Parents are always concerned about the reaction of neighbours when planning to implement these strategies for helping their children with their sleep problems. We recommend that parents tell their neighbours of the problem and of the planned intervention. The vast majority of people will be sympathetic and supportive once they are told, especially if the eventual outcome will be peace and quiet for everyone.

Use of medications

Drugs have a limited place in the treatment of sleep disorders. They are not the cure or the answer to these problems, and are probably used too frequently and for too long. The management of sleep problems in childhood revolves around the behavioural techniques described above. Most children will respond readily to these suggestions, and drugs are not needed.

In a small number of cases, medications are useful over a short term to break the cycle and give the behavioural techniques a better chance of working. They are given in full doses for 2-4 nights, then the dose is gradually reduced over the next week while the other strategies are being put into place.

Drugs should never be used as the only form of treatment of sleep problems, and should never be used for longer than two weeks.

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Part of us needs to stand back and observe the whole process. All we need to do at this stage is to observe our thoughts. Don’t analyse them or interfere with them. Just watch them as they come tumbling in. Then bring the awareness to the body. Watch how our body responds to our thoughts and how in turn our thoughts respond to the symptoms. It isn’t the symptoms which create the fear. The way we think creates the fear, which creates the symptoms, which creates further thoughts, which creates further fear and the cycle continues.

Nor do we need to be thinking about the disorder or symptoms. Whatever we are thinking about is usually negative, the mental abuse, ‘I’m stupid, weak, hopeless’; the negative internal conversations; guilt; what we should have done, or shouldn’t have done. The overall result is the same-anxiety and attacks. When we see this relationship, we begin to see through the fear.

We need to become aware of the whole process of our thinking and our physical reaction to our thinking. We need to see how they build upon each other and create our symptoms.

If I ask people what they were thinking about before their last attack, they usually say that they weren’t thinking of anything. This is not so. They were thinking, they just weren’t aware of their thoughts. Asking the same question of people who feel continually anxious brings the same reply. They also are not aware.

We need to be aware of the relationship between our thoughts and our symptoms. When we see the relationship we will

understand why there is nothing to fear. The anxiety and the panic are a response to our thinking. We are simply frightening ourselves. Nothing more.

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You are ready to make some changes. But you wonder…when is the best time to start working on it? When can I realistically expect my child to make some changes? The answer to the question “when” is a complex one and mu be examined on two levels: a child’s readiness and the parents’ readiness.

Child’s Readiness. Before you decide to change your child’s sleep behavior review her readiness. There are a few factors to consider.

Check developmental stage. Be certain that your expectations a appropriate for your child’s developmental level. Know what is considers “average” for your child’s age. For example, when you learn that most two year olds need a nap, you will feel more confident in expecting one. Although you can take preliminary, stage-setting steps beforehand, a child might not have the neurological maturity to sleep all night until he is six months old. Do not feel burdened by norms, but use them as guideposts.

Consider temperament. Personality or temperament should also be taken into consideration—especially during developmental upheaval, when getting through a typical day is a feat. Generally, this would not be a logical time to introduce new expectations.

Other factors. Never begin a new program when a child is ill or is dealing with other changes—for example, a new house or a new sibling. Try to consider the whole situation, but if there never seems to be a “right” time, ó may be making too many allowances. There will never be the perfect time; ó may just have to plunge in. Children are incredibly resilient and adaptable.

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Incontinence due to nerve damage can take a special form called overflow incontinence. Here the bladder muscle is so weakened that to start with you can’t pass urine at all. Then the bladder gets so full that small amounts of urine start to leak away, quite out of your control. A similar thing can happen with the bowels—they can get stretched with motions which you cannot pass. At that stage, small amounts of slimy fluid may start to come away, again, quite out of your control. This form of incontinence in the case of the bladder can be mistaken for cystitis and in the case of the bowel can be mistaken for diarrhoea. Such mistakes will not be made if a doctor or nurse examines you properly, including examining inside your rectum and your vagina with a gloved finger. In fact, this form of examination is necessary to work out the reason for every form of incontinence.

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Sometimes, it may be necessary to use laxatives to ensure that the bowel works without undue strain. Bulk-forming or softening agents are better than harsh purgatives, as these latter may become habit-forming and the bowel gets lazy and requires larger doses.

Proper examination of the bowel is always necessary to exclude a primary cause for the bleeding, such as a cancer. It may be that some other condition such as a cancer of the rectum may be present as well.

Injection of haemorrhoids is a satisfactory method of dealing with first and early second degree piles. A solution, usually of phenol in almond oil, is injected into the mucosa around the dilated veins and causes clotting in the veins and eventual fibrosis, which occludes the dilated veins.

Another technique for second degree piles is to insert a proctostope to see the projecting pile and slip a small rubber band over it. This cuts off the blood supply at the base and, after a week or so, the obstructed pile sloughs off. This procedure is sometimes associated with secondary bleeding.

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When a woman’s reproductive life first starts, many of the cycles are anovulatory. This means that no ovum is released. At the menopause, the same thing happens.

The menarche, or onset of the periods, is occurring at a younger age. This is believed to be due to better nutrition as girls seem to be growing taller, quicker and to be reaching sexual maturity earlier.

Recent research seems to indicate that women are going through menopause at a later age and these factors are extending the menstruating years. Studies in Australia and Britain show that the average age for menopause is just over 50.

The assumption that those who started their periods early finish late, and vice-versa, appears not to be true. It also appears that the age at which the first child is born and the number of children the woman has does not influence menopause.

As the average age of the start of the periods is just over 13, most women can expect a menstruating life of nearly 37 years.

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Consume 30 to 60 grams of carbohydrate per hour during the event.

Events where the G.I. factor can give you the edge:

running marathon, swimming marathon, triathlon, non-stop tennis competition, football game (depending on the player’s position), cross-country siding, mountain climbing, prolonged strenuous aerobics and gym work-outs (longer than 90 minutes).

The pre-event meal. How much should I eat before the event?

About I gram of carbohydrate for each kilogram of body weight (i.e. 50 grams of carbohydrate if you weigh 50 kilograms, or 75 grams of carbohydrate if you weigh 75 kilograms).

How soon before? I to 2 hours before the event is a good starting point. You should experiment to determine the timing that works best for you.

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2. Factors which may indicate a genetic influence in fat loss response (i.e. parental body shape; early onset of overfatness; duration of effect) should be included in any pre-program screening.

3. It may be necessary in certain groups (i.e. the aged, pre-meno-pausal exercising females) to check the level of spontaneous physical activity being carried out outside a planned exercise regime and attempt to increase this through ‘incidental’ activity.

4. Individuals with a genetic predisposition to obesity may have difficulty limiting food intake and the taste for fatty foods.

5. Recognise the major gender differences in fat loss responsivity to both energy input restrictions and energy output and design fat loss programs accordingly.

6. Avoid severe restrictions of food intake or heavy exercise prescription in females as these may have a counter-productive effect on the biological propensity of females to conserve energy for reproduction.

7. Recognise the potential for excessive fat gains during and following pregnancy in some women and attempt to offer preventive prescriptions for this, particularly in those most likely to be at risk.

8. Avoid programming which involves unrealistic expectations about body image, particularly in females.

9. Extreme forms of body building with accompanying overeating disorders in men should be seen as the equivalent of anorexia in females—there are comparative body shape obsessions and distortions.

10. Programming should be modified to account for differences in responses that occur with ageing with both men and women, but particularly in post-menopausal women.

11. Monitor possible changes in eating patterns that occur with ageing, of which the client should be aware.

12. Use body fat and fat distribution measures such as BMI and waist-to-hip ratio cautiously in some racial groups (such as Pacific Islanders, Asian and Negroid women) for whom these measures are not necessarily appropriate.

13. Recognise racial differences in body shape and composition and the implications of this for healthy body weight and fat maintenance.

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Fat mass. As body fat levels increase so does RMR. Most of this is due to the increased FFM, but even at the same amounts of FFM, the person with the higher fat mass (FM) has a higher RMR. Similarly, as FM decreases, RMR will decrease and tend to ‘brake’ the reduction in body fat which might otherwise occur.

Age. Recent research estimates that RMR decreases at a rate of approximately 2 per cent per decade between the ages of 20 and 70 years. This reduction is accounted for primarily by decreases in FFM which is mostly due to reduced overall physical activity. However, at the same levels of FFM and FM, older people have a slightly lower RMR.

Gender. For a given body weight, females have a lower RMR than males due to a lower FFM to FM ratio. Females also have a slightly lower RMR than males independently of FFM, FM and age, most probably due to the effects of sex hormones on RMR. Several studies have shown that energy expenditure varies within the female menstrual cycle. During the preovulatory (progesterone) stage, RMR appears to be 6-15 per cent lower than during the pre-menstrual (oestrogen) stage. RMR may also be reduced in women taking progesterone-only oral contraceptives.

Genetics. FFM, FM, sex and age account for about 70-80 per cent of the differences in RMR between people. Other genetic factors account for some of the remaining differences. This suggests that RMR is at least partially genetically determined. These findings are supported by studies involving identical (monozygotic) and non-identical (dizygotic) twins which showed that identical twins are more alike with respect to RMR than non-identical twins.

Sympathetic nervous system (SNS) activity. The SNS is that part of the nervous system involved in generally speeding up the body’s responses, for example through increased heart rate, constriction of blood vessels and release of hormones such as adrenalin. The SNS also stimulates lipolysis resulting in the release of free fatty acids (FFA). The degree of SNS activity may have a small influence on RMR.

Ambient environmental temperature. When the environmental temperature is low, maintenance of normal body temperature at 37°C is an active process requiring extra energy. For this reason more energy needs to be expended in cold conditions than in warm. The cooling process (for example, sweating) is more energy efficient than the heating process (for example, shivering). The use of a sauna bath may result in fluid loss (and therefore weight loss), but not significant fat, or energy loss. Similarly, exercising while rugged up to increase sweating is only likely to have a short term effect on fluid loss and no extra effect on fat loss over and above the exercise. On the other hand exercising in the cool or cold, while only lightly dressed, would require that the body increase its energy use to maintain body temperature. Of course, this needs to be balanced by the injury protection benefits of warming up muscles before exercising.

Physical activity. One question which is often asked is whether physical activity has a carry-over effect on RMR? In the short term immediately after exercise, there is an excess post-exercise oxygen consumption (EPOC) which reflects an ongoing excess metabolic rate. The duration of EPOC is dependent on the duration and intensity of the exercise, but it may last for a few hours. In the longer term, the question of whether fit people have a higher RMR after the EPOC has disappeared (say 24 hours after an exercise bout), is less clear. A recent review of all the major work earned out in this area’ suggests that regular physical activity does have a positive effect on increasing RMR but this is mainly because of the relative increase in FFM in the body. The longer term benefit of regular exercise on metabolism is probably more related to changes in the respiratory exchange ratio (RER) than RMR.

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Treatment

Treatment is usually difficult. Special antibiotics are needed, and the requirements may be ongoing. Specialist care centred in a major hospital which has full facilities is usually necessary. The final outlook is grave, and most patients perish before reaching adult life. Parents are cautioned that, being an inherited disorder, there is a one chance in four that with any subsequent pregnancy another child with the same disease could be born. It is a sad fact of life, but one worth knowing about.

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