
3. You need to proceed from top to bottom. The best way to do this is starting at the top of the testicle and squeezing it in a rotational movement all the way down to the bottom. It’s not the most pleasant of sensations, which means a lot of men do not examine their scrotum properly. While it may be uncomfortable, it is a really good habit to get into as it could very well save your life.
4. Look and feel for any hard lumps or nodules (smooth rounded masses) or any change in the size, shape, or consistency of your testicles.

It’s normal for one testicle to be slightly larger than the other, and for one to hang lower than the other. You should also be aware that each normal testicle has a small, coiled tube called the epididymis that can feel like a small bump on the upper or middle outer side of the testis. Normal testicles also contain blood vessels, supporting tissues, and tubes that carry sperm. Some men may confuse these with abnormal lumps at first. If you have any concerns, ask your doctor.

A testicle can get larger for many reasons other than cancer. For example, fluid can collect around the testicle to form a hydrocele. Or the veins in the testicle can dilate and cause enlargement and lumpiness around the testicle. This is called a varicocele. If your testicle seems larger, have a doctor examine you to be sure you have one of these conditions and not a tumor. The doctor may order an ultrasound exam. This is an easy and painless way of finding a tumor.

If you choose to examine your testicles regularly, you will get to know what’s normal and what’s different. Always report any changes to your doctor without delay.

What is a greenstick fracture

A greenstick fracture occurs when a bone bends and cracks, but doesn’t break all the way — like what happens when you bend a green stick of wood. Most broken bones in children are greenstick fractures because children’s bones are softer and more flexible than are those of adults. Greenstick fractures are caused by a bending force such as when one tries to break a soft branch. The fracture looks similar to what happens when you try to break a small, “green” branch on a tree.

A greenstick fracture occurs when a bone bends and cracks, but doesn’t break all the way instead of breaking completely into separate pieces.

Most greenstick fractures occur in children younger than 10 years of age. This type of broken bone most commonly occurs in children because their bones are softer and more flexible than are the bones of adults.

Even mild greenstick fractures are usually immobilized in a cast. In addition to holding the cracked pieces of the bone together so they can heal, a cast can help prevent the bone from breaking all the way through if the child falls on it again.

Greenstick fracture healing time

Greenstick fractures in young kids can heal as quickly as 3 weeks.

Buckle vs Greenstick fracture

In childhood, the periosteal sleeve is thick and protects the cortex. The bone is softer and more pliable than in adults. This accounts for the range of different fracture types that is uniquely seen in childhood. Buckle (torus) fractures are characterized by a compression failure of bone without disruption of the cortex on the tension side of the bone ¹⁾. Buckle (torus) fracture occurs when one side of the bone is compressed, which causes the other side to bend (buckle). This type of fracture is also more common in children.

The greenstick fractures differ from the buckle fracture as the cortex is disrupted on the tension side, but intact on the compression side of the fracture ²⁾.

Figure 1. Greenstick fracture

Figure 2. Buckle fracture

Greenstick fracture causes

Childhood fractures most commonly occur with a fall. Arm fractures are more common than leg fractures, since the common reaction is to throw out your arms to catch yourself when you fall.

Greenstick fracture symptoms

Signs and symptoms will vary, depending on the severity of the greenstick fracture. Mild fractures might be mistaken for sprains or bruises. More-severe greenstick fractures may cause an obvious deformity, accompanied by significant pain and swelling.

Greenstick fracture diagnosis

During the physical exam, your doctor will inspect the affected area for tenderness, swelling, deformity, numbness or an open wound. Your child may be asked to move his or her fingers into certain patterns or motions to check for nerve damage. Your doctor may also examine the joints above and below the fracture.

X-rays can reveal most greenstick fractures. Your doctor may want to take X-rays of the uninjured limb, for comparison purposes.

Greenstick fracture treatment

Depending on the severity of the greenstick fracture, the doctor may need to straighten the bone manually so it will heal properly. Your child will receive pain medication and possibly sedation drugs for this procedure.

Greenstick fractures have a high risk of breaking completely through the bone, so most of these types of fractures are immobilized in a cast during healing.

On occasion, your doctor may decide that a removable splint could work just as well, particularly if the break is mostly healed. The benefit of a splint is that your child might be able to take it off briefly for a bath or shower.

X-rays are required in a few weeks to make sure the fracture is healing properly, to check the alignment of the bone, and to determine when a cast is no longer needed. Most greenstick fractures require four to eight weeks for complete healing, depending on the break and the age of the child.

Secondhand smoke

Secondhand smoke also known as environmental tobacco smoke, is the smoke a smoker breathes out and that comes from the tip of burning cigarettes, pipes, and cigars. Secondhand smoke contains about 4,000 chemicals. Many of these chemicals are dangerous; more than 50 are known to cause cancer. Anytime children breathe in secondhand smoke they are exposed to these chemicals.

Thirdhand smoke is the smoke left behind, the harmful toxins that remain in places where people have smoked previously. Third hand smoke can be found in the walls of a bar, upholstery on the seats of a car, or even a child’s hair after a caregiver smokes near the child.

Even if you don’t smoke, breathing in someone else’s smoke can be deadly too. Many people think that the only people harmed by tobacco use are smokers who have smoked for a long time. The fact is that tobacco use can be harmful to everyone. This includes unborn babies and people who don’t smoke. Secondhand smoke causes about 3,400 deaths from lung cancer and 22,000 to 69,000 of thousands of deaths from heart disease to nonsmoking adults in the United States each year.

Multi-unit housing like apartments or condos is also a danger- when someone smokes in a nearby unit, nonsmokers are exposed to second hand smoke- more than 1 in 3 nonsmokers living in rental housing are exposed to second hand smoke

Smoking in a different room, using fans, or smoking in front of an open window does not prevent second hand smoke.

Women exposed to secondhand smoke are more likely to have a preterm birth (a baby carried for less than 37 weeks) as well as a baby with a lower birth weight. All pregnant women should stay away from secondhand smoke and ask smokers not to smoke around them.

Millions of children are breathing in secondhand smoke in their own homes. Secondhand smoke can be especially harmful to your children’s health because their lungs still are developing. If you smoke around your children or they are exposed to secondhand smoke in other places, they may be in more danger than you realize. Children whose parents smoke only outside are still exposed to the chemicals in secondhand smoke. The best way to eliminate this exposure is to quit.

If you smoke cigarettes, cigars, or pipes, or use smokeless tobacco like chew and snuff, quit! It’s the best thing you can do for yourself and for everyone around you is quit – it will protect your loved ones from harmful secondhand smoke.

For support in quitting, including free quit coaching, a free quit plan, free educational materials, and referrals to local resources, call 1-800-QUIT-NOW (1-800-784-8669).

Secondhand smoke harms children and adults, and the only way to fully protect nonsmokers is to eliminate smoking in all homes, worksites, and public places ¹⁾.

You can take steps to protect yourself and your family from secondhand smoke, such as making your home and vehicles smokefree ²⁾.

Separating smokers from nonsmokers, opening windows, or using air filters does not prevent people from breathing secondhand smoke ³⁾.

Most exposure to secondhand smoke occurs in homes and workplaces ⁴⁾.

People are also exposed to secondhand smoke in public places—such as in restaurants, bars, and casinos—as well as in cars and other vehicles ⁵⁾.

People with lower income and lower education are less likely to be covered by smokefree laws in worksites, restaurants, and bars ⁶⁾.

You can protect yourself and your family from secondhand smoke by ⁷⁾:

• Quitting smoking if you are not already a nonsmoker
• Not allowing anyone to smoke anywhere in or near your home
• Not allowing anyone to smoke in your car, even with the windows down
• Making sure your children’s day care center and schools are tobacco-free
• Seeking out restaurants and other places that do not allow smoking (if your state still allows smoking in public areas)
• Teaching your children to stay away from secondhand smoke
• Being a good role model by not smoking or using any other type of tobacco

Benefits of quitting smoking

1. Improve your health. The health benefits of quitting smoking begin just six hours after your last cigarette! And the longer you stay quit, the healthier you’ll be.
2. Save money. Want an extra $9000 a year? If you smoke a 20-pack a day, that’s how much you’d save if you quit. Work out how much you could save – it’s a powerful motivator.
3. Regain control. At times you might feel like smoking controls you. Quitting can give you a sense of freedom, lift your mood and boost your confidence about smoking, as well as other areas of your life.
4. Positive role model. Quitting sets a great example for the children, family, friends and others around you. It can even reduce the chances of them taking up smoking themselves.
5. Family time. Quitting can give you more energy to play with your kids and more money to spend on them too.
6. Protect others. Secondhand smoke can harm others. Quitting is the only way to protect your family and friends.
7. Less hassle. Disapproving looks or comments from non-smokers can make you feel embarrassed or judged. You might even try to keep your smoking a secret. It’s also a hassle having to make sure you have enough cigarettes with you or enough money to buy them when you run out.
8. Healthier appearance. Smoking ages your skin. It also makes your clothes, hair, house and car smell terrible. When you quit, your teeth become whiter, nicotine stains on your fingers fade and the skin of your face will show less signs of aging. Your house and your car will no longer smell like an ashtray.
9. Better surgery outcomes. If you’re having surgery, quitting can lower your risk of complications and help with recovery and healing. Your surgeon is obliged to talk to you about the risks of not quitting.

Creating a smoke-free environment

The following tips may help keep your children from being exposed to secondhand smoke:

• Set the example. If you smoke, quit today! If your children see you smoking, they may want to try it, and they may grow up smoking as well. If there are cigarettes at home, children are more likely to experiment with smoking—the first step in becoming addicted.
• Remove your children from places where smoking is allowed, even if no one is smoking while you are there. Chemicals from smoke can be found on surfaces in rooms days after the smoking occurred.
• Make your home smoke free. Until you can quit, don’t smoke inside your home and don’t smoke anywhere near your children, even if you are outside. Don’t put out any ashtrays. Remember, air flows throughout a house, so smoking in even one room allows smoke to go everywhere.
• Make your car smoke free. Until you can quit, don’t smoke inside your car. Opening windows isn’t enough to clear the air and can actually blow smoke back into the faces of passengers in the back seat.
• Choose a babysitter who doesn’t smoke. Even if the babysitter smokes outside, your children are exposed. Consider changing babysitters to find a smoke-free environment for your children.
• Encourage tobacco-free child care and schools. Help your children’s child care or school, including outdoor areas and teachers’ lounges, become tobacco free. Get your children involved in the effort to make schools tobacco free!

Second hand smoke statistics

Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Nearly 40 million U.S. adults still smoke cigarettes, and about 4.7 million middle and high school students use at least one tobacco product, including e-cigarettes. Every day, about 1,600 U.S. youth younger than 18 years smoke their first cigarette. Each year, nearly half a million Americans die prematurely of smoking or exposure to secondhand smoke. Another 16 million live with a serious illness caused by smoking. Each year, the United States spends nearly $170 billion on medical care to treat smoking-related disease in adults.

Many people in the United States are still exposed to secondhand smoke:

• During 2011–2012, about 58 million nonsmokers in the United States were exposed to secondhand smoke ⁸⁾.
• Among children who live in homes in which no one smokes indoors, those who live in multi-unit housing (for example, apartments or condos) have 45% higher cotinine levels (or almost half the amount) than children who live in single-family homes.9
• During 2011–2012, 2 out of every 5 children ages 3 to 11—including 7 out of every 10 Black children—in the United States were exposed to secondhand smoke regularly ⁹⁾.
• During 2011–2012, more than 1 in 3 (36.8%) nonsmokers who lived in rental housing were exposed to secondhand smoke ¹⁰⁾.

Smoking and death

Cigarette smoking is the leading preventable cause of death in the United States ¹¹⁾.

• Cigarette smoking causes more than 480,000 deaths each year in the United States. This is nearly one in five deaths ¹²⁾.
• Smoking causes more deaths each year than the following causes combined ¹³⁾:
  • Human immunodeficiency virus (HIV)
  • Illegal drug use
  • Alcohol use
  • Motor vehicle injuries
  • Firearm-related incidents
• More than 10 times as many U.S. citizens have died prematurely from cigarette smoking than have died in all the wars fought by the United States ¹⁴⁾.
• Smoking causes about 90% (or 9 out of 10) of all lung cancer deaths.1,2 More women die from lung cancer each year than from breast cancer ¹⁵⁾.
• Smoking causes about 80% (or 8 out of 10) of all deaths from chronic obstructive pulmonary disease (COPD) ¹⁶⁾.
• Cigarette smoking increases risk for death from all causes in men and women ¹⁷⁾.
• The risk of dying from cigarette smoking has increased over the last 50 years in the U.S ¹⁸⁾.

Smoking and increased health risks

Smokers are more likely than nonsmokers to develop heart disease, stroke, and lung cancer ¹⁹⁾.

Estimates show smoking increases the risk:

• For coronary heart disease by 2 to 4 times ²⁰⁾
• For stroke by 2 to 4 times ²¹⁾
• Of men developing lung cancer by 25 times ²²⁾
• Of women developing lung cancer by 25.7 times ²³⁾

Smoking causes diminished overall health, increased absenteeism from work, and increased health care utilization and cost ²⁴⁾.

Smoking and cardiovascular disease

Smokers are at greater risk for diseases that affect the heart and blood vessels (cardiovascular disease) ²⁵⁾.

• Smoking causes stroke and coronary heart disease, which are among the leading causes of death in the United States.
• Even people who smoke fewer than five cigarettes a day can have early signs of cardiovascular disease.
• Smoking damages blood vessels and can make them thicken and grow narrower. This makes your heart beat faster and your blood pressure go up. Clots can also form.
• A stroke occurs when:
  • A clot blocks the blood flow to part of your brain;
  • A blood vessel in or around your brain bursts.
• Blockages caused by smoking can also reduce blood flow to your legs and skin.

Smoking and respiratory disease

Smoking can cause lung disease by damaging your airways and the small air sacs (alveoli) found in your lungs ²⁶⁾.

• Lung diseases caused by smoking include COPD, which includes emphysema and chronic bronchitis.
• Cigarette smoking causes most cases of lung cancer.
• If you have asthma, tobacco smoke can trigger an attack or make an attack worse.
• Smokers are 12 to 13 times more likely to die from COPD than nonsmokers.

Smoking and cancer

Smoking can cause cancer almost anywhere in your body ²⁷⁾:

• Bladder
• Blood (acute myeloid leukemia)
• Cervix
• Colon and rectum (colorectal)
• Esophagus
• Kidney and ureter
• Larynx
• Liver
• Oropharynx (includes parts of the throat, tongue, soft palate, and the tonsils)
• Pancreas
• Stomach
• Trachea, bronchus, and lung

Smoking also increases the risk of dying from cancer and other diseases in cancer patients and survivors ²⁸⁾.

If nobody smoked, one of every three cancer deaths in the United States would not happen ²⁹⁾.

Smoking and other health risks

Smoking harms nearly every organ of the body and affects a person’s overall health ³⁰⁾.

• Smoking can make it harder for a woman to become pregnant. It can also affect her baby’s health before and after birth. Smoking increases risks for:
  • Preterm (early) delivery
  • Stillbirth (death of the baby before birth)
  • Low birth weight
  • Sudden infant death syndrome (known as SIDS or crib death)
  • Ectopic pregnancy
  • Orofacial clefts in infants
• Smoking can also affect men’s sperm, which can reduce fertility and also increase risks for birth defects and miscarriage ³¹⁾.
• Smoking can affect bone health. Women past childbearing years who smoke have weaker bones than women who never smoked. They are also at greater risk for broken bones.
• Smoking affects the health of your teeth and gums and can cause tooth loss ³²⁾.
• Smoking can increase your risk for cataracts (clouding of the eye’s lens that makes it hard for you to see). It can also cause age-related macular degeneration (AMD). Age-related macular degeneration is damage to a small spot near the center of the retina, the part of the eye needed for central vision ³³⁾.
• Smoking is a cause of type 2 diabetes mellitus and can make it harder to control. The risk of developing diabetes is 30–40% higher for active smokers than nonsmokers ³⁴⁾.
• Smoking causes general adverse effects on the body, including inflammation and decreased immune function ³⁵⁾.
• Smoking is a cause of rheumatoid arthritis ³⁶⁾.

Differences in second hand smoke exposure

Racial and ethnic groups

Cotinine is created when the body breaks down the nicotine found in tobacco smoke. Cotinine levels have declined in all racial and ethnic groups, but cotinine levels continue to be higher among non-Hispanic Black Americans than non-Hispanic White Americans and Mexican Americans. During 2011–2012 ³⁷⁾:

• Nearly half (46.8%) of Black nonsmokers in the United States were exposed to secondhand smoke.
• About 22 of every 100 (21.8%) non-Hispanic White nonsmokers were exposed to secondhand smoke.
• Nearly a quarter (23.9%) of Mexican American nonsmokers were exposed to secondhand smoke.

Income

• Secondhand smoke exposure is higher among people with low incomes.
• During 2011–2012, more than 2 out of every 5 (43.2%) nonsmokers who lived below the poverty level were exposed to secondhand smoke.

Occupation

• Differences in secondhand smoke exposure related to people’s jobs decreased over the past 20 years, but large differences still exist.
• Some groups continue to have high levels of secondhand smoke exposure. These include ³⁸⁾:
  • Blue-collar workers and service workers
  • Construction workers

Secondhand smoke harms children and adults

• There is no risk-free level of secondhand smoke exposure; even brief exposure can be harmful to health ³⁹⁾.
• Since 1964, approximately 2,500,000 nonsmokers have died from health problems caused by exposure to secondhand smoke ⁴⁰⁾.

Health effects in children

In children, secondhand smoke causes the following ⁴¹⁾:

• Ear infections
• More frequent and severe asthma attacks
• Respiratory symptoms (for example, coughing, sneezing, and shortness of breath)
• Respiratory infections (bronchitis and pneumonia)
• A greater risk for sudden infant death syndrome (SIDS)

Secondhand smoke can infiltrate into other units through hallways and stairwells.

Health effects in adults

In adults who have never smoked, secondhand smoke can cause:

• Heart disease. For nonsmokers, breathing secondhand smoke has immediate harmful effects on the heart and blood vessels ⁴²⁾. It is estimated that secondhand smoke caused nearly 34,000 heart disease deaths each year during 2005–2009 among adult nonsmokers in the United States ⁴³⁾.
• Lung cancer ⁴⁴⁾. Secondhand smoke exposure caused more than 7,300 lung cancer deaths each year during 2005–2009 among adult nonsmokers in the United States ⁴⁵⁾.
• Stroke ⁴⁶⁾.

Smokefree laws can reduce the risk for heart disease and lung cancer among nonsmokers ⁴⁷⁾.

Secondhand smoke on infants and children

• Infants exposed to secondhand smoke have about twice the risk for SIDS (Sudden Infant Death Syndrome) compared with infants living in a smoke free environment.
• Compared to children of non-smokers, the children of parents who smoke have higher rates of lung or airways infections such as bronchitis, bronchiolitis and pneumonia.
• Asthma is more common among children of smokers. Children with asthma exposed to secondhand smoke have a greater risk of getting symptoms earlier in life, and having more symptoms and asthma attacks. They are more likely to use asthma medications more often and for a longer period.
• Children of smokers have a lowering in lung function, meaning that on average, they cannot breathe in as deeply or breathe out as hard compared to children of non-smokers. Some evidence suggests that this reduced lung function may even persist into adulthood.
• Children of smokers are more likely to contract ear infections and have an increased risk of meningococcal disease, which can sometimes cause death, mental disability, hearing loss, or loss of a limb.
• Childhood cancers: leukemia, brain cancer and lymphomas (where both the pregnant mother and the child after birth were exposed to secondhand smoke).

Young children are also at risk from their own behaviors- crawling on floors and carpets is an easy way to ingest dust and smoke particles, as is putting hands in mouth after touching a surface (walls, floors, furniture) where smoke has settled.

Smoking harms infants and children

When parents expose their children to smoke, or let others do so, they are putting their children’s health in danger and sending a message that smoking is OK.

Secondhand smoke is the smoke a smoker breathes out. It’s also the smoke that comes from the tip of lit cigarettes, pipes, and cigars. It contains about 4,000 different chemicals, many of which cause cancer.

Breathing in smoke can cause:

• Asthma
• Respiratory infections (like bronchitis and pneumonia)
• Lung problems, pneumonia
• Ear infections
• Sudden infant death syndrome (SIDS) (for babies younger than 1 year)
• Tooth decay
• Sleep problems
• Developmental delays.

Children of smokers cough and wheeze more and have a harder time getting over colds. They miss many more school days too. Secondhand smoke can cause other symptoms including stuffy nose, headache, sore throat, eye irritation, and hoarseness.

Children with asthma are especially sensitive to secondhand smoke. It may cause more asthma attacks and the attacks may be more severe, requiring trips to the hospital.

Smoking harms unborn babies

Smoking during pregnancy or exposing pregnant women to smoke can lead to many serious health problems for an unborn baby, such as:

• Miscarriage
• Premature birth (born not fully developed)
• Lower birth weight than expected (possibly meaning a less healthy baby)
• Sudden infant death syndrome (SIDS)
• Learning problems and attention-deficit/hyperactivity disorder (ADHD)

Smoking harms teens

90% of smokers start before age 18. About one-third of them will die of a smoking-related disease. Other teen smokers may experience the same health problems as adult smokers, including:

• Addiction to nicotine
• Long-term cough
• Faster heart rate
• Lung problems
• Higher blood pressure
• Less stamina and endurance
• Higher risk of lung cancer and other cancers
• More respiratory infections
• Smoking also gives you bad breath, yellow teeth, and yellow fingernails; makes your hair and clothes smell bad; and wrinkles your skin.

Long-term effects of secondhand smoke

Children who grow up with parents who smoke are themselves more likely to smoke. Children and teens who smoke are affected by the same health problems that affect adults. Secondhand smoke may cause problems for children later in life including:

• Poor lung development (meaning that their lungs never grow to their full potential)
• Lung cancer
• Heart disease
• Cataracts (an eye disease)

Second hand smoke and pregnancy

If you smoke or are exposed to secondhand smoke when you’re pregnant, your baby is exposed to harmful chemicals too. When a pregnant woman breathes in secondhand smoke, chemicals from the smoke can pass through her lungs into the bloodstream. Nicotine, carbon monoxide and other chemicals can cross the placenta affecting her unborn child. This may lead to many serious health problems, including:

• Miscarriage
• Premature birth (born not fully developed)
• Lower birth weight than expected (possibly meaning a less healthy baby)
• Sudden infant death syndrome (SIDS)
• Learning problems and attention-deficit/hyperactivity disorder (ADHD)
• Decreased fetal breathing
• Learning problems
• Respiratory disorders
• Heart disease as an adult

Smoking during pregnancy can also cause:

• Orofacial clefts (cleft lip, cleft palate) in the baby
• Placenta previa (the placenta covers some or all of the cervix, causing bleeding and pre-term labor)
• Placental abruption (placenta detaches from the uterus causing bleeding in the mother and anything from increased heart rate to stillbirth in the fetus)

The health risks go up the longer the pregnant woman smokes or is exposed to smoke.

After birth, children exposed to secondhand tobacco smoke have more respiratory infections, bronchitis, pneumonia, poor lung function, and asthma than children who aren’t exposed. Smoke exposure is most dangerous for younger children because they spend more time in close proximity to parents or other smokers, and they have immature lungs.

The health risks go up the longer the pregnant woman smokes or is exposed to smoke. Quitting anytime during pregnancy helps—of course, the sooner the better. All pregnant women should stay away from secondhand smoke and ask smokers not to smoke around them.

How to quit smoking when you’re pregnant

Quitting at any time during your pregnancy will give your baby a better chance of a healthy start in life.

Expecting a baby usually increases the pressure to stop smoking. We get that, and we’re here to help. We want to let you know that there’s a lot of support out there.

Quitline counsellors are trained to help you during your pregnancy. Your midwife and doctor can also offer quitting information and support.

Tips for quitting during pregnancy:

• Gentle exercise such as swimming, walking and supervised yoga can help the body adjust to being without cigarettes.
• If your partner or other people in your household smoke, encourage them to consider quitting or to only smoke outside.
• Don’t forget you can call the Quitline for support, call 1-800-QUIT-NOW (1-800-784-8669).

Using nicotine replacement therapy products while pregnant

If you’re having trouble quitting, some nicotine replacement therapy products are an option. Using nicotine replacement therapy products is safer than smoking, but discuss the risks and benefits with your doctor or pharmacist before using it. If you plan to use nicotine replacement therapy products, you should also tell the doctor supervising your pregnancy.

If you are pregnant, the better options are the nicotine lozenge, mouth spray, gum or inhaler. These products usually provide a lower daily dose of nicotine than the patch. However, if you have nausea or sickness, you may prefer using a patch. You can use the daytime patch to help you quit, and you must remove it before going to bed. Do not use the 24 hour nicotine patch.

Do not use the nicotine patch if you are breastfeeding. If breastfeeding, you can use the nicotine gum, mouth spray, lozenge or inhaler. Breastfeed your baby first, then use your preferred nicotine product soon after.

Quitting medications – Champix (varenicline) or Zyban (bupropion) – are not recommended for women who are pregnant or breastfeeding.

When the urge to smoke strikes remember the 4Ds:

1. Delay: Delay for a few minutes and the urge will pass
2. Deep breathe: Breathe slowly and deeply
3. Do something else: Ring a friend, listen to music, or practice pre-natal exercises
4. Drink water: Take ‘time out’ and sip slowly

Secondhand smoke on adults

Secondhand smoke causes the following diseases and conditions in adults:

• Heart disease
• Lung cancer
• Stroke
• Irritation of the eyes and nose

Secondhand smoke has also been linked to:

• Cancers of the breast, throat, voice-box, nose and cervix
• Diabetes
• Disease of the blood vessels
• short term respiratory symptoms including cough, wheeze, chest tightness and difficulty breathing
• Long term respiratory symptoms
• Development of asthma and worsening of asthma control
• Chronic obstructive pulmonary disease (COPD).

What is tummy time

Babies spend the majority of their days lying on their backs, which is why time spent on their tummy is very important. Tummy time is laying your baby on the stomach for brief periods while awake is an important exercise because it helps strengthen neck and shoulder muscles and prepares your baby for crawling. Tummy time is especially useful for a baby with torticollis and a flat head and can actually help treat both problems at once. Always place babies on their backs to sleep, even for short naps.

Tummy time should start soon after birth as part of a pleasurable daily routine. You might begin with 1 to 2 minutes a few times a day.

Over time, you can gradually build up to 10-15 minutes, several times a day. You might start by laying your baby across your lap on their tummy. As your baby grows stronger, you can put them on a rug on the floor to play.

Tips for tummy time

It’s best to choose a time when your baby has had their nappy changed and is happy, alert and interested in their surroundings. To make tummy time more fun, you can:

• lie alongside your baby and chat to them, perhaps turning the pages of a picture book and talking about what you see
• let your baby know they have company by singing, or by stroking their back or hands
• hold a non-breakable mirror next to your baby so they can see their reflection
• place safe toys near your baby, moving them from side to side to encourage your baby to move their head, focus their eyes and stay interested
• do tummy time in different locations, including outdoors on a rug in warm weather.

If your baby becomes sleepy during tummy time, put them on their back to sleep in their crib. As your baby gains more control of their head and arms, give them a ball to play with, rolling it back and forth from you to them. As they start to move around more, clear away any objects that might be dangerous, and introduce new toys and games.

An adult should always be there during tummy time to make sure the baby is safe.

Safety considerations

Always supervise your baby during tummy time. As your baby gets closer to an age where they are strong enough to roll over, be careful where you place them so they don’t roll off a surface.

How to do tummy time

Here’s how to do tummy time:

• Lay your baby on your lap for tummy time. Position your baby so that his or her head is turned away from you. Then, talk or sing to your baby and encourage him or her to turn and face you. Practice this exercise for 10 to 15 minutes.
• Baby can lie across your legs while you’re sitting, or on your chest while you’re leaning against the couch or lying on your back against a pillow. Your baby will love feeling the warmth of your body and your heartbeat.
  • Get down on the floor in front of your baby and sing or talk face to face.
  • If getting tired, you can roll your baby onto the back to rest for a moment, or carry for a while, and then try tummy time again.

Tummy time strengthens the back, neck, and arm muscles, which are needed for holding the head upright, rolling, sitting, and crawling. Tummy time is also good for visual and mental stimulation because your baby is encouraged to look around to explore the surroundings.

Why tummy time is important?

Experts recommend that babies sleep on their back to reduce the risk of sudden infant death syndrome (SIDS). So babies spend a lot of time lying on their back.

Tummy time gives your baby the chance to try a new position and helps prevent them getting a flat spot on their head from lying on their back so much.

Tummy time builds your baby’s head, neck and upper body strength.

It also helps to develop the skills they’ll need to crawl, roll over, sit up and stand.

When to start tummy time?

The sooner you start tummy time, the sooner your baby will get used to it, benefit from it, and come to enjoy it. Babies who have not spent much time on their tummies may need extra encouragement and practice to get used to it. Here are some ideas to help your baby learn to enjoy tummy time. Remember, tummy time should always be supervised, never leave baby alone on her tummy or on these positioning products.

• Back to Sleep, Tummy to Play
  • Healthy babies are safest when sleeping on their backs at nighttime and during naps. Side sleeping is not as safe as back sleeping and is not advised.
  • Tummy time is for babies who are awake and being watched. Your baby needs this to develop strong muscles.
• It works best if your baby is well rested and happy before trying tummy time.
• Start with 5 minutes of tummy time every time your baby is awake and slowly work up to 20 minutes.
• Put your baby’s favorite toys within reach. Play some favorite music.
  • Put a mirror in front of your baby.
• Your baby will need to first develop the strength and experience to lift the head and play. If playing on the floor is challenging, propping your baby at an angle can make it easier to lift the head. You can use:
  • a small pillow (such as a Boppy® pillow).
  • a towel roll under the arms and chest.
  • a foam wedge.

Be patient. Your baby may be challenged a bit at first, but it is important to keep trying. As your child gets stronger, tummy time will be more fun. The benefits are worth it.

Talk with grandparents, child-care providers, and babysitters. Make sure everyone who cares for your baby knows about safe sleep:

• Every sleep time counts! Put baby on his or her back for sleep in a safety-approved crib.
• Keep soft items out of the bed:
  • No pillows
  • No blankets
  • No bumper pads
  • No toys
• Put your baby on the tummy to play during supervised awake time.

How can I exercise the baby while he is on his tummy?

There are lots of ways to play with the baby while he is on his tummy.

• Place yourself or a toy just out of the baby’s reach during playtime to get him to reach for you or the toy.
• Place toys in a circle around the baby. Reaching to different points in the circle will allow him to develop the appropriate muscles to roll over, scoot on his belly, and crawl.
• Lie on your back and place the baby on your chest. The baby will lift his head and use his arms to try to see your face.
• While keeping watch, have a young child play with the baby while on his tummy. Young children can get down on the floor easily. They generally have energy for playing with babies, may really enjoy their role as the “big kid,” and are likely to have fun themselves.

How much tummy time should an infant have?

Beginning on his first day home from the hospital or in your family child care home or center, play and interact with the baby while he is awake and on the tummy 2 to 3 times each day for a short period of time (3-5 minutes), increasing the amount of time as the baby shows he enjoys the activity. A great time to do this is following a diaper change or when the baby wakes up from a nap.

Tummy time prepares babies for the time when they will be able to slide on their bellies and crawl. As babies grow older and stronger they will need more time on their tummies to build their own strength.

What if the baby does not like being on her tummy?

Some babies may not like the tummy time position at first. If your baby becomes restless during tummy time, try changing the activity or the location. If your baby doesn’t like being on the floor, lie down and place them on your chest while you gently play with their hands and feet. Give them a gentle rock, sing songs or rub their back.

Place yourself or a toy in reach for her to play with. Eventually your baby will enjoy tummy time and begin to enjoy play in this position.

Some babies with reflux don’t like tummy time at first, but if you persevere, you will probably find they are able to tolerate it for longer periods as they grow older and stronger.

Why should babies sleep on their backs?

More than 3,500 babies in the U.S. die suddenly and unexpectedly every year while sleeping, often due to sudden infant death syndrome (SIDS) or accidental deaths from suffocation or strangulation. The American Academy of Pediatrics ¹⁾ has recommended the following to help reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep related infant deaths, such as suffocation.

• All healthy babies should sleep on their backs, in a safety approved crib bassinet or play yard on a firm mattress covered by a fitted sheet.
• Keep the head of the crib flat, unless the doctor gives other instructions because of your child’s medical condition.
• Keep loose bedding (pillows, blankets, bumpers) and soft toys out of the crib.
• Consider using a wearable blanket to keep baby warm for sleep rather than a loose blanket
• Keep baby in the same room-not the same bed. Babies and children younger than 2 years should not sleep in the same bed with anyone else, due to the risk of suffocation. If you bring baby to bed to breastfeed place him back in his own crib, bassinet or pack and play when you are finished.
• A pacifier is okay when settling to sleep. When it falls out after your baby is asleep, leave it out.
• Babies who can roll over should be put to bed on their backs, but allowed to change positions as they like. You don’t need to roll them back.

How to keep your sleeping baby safe

The American Academy of Pediatrics Recommendations for Infant Sleep Safety ²⁾

• Until their first birthday, babies should sleep on their backs for all sleep times—for naps and at night. Scientists know babies who sleep on their backs are much less likely to die of SIDS than babies who sleep on their stomachs or sides. The problem with the side position is that the baby can roll more easily onto the stomach. Some parents worry that babies will choke when on their backs, but the baby’s airway anatomy and the gag reflex will keep that from happening. Even babies with gastroesophageal reflux (GERD) should sleep on their backs.
  • Newborns should be placed skin-to-skin with their mother as soon after birth as possible, at least for the first hour. After that, or when the mother needs to sleep or cannot do skin-to-skin, babies should be placed on their backs in the bassinet. While preemies may need to be on their stomachs temporarily while in the NICU due to breathing problems, they should be placed on their backs after the problems resolve, so that they can get used to being on their backs and before going home.
  • Some babies will roll onto their stomachs. You should always place your baby to sleep on the back, but if your baby is comfortable rolling both ways (back to tummy, tummy to back), then you do not have to return your baby to the back. However, be sure that there are no blankets, pillows, stuffed toys, or bumper pads around your baby, so that your baby does not roll into any of those items, which could cause blockage of air flow.
  • If your baby falls asleep in a car seat, stroller, swing, infant carrier, or sling, you should move him or her to a firm sleep surface on his or her back as soon as possible.
• Use a firm sleep surface. A crib, bassinet, portable crib, or play yard that meets the safety standards of the Consumer Product Safety Commission (https://www.cpsc.gov/) is recommended along with a tight-fitting, firm mattress and fitted sheet designed for that particular product. Nothing else should be in the crib except for the baby. A firm surface is a hard surface; it should not indent when the baby is lying on it. Bedside sleepers that meet Consumer Product Safety Commission safety standards may be an option, but there are no published studies that have examined the safety of these products. In addition, some crib mattresses and sleep surfaces are advertised to reduce the risk of SIDS. There is no evidence that this is true, but parents can use these products if they meet Consumer Product Safety Commission safety standards.
• Room share—keep baby’s sleep area in the same room where you sleep for the first 6 months or, ideally, for the first year. Place your baby’s crib, bassinet, portable crib, or play yard in your bedroom, close to your bed. The American Academy of Pediatrics recommends room sharing because it can decrease the risk of SIDS by as much as 50% and is much safer than bed sharing. In addition, room sharing will make it easier for you to feed, comfort, and watch your baby.
• Only bring your baby into your bed to feed or comfort. Place your baby back in his or her own sleep space when you are ready to go to sleep. If there is any possibility that you might fall asleep, make sure there are no pillows, sheets, blankets, or any other items that could cover your baby’s face, head, and neck, or overheat your baby. As soon as you wake up, be sure to move the baby to his or her own bed.
• Never place your baby to sleep on a couch, sofa, or armchair. This is an extremely dangerous place for your baby to sleep.
• Bed-sharing is not recommended for any babies. However, certain situations make bed-sharing even more dangerous. Therefore, you should not bed share with your baby if:
  • Your baby is younger than 4 months old.
  • Your baby was born prematurely or with low birth weight.
  • You or any other person in the bed is a smoker (even if you do not smoke in bed).
  • The mother of the baby smoked during pregnancy.
  • You have taken any medicines or drugs that might make it harder for you to wake up.
  • You drank any alcohol.
  • You are not the baby’s parent.
  • The surface is soft, such as a waterbed, old mattress, sofa, couch, or armchair.
  • There is soft bedding like pillows or blankets on the bed.
• Keep soft objects, loose bedding, or any objects that could increase the risk of entrapment, suffocation, or strangulation out of the baby’s sleep area. These include pillows, quilts, comforters, sheepskins, blankets, toys, bumper pads or similar products that attach to crib slats or sides. If you are worried about your baby getting cold, you can use infant sleep clothing, such as a wearable blanket. In general, your baby should be dressed with only one layer more than you are wearing.
• It is fine to swaddle your baby. However, make sure that the baby is always on his or her back when swaddled. The swaddle should not be too tight or make it hard for the baby to breathe or move his or her hips. When your baby looks like he or she is trying to roll over, you should stop swaddling.
• Try giving a pacifier at nap time and bedtime. This helps reduce the risk of SIDS, even if it falls out after the baby is asleep. If you are breastfeeding, wait until breastfeeding is going well before offering a pacifier. This usually takes 2-3 weeks. If you are not breastfeeding your baby, you can start the pacifier whenever you like. It’s OK if your baby doesn’t want a pacifier. You can try offering again later, but some babies simply don’t like them. If the pacifier falls out after your baby falls asleep, you don’t have to put it back in.

What Moms Can Do: Recommendations for Prenatal & Postnatal

• Do not smoke during pregnancy or after your baby is born. Keep your baby away from smokers and places where people smoke. If you are a smoker or you smoked during pregnancy, it is very important that you do not bed share with your baby. Also, keep your car and home smoke-free. Don’t smoke anywhere near your baby, even if you are outside.
• Do not use alcohol or illicit drugs during pregnancy or after the baby is born. It is very important not to bed share with your baby if you have been drinking alcohol or taken any medicines or illicit drugs that can make it harder for you to wake up.
• Breastfed babies have a lower risk of SIDS. Breastfeed or feed your baby expressed breast milk. The American Academy of Pediatrics recommends breastfeeding as the sole source of nutrition for your baby for about 6 months. Even after you add solid foods to your baby’s diet, continue breastfeeding for at least 12 months, or longer if you and your baby desire.
• Schedule and go to all well-child visits. Your baby will receive important immunizations at these doctor visits. Recent evidence suggests that immunizations may have a protective effect against SIDS.
• Make sure your baby has tummy time every day. Awake tummy time should be supervised by an awake adult. This helps with baby’s motor development and prevents flat head syndrome. See Back to Sleep, Tummy to Play for more information and ways to play with the baby during tummy time.

Use Caution When Buying Products

• Use caution when a product claims to reduce the risk of SIDS. Wedges, positioners, special mattresses and specialized sleep surfaces have not been shown to reduce the risk of SIDS, according to the American Academy of Pediatrics.
• Do not rely on home heart or breathing monitors to reduce the risk of SIDS. If you have questions about using these monitors for other health conditions, talk with your pediatrician.
• There isn’t enough research on bedside or in-bed sleepers. The American Academy of Pediatrics can’t recommend for or against these products because there have been no studies that have looked at their effect on SIDS or if they increase the risk of injury and death from suffocation.

How does sleeping on the back affect my baby?

As a result of these recommendations, the SIDS (Sudden Infant Death Syndrome) rate has dropped almost 50 percent. During this same time, however, plagiocephaly (head flattening) and torticollis (a one-sided tightness in neck muscles) have increased.

Some babies tend to keep their heads in a favorite position while on their backs. This can affect their development. It makes it hard for them to strengthen their neck muscles evenly, and hard to learn to use both sides of their body.

Sleeping

Place your baby on the back to sleep, alternating head position so not always lying on the same side of the head. Or alternate positions in the crib (feet toward one end, then the other end) so your baby needs to turn the head to look toward activity in the room.

If your baby always lies on one side of the head, try changing the direction of the crib or move things in the room that your baby likes to look at.

Some products claim to be designed to keep a baby in one position. These products have not been tested for safety and are not recommended.

Equipment

Limit the use of toys such as swings, infant seats, and exercise saucers. Always use a car seat for travel, but take your baby out of it as soon as the trip is over. When awake, babies need to be held, or on the floor exploring and developing motor skills as much as possible.

Doesn’t sleeping on her back cause the baby to have a flat head?

Parents and caregivers often worry about the baby developing a flat spot on the back of the head because of sleeping on the back. Though it is possible for a baby to develop a flat spot on the head, it usually rounds out as they grow older and sit up.

There are ways to reduce the risk of the baby developing a flat spot:

• Alternate which end of the crib you place the baby’s feet. This will cause her to naturally turn toward light or objects in different positions, which will lessen the pressure on one particular spot on her head.
• When the baby is awake, vary her position. Limit time spent in freestanding swings, bouncy chairs, and car seats. These items all put added pressure on the back of the baby’s head.
• Spend time holding the baby in your arms as well as watching her play on the floor, both on her tummy and on her back.
• A breastfed baby would normally change breasts during feeding; if the baby is bottle fed, switch the side that she feeds on during feeding.