Tag Archives: children

How to tell your kids when a loved one has been diagnosed with cancer or other serious illness

It is hard enough for us adults to have to deal with bad news that affects ourselves or a closed loved one. But it can be even harder on the adults if they have kids they need to inform that mom or dad, or grandma or grandpa or uncle Joey are seriously ill. In this blog article I will describe the when, why and how to tell kids these things.

Should I tell my child that Uncle Joey has cancer?
Absolutely you should tell. There has been much research on this topic. If you are not honest with your child about this, how can they trust you when they have tougher questions later on? Kids are also very perceptive and smart. It is hard to hide things from them, and they will hear things you think they can’t. It is much better to tell them directly and be open about it. Dont’t make up words or try to soften the blow too much. Use the actual word for cancer, e.g. leukaemia, lymphoma, breast cancer, brain tumor etcetera
When should I tell my child that a family member has a serious condition?
The sooner, the better. As soon as you know, you should tell them. It might explain to them why mom or dad are sad or are away from home more. You may get more snuggles and kisses, which is a great cure when you are feeling sad.
How should I tell my child that grandpa has an aggressive form of lung cancer?
You should tell any kids of any age, but the details of what you tell them, differs per age. Under age 8 yrs, basic terms and a very brief summary are usually enough. Between 8-13 yrs they may want more details or maybe even see pictures. Teens might want to read articles or books about it.
There are some good references out there that can help you (see this link)
These are the things that I would include:
  • that grandpa has cancer and it is located in the lungs
  • a short summary what next steps are (e.g. surgery, chemo, radiation)
  • what this might mean for the kids themselves in the near future and longer term (e.g. being picked up by others, more play dates, understanding why mom and dad are more emotional etc)
  • remember that kids still believe in magical world. make sure they understand they did NOT cause the cancer to occur (e.g. say something like “Doctors tell us nobody understands how the cancer gets there, but we DO know it is NOT caused by someone else”)
  • you can NOT catch cancer; it is NOT contagious like a cold (please give grandpa lots of hugs, he could use them)
  • please reassure your child that they may ask you questions at any time
What do I say if my child asks me if mommy is gonna die from the breast cancer she has been diagnosed with?
This is probably one of the hardest questions to deal with. It is already hard and painful enough for the adult to think about death in relation to the illness, let alone having to deal with answering this question. As much as you may want to reassure and say that “everything will be alright”, you cannot say this as nobody knows the answer to the question. Probably the best way to try to answer it is by not saying “no”, but rather “the doctors are gonna do everything they can to get rid of the cancer; what can help mommy is giving lots of hugs and writing cards/drawing pictures”, etc.
  1. Be honest when it comes to telling your kids about the diagnosis
  2. Make sure to reiterate cancer is NOT contagious
  3. Ensure that your kids understand they did NOT cause the cancer to occur
  4. Answer questions honestly without being too blunt
  5. Invite the kids that they can ask you questions about this at any time

Not Vaccinating has Side Effects too: the impact families who DON’T vaccinate have on families that CAN’T


I have been following the situation around the rise in number of cases of vaccine-preventable diseases closely over the past few years, and I feel strongly it is time I summarize my feelings about this now.

In the past few years we have seen small epidemics of whooping cough (2010 and 2014 in California, and 2014 in Alberta), measles (2014 in Alberta) and more recently measles in Disneyland around Christmas time 2014 with ongoing new cases still in January 2015.

I have been practicing as a paediatrician for 10 years. In these 10 years the number of parents that are indicating they wish to postpone/change their child’s vaccination schedule or to not vaccinate at all, has grown. Let me be very clear in saying that it is still a small minority that do this, however the impact their decision has on not only their child but the entire community as a whole, cannot be underestimated.

The recent measles outbreak in North-America which was mostly related to an infected patient at Disneyland in California has reminded the world again how contagious measles are (1 measles patient can infect 15 others) and how people who are advocating against immunizations (the “Antivax movement”) are largely to blame for this.
Is the notion of groups choosing to not vaccinate new?
NO, it is not.
For many years there have been groups who choose not to vaccinate based on their religious belief (I freely summarize it as “it is in God’s hands”). I always maintain that the only thing that is hard to argue with is religion. Nobody can show them proof that God is asking them to vaccinate just as much as they can’t show proof God is saying to not vaccinate.
Those groups have maintained such a stance for many decades and in fact it did not cause too many outbreaks because the other people around them were vaccinated. This is called “herd immunity“. Herd immunity is effective for those unvaccinated ones if the percentage people getting vaccinated is roughly 93-94% or higher.
Unfortunately the Antivax movement has caused the percentage of people to be vaccinated in some provinces in Canada and  states in the US to fall to as low as 85%. This is causing a rise in the number of kids sick with vaccine-preventable diseases.
Why do you make a difference between somebody choosing not to vaccinate based on their religion versus any other reason?
What I do have a hard time accepting, is people that choose not to vaccinate based on information not supported by medical evidence. They can’t show me evidence that backs their claims while I can show multiple evidence-based facts that clearly show the benefits of immunizations. I do not stand alone in this. My claim is factual and is supported by the World Health Organization, Centre for Disease Control, Health Canada, American Academy of Pediatrics, Canadian Pediatric Society, and many more.
How did we get to this vaccine-hesitant frame of mind in some groups?
A. The first one that had (and in fact still has) a major impact on people’s choices to vaccinate, is the study by Andrew Wakefield in 1998 in which he claimed there was an association between MMR vaccine and autism. Please note that I did not post a link here as the study has been retracted because of fraudulent research, false claims and questionable ethics (to put it mildly). At least 20 other studies have looked at that relationship after Mr Wakefield’s study, and none have found any causal relationship between MMR vaccine and autism. I repeat, there is NO evidence between MMR vaccination and autism. If you are interested in reading more on that story, a very detailed and excellent job was done by Brian Deer on this, which you can read more about here.
B. Then there are celebrities who are not medical doctors, but have a strong opinion for which they are receiving a platform. One of the more vocal celebrity advocates would be Jenny McCarthy who claimed that vaccinations caused her son’s autism. Amazingly she was given a large platform in the media even though there is no scientific evidence backing her statement. Jenny McCarthy is an expert on her son, but she is not a medical expert.
C. A journalist who normally tries to balance both sides of the coin on any topic, and who famously had her own colonoscopy aired (which actually increased people getting colonoscopies done by 20% !) got into some heat after tackling the issue of vaccines. Katie Couric did a segment on HPV vaccines and had such a skewed anti-vaccine portrayal of the matter, that she needed to issue an apology after.
D. Then there are those that believe offering a postponed (no medical evidence for that) or an alternative vaccine schedule is the better way to go. If you are considering such an alternative vaccine schedule I would suggest you read this excellent rebuttal to Dr Sears’ alternative vaccine schedule, written by 2 physicians and published in the Journal of Pediatrics in 2009.
So what have the combination of all these “incidents” led to?
A decline in vaccination rate, a decline in the percentage of vaccinated people needed to get herd immunity. And what has that led to? A resurgence of diseases that are vaccine-preventable and are now reminding us of how contagious they are.
Two stories that show the impact of not vaccinating:
Dad (and fellow pediatrician) Dr. Tim Jacks wrote an excellent piece on how a recent exposure to measles has affected his family (they have an immunosuppressed daughter undergoing chemo treatment for leukemia and a 10-mth old baby boy who has not received his MMR vaccine yet). You can read his article here about the impact parents who DON’T vaccinate their children have on parents who CAN’T vaccinate theirs.
The world-famous children’s books author Roald Dahl described in a letter in 1988 how he felt about vaccine-preventable diseases after he lost his 7-yr old daughter to measles in 1962.
Sometimes cartoons can be very impactful. New Yorker cartoonist Emily Flake tried to depict it as follows: daily-cartoon-150202-measles-1200
So where does that leave me, a community pediatrician seeing primary care patients (this means healthy babies too) as well as consultations (some of which are immunosuppressed children, premature babies and babies with complex congenital heart disorders)?
What should I do when a family indicates they do not wish to vaccinate?
And how do I protect my patients (both the vaccinated and the unvaccinated)?
This is not an easy question to answer, but I will attempt to do so.
First and foremost I strongly believe all kids should be vaccinated according to their regional vaccination schedule. This is supported by medical evidence over decades of research (as per WHO, CDC, Health Canada etc). It is also important to note there is still ongoing research into vaccines we give and any potential adverse events they might have.
I will always ask a new family if their child is uptodate on their immunizations. If they answer that they do not vaccinate I open the dialogue as to why they don’t. I will then give them the data on benefits of vaccinating, what the medical evidence is and what the most common side effects are. I will give them this handout by the Canadian Pediatric Society (CPS) and I will encourage them to read it at their leisure, and that they can come back with questions about this any time.
There are some colleagues who will discharge families if they don’t vaccinate and/or not accept families that don’t vaccinate. Whereas I understand where those physicians are coming from, I feel I have both a legal and moral obligation to the parents and their children to continue to serve them. In 2007, the CPS published an excellent article on the legal aspects of this.
Personally, I feel I need to protect ALL my patients, those who are vaccinated, those who are not vaccinated yet, and those whose parents chose not to vaccinate them (after all, it’s not the kid’s fault).
Some have suggested to have a separate waiting area for unvaccinated kids. Not only is that physically impossible in most existing community office spaces, it also increases the chance that one unvaccinated child with a vaccine-preventable disease will infect the other unvaccinated children who are in same waiting room. For that same reason I would also not schedule them at an “after-hours time slot”.
So what have I done and what will I continue to do? I will continue to keep the lines of communications open with my patients and their parents. The CPS published a guide for health providers how to work with vaccine-hesitant parents. I will do my best to educate them on vaccines and encourage them to do it. I will try as best as I can to protect ALL my patients. I will ask those parents of unvaccinated children to remind my staff on the phone when calling in with fevers and rashes that their child is not vaccinated. In those instances, I will put the kids into an exam room immediately and if clinically suspected or confirmed , not use that room for the rest of the day and disinfect it.
Here are 6 take-home messages I would like to leave you with:
1. Vaccinating your child is important and proven to be of benefit and is safe (supported by medical evidence). Saying your child does not need vaccines because he is always healthy, is like saying you will not wear a seatbelt because you will not be in a car accident.
2. Vaccinating your child is an important civic duty and contributes to a healthy society. It is important to remember that we are not only protecting the patients we are vaccinating, but also those who cannot be vaccinated.
3. As a physician, it is important to keep the lines of communication open with your patients. Sometimes it takes multiple visits, questions raised and answered for vaccine-hesitant parents to come to the realization that indeed vaccines work and are safe.
4. Everybody, and I mean EVERYBODY (vaccinated and unvaccinated) should stay home if they suspect they have a communicable disease and call a healthcare provider for further advice. This helps to keep these cases from evolving into an epidemic.
5. Just because celebrities might be people you see/hear a lot of in the media, does not make them medical experts overnight. 
6. It is my hope media will cover the horrible effects the Antivaxers have caused just as much (or more) as they have covered the false claims.

“Stuck in a tunnel”: the common problem that is constipation

One of the most common problems I encounter in the pediatric office, are problems with regards to bowel movements. It is very frustrating as a parent to see your baby, toddler or child in pain while trying to push out that stool. You just wish you could do something for them. Constipation can present as abdominal pain, skipping days of bowel movements (or weeks in extreme case) or even as diarrhea. In this article I will discuss the most common causes of constipation, how to treat it, and how to maximize everything you can do to prevent it from happening (again).

What is constipation?

Constipation is defined as having a bowel movement fewer than 3x a week. Often the stools will be dry and hard, but this does not always need to be the case. Stools come in all shapes and forms (just look at the picture; Types 4 and 5 are considered “normal”). In fact, in cases of really bad constipation stools can actually become quite liquid, and soiling may occur.

What are conditions/situations that make constipation appear most often?

Babies can have irregular bowel movements, and only have a bowel movement once every 4-5 days. As long as they are not bothered by it, that is ok. Some babies will have a bowel movement with every diaper change, some will skip 4 or 5 days.

When transitioning to solid feeds (often with the introduction of rice cereal) some babies may get constipated.

Another common time one can encounter constipation, is when your child is getting potty-trained. We are teaching them to hold their bowel movement until they reach their potty. Some kids love to have the power to hold their stools, and will try to hold it for as long as possible. Others are only inclined to have a bowel movement in their own home, and will hold it while at daycare, school or out camping. This ultimately leads to the most common vicious cycle in constipation: they will hold it, making the stool harder and bigger. When they do eventually have a bowel movement, it will cause them pain because it is too large. The next time they have to go to the washroom they will hold it even more because (like any human being) they do not want to experience pain again. This eventually turns into a vicious cycle, and at this point a doctor’s visit is often required to help resolve the constipation.

If one is prone to constipation, then a time when one is dehydrated (for example after a stomach flu with lots of vomiting and/or diarrhea) or when your child is hardly eating or drinking because they feel sick, could be the start of constipation.

All of these forms of constipation are called “habitual constipation”. There are also medical conditions that can cause constipation. These are rare, but in persistent cases of constipation, your primary care physician should rule them out and/or refer your child to a specialist. Again these are rare, but here is a list of some of the most common, rare causes: celiac disease (a gluten-allergy), hypothyroidism (thyroid is working too slow), Hirschsprungs disease (last part of intestine is missing nerves) and (exceedingly rare) Cystic Fibrosis (there is usually a family history of this, and many more other symptoms). With Hirschsprungs disease it will often manifest itself in the first week of life, when it will take very long for your baby to have their first bowel movement after birth (the so-called “meconium stool”). If your baby’s first meconium occurred > 48 hrs after birth, and they continue to suffer from constipation that is hard to treat, you should talk to your child’s physician about ruling out this disease.

How do we treat constipation?

If the constipation is mild and only started relatively recently, one can try diet modifications such as increasing fluid intake, eating prunes and/or drinking dilated prune or pear juice (1:1 ratio of prune/pear juice and water). In babies sometimes the old-fashioned trick of brown sugar-water can help (2 oz of water with 1 teaspoon of brown sugar). It is important to note that this should not be given daily. If these conservative measurements are not helping do not wait too long before seeking medical attention.

Your child’s physician may decide to prescribe a stool-softener which will basically attract water into the intestine, making the stool softer (for example lactulose liquid, or Polyethylene glycol powder also known as PEG3350). It is important to stress that one can NOT become dependent on these products.

On occasion it may be necessary to give your child enemas. These are typically given to children who are so full of stool, that they need to “get the cork out” in order to facilitate the rest of the stool to start moving.

“My child has a tendency to get constipated. Is there something I can do to prevent it from happening so often?”

Making sure the children are properly hydrated is by far the most effective way to prevent constipation. Ideally toddlers should drink at least 4 cups of water a day, and older children 6-8 cups of water a day. One of the contributing factors to constipation in toddlers is that they do not drink enough water in the first place. Some parents will put a tiny bit of juice in a cup, and then add lots of water and for some children that works. If that is not effective, sometimes a physician may give the kids a stool softener to help them.

Some parents might buy over-the-counter fibre products such as Benefibre or Metamucil. These products certainly provide extra fibre, however they only help treat the constipation if you drink even more water than your physician told you. This is often not possible for the kids. So, I do NOT recommend using these products. I suggest trying to encourage the kids to eat their fruits and vegetables to provide them with a natural source of fibre. The third step in preventing constipation is exercise. Luckily, most kids are very active so this is something that already occurs naturally.

Lastly, a regulated toilet regime can help your child prevent constipation. I suggest putting your child on the potty or toilet 3x a day for 5 minutes. If they produce, that is wonderful, if they don’t it is ok too. Typically about 15-20 minutes after a meal our bowels are most active. So for example, after breakfast, lunch and dinner would be a good time to put your child on the toilet/potty.

“My doctor/pharmacist told me to use a suppository to help with constipation”

It is true that glycerine suppositories can help getting some stool out of the rectum. I tend not to recommend them in most cases, for 2 main reasons: it only helps to get rid of the stool that is in the rectum (much more stool is left in rest of intestine), and sometimes you can create a small cut (also known as fissure) with the introduction of the suppository. Now your child or baby may experience pain again with a bowel movement, start holding the stool etc. Now we have actually created more problems than help with that suppository.

“My child has a bowel movement every day (albeit a bit hard); he cannot be constipated, can he?”

Oh yes, he can be constipated. The analogy I like to use for this is the accident in the tunnel. Imagine about 3/4 into a tunnel a traffic accident occurred and the 2-lane road has turned into a single lane (don’t worry, nobody got hurt). If you look at the entrance of the tunnel, you will see free-flowing traffic in 2 lanes going into the tunnel. However, if you are standing at the exit of the tunnel, you see cars coming out one by one, slowly in a single lane. Once the site of the accident in the tunnel has been cleared, there will be free-flowing traffic in the tunnel again. At no point did cars stop coming out of the tunnel, it was just slower and it took more time. With this kind of constipation, we need to help your child “clear the site of the accident” so to speak.

“Our doctor has already prescribed a stool softener, but it is not working”

This could indeed be the case, and then more vigorous treatments, possibly further investigations and/or referral to a specialist would be necessary. Alternatively, the dose of the stool softener prescribed was not high enough, or the stool softener was not used for an adequate amount of time.

Dr Raffi’s constipation tips:

1. Make sure your child drinks enough fluids, and eats their fruits and vegetables to provide sufficient fibre intake

2. Have a strict toilet regime

3. Don’t wait too long before seeking medical help (or restart previously prescribed stool softeners) in order not to get stuck in the vicious cycle of holding, experiencing pain and constipation.

4. If constipation persists despite all these therapies, talk to your child’s physician to rule out rare medical causes, and/or refer to a specialist Pediatrician or Pediatric Gastro-Enterologist

Everything you always wanted to know about allowance, but were afraid to ask

This is a topic which is often discussed amongst parents and their friends. “Did you start giving an allowance yet? How much are you giving? Do you pay your kids something for doing the dishes?”

If you talk to several people you will not find a consensus: Some people do not believe in giving their children allowances at all, others cannot afford to. This blog is written for those parents that are considering starting their kids on an allowance.

Parents will start off their kids’ allowances at different ages, and at different amounts. Unfortunately, no solid data can be found on this.

In this blog I will summarize information from data I gathered from different groups: psychologists, pediatricians and parents. After reading this, you will hopefully have enough information to decide for yourself what you will do for your child. And it may not be exactly the same as we did for our kids. And that’s alright.

At what age should I start allowance?

As a rule of thumb, most experts agree that we should start paying allowance when your child is old enough to understand the concept of money. This is usually around age 5 or 6 yrs.

How much allowance should I pay?

In general, the amount of allowance should be enough for kids to spend on whatever they want, but at the same time not too much as to cause the parent a financial loss (i.e. you are ok for them to squander it). You should talk to your child or teen about what you expect their allowance to cover. Of course this also directly impacts the amount you will have to pay them; e.g. if your 11-yr old daughter is expected to buy her own clothes, you may wish to give her slightly more than the rules I am about to describe below.

There are some experts that feel the weekly allowance in dollars should be equal to the age of the child in years. I am in favour of paying the kids a weekly allowance that is equal to half their age in years. At the end of every month, as an encouragement to saving, tell them you will match whatever they saved that month.

What do I pay allowance for?

Some believe that the kids should do chores to “earn” their allowance. I believe that performing small chores (e.g. cleaning up table after dinner, doing dishes, making your bed etc) teaches kids responsibility as well as encourages the feeling of being part of a family. Each member of the family contributes in his or her own way. They are part of the value system that kids learn. These contributions should not be remunerated. However, if it is an unusually large and/or infrequent chore (e.g. spring cleaning of garage), then some “extra allowance” could be given.

Young children might use allowance towards buying candies or toys. Or they may choose to save their allowance to buy a bigger present.

Older kids may buy (video) games or clothes from their allowance.

If you would like to research more on this topic, check out this link to a statement of the National Association of School Psychologists which dates back to 1998 but is still applicable, or read Janet Bodnar’s book “Dollars and Sense for Kids”.

Bottomline, Dr. Raffi’s tips on allowance:

1. Start at age 5 or 6 yrs old

2. Weekly allowance in dollars equals half the child’s age in years

3. Do not pay for chores unless it is an infrequent or unusually large chore

4. Try to encourage your child to save by offering to match whatever they have saved at the end of the month