Antidepressants Blog

Most children with epilepsy go to a normal school and do well. When your child starts at any new school you should talk to their new teachers, who may have very old-fashioned or mistaken ideas about what someone with epilepsy can or can not safely be allowed to do.
Explain to the school about your child’s epilepsy, and tell his or her teachers what will happen if they have a seizure. Tell the matron what drugs the child is on. Usually schools are understanding and co-operative, and a headteacher will pass on to the teachers in charge of the child whatever information you give them. But just occasionally they fail to do so. If the school is large and you get the feeling that the headteacher is insufficiently concerned, it would probably be worthwhile talking to your child’s class teacher yourself, just to make sure that the information filters down to the right level.
The child’s own friends usually accept the fact that he or she has seizures quite matter of factly. A few children do get teased, but teasing is often not as big a problem as most parents expect it to be. Some children even find that their seizures make them more interesting to their peers.
Your child’s teachers probably see almost as much of them as you do and an observant and co-operative teacher is a valuable asset. They may recognize changes in your child’s behaviour or physical state even before you do. Always ask them to discuss any changes they do notice with you; these changes may be an indication that your child’s medication needs adjusting.

WHAT TO TELL THE TEACHERS
Make it clear to the school that you want your child to take part in the whole range of the school’s activities. There is no reason why they should not play games, for example, or swim; in fact (except in rare cases) there is every reason why they should do these things.
Explain to teachers that there is usually no need to send your child home after an attack unless they have been hurt. It is enough just to allow them to sit quietly for a while to recover, before carrying on with normal school activities.
Get a clear and realistic assessment from your doctor about what your child should be capable of. It is a good idea, too, to ask your doctor to arrange for the child to be tested by a psychologist so that you know what his level of intelligence is and where his skills or difficulties lie. Once a child is labelled an ‘epileptic’ there is a real danger that their teachers may underestimate their academic potential and give them neither stimulation nor encouragement. The child who is expected to do badly almost certainly will do badly.
Keep a positive attitude. Emphasize what the child can do, not what they can not. Help them to develop social skills so that they are a likeable person.
Make sure that the staff are prepared to treat your child as far as possible just like the other children, both in terms of punishment as well as reward. Teachers may be tempted to let them get away with too much because they are afraid that discipline or reprimand might cause a seizure. Such special treatment will not make your child popular with the other children.
Keep the child’s attendance at school as regular as you can. The reason many children with epilepsy do badly is simply because they have missed so much schooling.

TAKING MEDICATION AT SCHOOL
Most children with epilepsy are able to take their medication twice daily, outside school hours. But a few may need a dose during the school day. And very occasionally, staff may have to give emergency treatment with rectal diazepam to a child in status epilepticus.
If your child needs to take a dose of anticonvulsant during school hours, make sure that the school has written details about how and when the medicine is to be taken, whether it should be given by a named teacher (in which case the parent should give written permission) or whether the child is to be responsible for their own medication. Secondary school children (unless they have learning difficulties that would make it impossible) should be responsible for taking their own medication. Younger children should be encouraged to be self-reliant too, but it will depend very much on how responsible the child is generally, and whether the school is prepared to allow them this particular responsibility. If the medicine is to be stored (for example, if the school is to keep rectal diazepam for emergency use) you need to agree with the school who is responsible for giving it (they may need special training) and where it is to be kept for easy access if it is needed. Label all medication with the child’s name and the dose and frequency of its administration.
In the current climate, many teachers are uneasy about giving rectal diazepam to a child. To protect teachers against the possibility that they might be vulnerable to allegations of child abuse in these circumstances, two adults should be present if rectal diazepam has to be given to a child.

CHILDREN WHO DO NOT ACHIEVE
When your child is first diagnosed as having epilepsy, one of your first concerns is likely to be about the effect the epilepsy will have on their intelligence and mental ability.
Some children who have epilepsy do, undoubtedly, fail to achieve what they should be capable of at school. But once again, this is nearly always a by-product of the epilepsy and not a direct result of it. Sometimes children underachieve because they have fallen behind in their school work through frequent absences, more often underachievement is due to the drugs they are on, though probably a major factor is also the attitude of parents and the school towards children with epilepsy. For everyone’s sake, ask for your child to be properly assessed by a neuropsychologist so that you and the school have a realistic idea of what they should be capable of, and in which subjects they are likely to have difficulties. If the school is unable to organize this itself, ask your doctor to arrange it by referring your child to the local mental health services for psychometric (IQ and skill measurement) assessment.
Whether epilepsy does cause mental deterioration has been a matter of debate for over 100 years. Rapid diagnosis and assessment of the epilepsy after the onset of the first seizure, and good control of seizures seem to be the most important factors involved. If there is mental decline, it is likely to be most noticeable in the first years (or perhaps even the first few months) after the onset of epilepsy. This initial phase is followed by a stable phase with little further deterioration.
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Many women comment ‘I didn’t feel ill, so the cancer diagnosis came as a huge shock!’ One of the first reactions is that the cancer will kill you, and so the fear and worry start. Often women worry unnecessarily about ‘what might happen’ based on their fear. Try not to ‘cross bridges’ unless they are there to cross. Focus on today, keeping in mind that your doctor will have been open and honest with you about the current state of your condition. Live every day to the fullest. Find pleasures (often small) in every day and something to have humour about. This will lighten the burden for you and help you cope even at the bleakest moments.
Many people ‘live’ with cancer . . . fewer and fewer are dying of cancer. You have every reason to remain hopeful the outset. A good relationship with a medical team u trust will reinforce this optimism.
• Do you know most women with gynecological cancer do not get a recurrence . . . and the good news . . . More women now SURVIVE gynecological cancer than die from it.
Remember: that while it is a human reaction to worry at times like this (after all the uncertainty and fear for life is enormous!) Worry does not work! All it does is sap your energy and distort your mind from planning and implementing your way back to good living, worry plays games with the mind. Who will win? You – or the worry? However, in order to have the greatest energy to cope with the challenges ahead, it is ‘OK’ to feel scared. For a short time . . . until you start feeling confident in your ability to meet the challenges that lie ahead, whatever the outcome. After all, it is a new experience for most, and one where the negative aspects are the most broadly advertised. All the great actors of the world have ‘butterflies’ before they play their most important roles. However the anxiety does not last when a skilled cast and appropriate props and scenery ‘on stage’ support the actor. It is no different with starting cancer treatment. The developed world is most fortunate to have such a high level of skilled, knowledgeable and caring staff and such well-equipped hospitals with so many props’ or resources for the patient and carers.
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1. Does having a single (isolated) fit mean that someone has epilepsy? No. By definition, epilepsy means having recurrent seizures, so a single fit does not mean that that person has epilepsy. About 60% of people with an isolated fit never have another one. On the other hand, for someone who is destined to develop epilepsy, the first fit will be followed by others in due course.
2. I find the words ‘fits’, ‘convulsions’ and ‘seizures’ confusing as they are used interchangeably. Are they all the same? Yes, they all have the same meaning. ‘Seizures’ is the preferred term, but both the others are quite acceptable. Other expressions which are vague and confusing such as ‘turns’ or ‘funny spells’ are of no value.
3. Our four-year-old son has had two convulsions associated with tonsillitis and fever. Does he have epilepsy? Almost surely not. He has almost certainly had two febrile convulsions which very rarely lead to epilepsy. Febrile convulsions are common, occurring in about 4% of children under the age of five years. These convulsions are due to fever, usually associated with a sore throat, tonsillitis or an ear infection. It is quite uncommon that febrile convulsions require treatment with anticonvulsant medication, but it is of value to try and prevent recurrent episodes by cooling the child down when he or she has a fever and giving medication to bring the fever down (paracetamol).
4. A friend of mine with epilepsy talks about the warning that he gets before a fit. My son has epilepsy but he does not seem to get any warning at all. What does this mean? Some people with epilepsy may get a warning, which is called an aura, at the beginning of a fit. This usually affects people with partial (involving part of the brain only) epilepsy before they then develop a generalised fit. The nature of the aura will vary from person to person and will depend on that part of the brain involved. An aura should not be confused with prodromal symptoms which some people may have for hours or even days before having a fit. These symptoms include irritability, headache, feeling ‘generally unwell’, tummy aches and so on.
5. Did my child’s birth lead to his epilepsy? During birth, the child’s head is subjected to quite strong pressures from the outside, so that small areas of bleeding may occur on the surface of the brain. It is also possible for the same thing to occur inside the brain. Occasionally there may be problems at birth so that the child is born very rapidly or with great difficulty and the stresses on the baby’s head and brain are therefore greater than usual. This is called cerebral (brain) birth trauma (injury).
Naturally it is difficult to be certain that events which occurred at birth are related to the development of epilepsy which may occur some years later. However, in some instances there is a strong suspicion that this may be the case.
It is often confusing for parents to be told that their child’s fits are due to something which occurred at birth, as they would have expected the fits to have started at the time of the injury. This is often not the case and the seizures may only begin in childhood or even later in life.
6. Can seizures occur in newborn babies? Seizures in the
neonatal period (the first month of life) are not uncommon, with
most fits occurring on the first and second days of life. Neonatal
fits have not been discussed in this book as they may not lead
to epilepsy and many of the causes of neonatal fits can be
defined and treated. Causes include difficulties during labour or delivery, abnormalities of the brain, bleeding into the brain, meningitis, hypoxia (a lack of oxygen to the brain), hypoglycaemia (low blood sugar) or a low blood calcium or magnesium. As already mentioned, neonatal seizures in themselves do not necessarily predispose to epilepsy but, if there is associated brain damage, epilepsy may develop in later childhood.
7. Do fits have any effect on memory? It is quite common for people with epilepsy to complain of a poor memory. This seems to be most common in persons with temporal lobe epilepsy, but very frequent seizures, long fits and heavy anticonvulsant therapy may also contribute. There is not a great deal that can be done about this sort of memory loss other than to try and get better seizure control if that is possible.
8. How do anticonvulsant drugs work? Despite the existence of these drugs for many years, the answer to this question is uncertain. In general terms, it seems that anticonvulsant drugs increase the seizure threshold (the resistance of the brain to seizures) and this is probably why they are effective. They seem to prevent, or limit, the production of abnormal electrical activity by the brain.
9. Do fits themselves damage the brain? This of course is difficult to answer accurately as it is not possible to do controlled studies in humans to get the answer. It is probably only prolonged grand mal seizures, including prolonged febrile convulsions, which may be harmful. Again it is difficult to say how long a fit has to be before it becomes dangerous. Most doctors would suggest 15-30 minutes. The damage does not occur from the fit itself, but from the lack of oxygen to the brain during the fit. Probably the most commonly damaged part of the brain, especially in children, is the temporal lobe. Most seizures do not seem to do any harm to the brain.
10. Is it possible to do something which will prevent a fit when you can feel it coming on? If you are lucky enough to be able to develop some way of preventing some of your fits you are indeed fortunate. It is very uncommon that this can be done, but very occasionally some sort of self-control measure may be helpful and will either abort or delay the fit. Self-hypnosis may be useful in the very few people who have an aura of such length that they can hypnotise themselves. Overall there is little that can be done to prevent fits in this way.
11. Can epilepsy be caused by stress? The answer to this common question is that epilepsy is probably never caused by stress or a shock. However, stress may make fits worse, or more frequent, in someone with established epilepsy.
12. Can excitement bring on fits? This is certainly possible and it is known that some people may have more fits when they are excited.
13. Is it possible for someone to bring on fits? Yes, it certainly is. There are two common situations in which people induce fits. Firstly, some people may use a known provoking factor such as overbreathing, flickering light and so on, to bring on a fit at a time that suits them. These are real fits. The second group are those who have false fits (pseudoseizures). These fits have many of the outward appearances of being real, but if the EEG is examined during the so-called fit, it is normal. It may be very difficult to diagnose pseudoseizures, as they often occur in people with epilepsy. As a generalisation, most people with epilepsy, once on regular medication, will have an improvement in seizure control or at least will remain static. It is unusual to see a deterioration. The hallmark of pseudoseizures is deteriorating seizure control despite more and more medication. The diagnosis is best made by video-telemetry so that the fit can be seen and an EEG recorded simultaneously. There is almost always an underlying psychological problem to account for pseudoseizures. In essence, patients are using their existing epilepsy to have more fits so that they can achieve a particular purpose, for instance get out of a difficult situation, although they may be doing it subconsciously. Pseudoseizures are not all that common, but present a diagnostic and treatment problem.
14. My 20-year-old son has just been diagnosed as having epilepsy. He enjoys the occasional beer – is that okay?
Alcohol in moderation is unlikely to have any deleterious effect on epilepsy. However, it is important that people with epilepsy realise what alcohol may do:
It may affect the working of the liver in such a way that anticonvulsant drugs, which are broken down in the body by the liver, may be broken down more rapidly. This may make the drugs less effective.
As we all know, alcohol slows one down. So do the barbiturates and the benzodiazepines (Valium-related drugs such as clonazepam, nitrazepam and clobazam), so it is a good idea to avoid these combinations.
Heavy drinking may provoke seizures, especially during the hangover period the next morning.

15. Does climate have any effect on epilepsy? There is no relationship between climate and epilepsy. There is no scientific evidence that a hot climate is hazardous, although some epileptics feel that their fits are worse in extreme heat.
16. How does a doctor know what dosage of an anticonvulsant to use? The dosage has been learnt from experience over the years. In general, young children tend to use up anticonvulsants more rapidly in their body than do adults. For that reason they need larger amounts of anticonvulsant relative to their body weight than adults do. In children, dosage is usually worked out from the child’s weight and may need to be increased as the child grows. Blood level monitoring may also be useful to guide the doctor in finding the right dosage for an individual patient.
17. I have grand mal seizures which are well controlled. I am a trained secretary who is about to do a word processor course. Is there a risk of having fits from working in front of an electronic screen? You are referring to photosensitive epilepsy. As has already been discussed earlier in this book, some people may have a photosensitive tendency. Their fits may be provoked by various light sources including television, flickering lights and so on. There is no evidence that video display units (VDUs) present a photosensitive problem.
18. I have heard it said that people with epilepsy have an ‘epileptic personality’. Is this true? No. This is based on old observations of people with severe epilepsy who used to live in institutions. Epileptics may have some psychological problems -these may be seen in people with epilepsy and brain damage, in some patients with temporal lobe epilepsy and in those who have had multiple setbacks as a result of their epilepsy. Not surprisingly, if someone has been knocked back for job after job, they are likely to become gloomy and withdrawn. This is not a direct association with their epilepsy. In some people, anticonvulsants, especially barbiturates and benzodiazepines, may cause irritability and drowsiness. But the idea of an epileptic personality should no longer be discussed.
19. Phenytoin may produce unsightly gum swelling. Can this be avoided? Gum swelling probably cannot be avoided completely, but it can be minimised by good oral hygiene. Regular dental supervision and brushing of the teeth associated with the use of dental floss goes a long way to keeping this side effect under control. When treatment with phenytoin is stopped, the gum swelling usually settles down over the next year.
20. How often should someone with epilepsy consult their doctor? This is very much a matter of commonsense. If the patient has mild epilepsy and infrequent seizures, then a checkup every six or twelve months may well be sufficient. On the other hand, if seizure control is inadequate or if the patient is taking a drug like phenytoin which, as we discussed before, is handled with difficulty in the body, then it may be necessary to see your doctor more frequently.
21. Every time I visit my doctor for a check-up or for a prescription, I have a blood level test done. My fits are well controlled and I wonder if this is necessary? No, it is not necessary. It is only necessary to check blood levels if there is a problem that will be helped by knowing the level. Obviously, when the fits are poorly controlled, when starting someone on phenytoin or for some other specific reason, there is value in knowing the blood level. Measuring blood levels should not be a substitute for the much more important matter of the doctor discussing your epilepsy with you. Even if the fits are well controlled, an encouraging chat is usually appreciated by the patient.
22. Why is it necessary to take anticonvulsant medication regularly? To obtain adequate seizure control, anticonvulsants need to be taken regularly to ensure a constant blood level of the drug. This in turn provides a constant brain level of the drug, which helps to control the fits. Taking medication sporadically will not allow this to occur.
23. Do anticonvulsants have any long-term effects? The answer to this is difficult as it is necessary to follow up patients for a long time to obtain this information. In addition, it is hard to separate the possible effects of frequent, severe seizures from the effects of medication. It is felt that the long-term use of barbiturates, and possibly phenytoin, for more than 15 to 20 years may be associated with some intellectual dulling.
24. Do anticonvulsants affect behaviour? Phenobarbitone and primidone can cause overactivity in a proportion of children; probably 20-40% of children may be affected. This does not appear to be the case with the other anticonvulsants.
25. Can epilepsy be cured? Epilepsy cannot be ‘cured’ in the usual sense of the term. However, it can be controlled by medication. For a few people a cure may be achieved surgically. On the other hand, for many people, especially children, the seizures will cease and they will be able to come off their medication .
26. I have recently been doing a lot of physical training for a canoe marathon and have had several fits. Before starting training, I had not had a fit for at least six months. Is there a reason for this? Amongst many other effects on the body, really vigorous physical training tends to make the liver metabolise (break down) anticonvulsants more rapidly, thus lowering the blood level. This has been noted with phenytoin and may apply to other drugs. It is worth getting your blood level checked from time to time during your training and perhaps increasing the anticonvulsant dosage if necessary. You will need to remember that when you stop training and lapse back to a more sedentary life, the situation will return to its previous state and it may be necessary to lower the dose to its previous level.
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Epilepsy

The future of a child with epilepsy depends a great deal on the management of the condition during the younger years. The attitude adopted at home and at school is very important. These children need to share the company of other children, go to normal schools and partake in the usual activities. They are normal children with a particular problem which is in fact much less disabling for many of them than, for example, asthma might be.
Some parents and teachers blame any unusual behaviour, such as outbursts of anger or irritability, on the epilepsy. There is usually no connection between the two unless there are clear indications otherwise. However, there is evidence that in some children learning and behaviour problems do arise in connection with their epilepsy. Those with particular types of epilepsy (especially left-sided temporal lobe epilepsy) are more likely to be affected in this way, and boys more so than girls.
What are the school problems? Children with epilepsy are variously said to be absent minded, lethargic, sleepy and lacking in concentration. Some anticonvulsant drugs may have adverse effects on the child’s schoolwork. Difficulties with reading, inattention of various types, dependency and other kinds of disturbed behaviour may occur. An enlightened teacher may take advantage of a seizure in class to explain to the other students about epilepsy. This is useful both for the child with epilepsy and the other students. Many children with epilepsy (about 50%) have some sort of school problem which may stop them achieving their academic potential. The reasons for this are not entirely clear, but may include the following:
The effects of the anticonvulsant drugs. Phenobarbitone and primidone may affect concentration span and attention to some extent. Chronic intoxication with phenytoin may lead to intellectual deterioration. There is little information about the other anticonvulsants.
Perceptual problems. The information on the effects of epilepsy on reading skills is that:
the reading skills of children with generalised epilepsy are similar to those of non-epileptic children.
children, especially boys, with EEG abnormalities or with focal EEG abnormalities on the left side of the brain, read less well than non-epileptic children.
reading skills of boys with epilepsy, of whatever type, are less good than those of epileptic girls.
long-term phenytoin use is associated with lower reading skills than with other anticonvulsants.
In summary, there may be quite definite learning problems in about half of children with epilepsy, boys more so than girls. These need to be recognised and dealt with as well as possible at an educational level.
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Epilepsy

Work out the Facts — Iron out the Kinks I

Lower-back injury from weight-lifting… tendon strains from Taekwondo… a damaged sternum from piling on too many weight plates at the gym.

Too much exercise — or wrongly-executed moves — can lead to injury, exhaustion or even, over the long haul, a suppressed immune system… which can lead to the worst result of all: having to stop exercising cold turkey.

In women, experts caution, over-exercising carries particular problems — menstrual irregularity, infertility, loss of bone density!

Stay on the healthy side of the injury chasm. It’s not easy, because exercise makes you feel so good and most of us are shameless endorphin junkies. When you hit that aerobic plateau, when those natural opiates wash through your system, you just want to keep going. Like a drug addict, you don’t want the high to end.

Figuring out just how far or how long is too far or too long is the problem. Here are suggestions that can help.

Check it out. Before you begin, see a doctor, especially if you’re over 60, have a disease or disability, are taking medications, are recovering from an illness or surgery.

Also consult a doctor if you’re worried that exercise may affect any other aspect of your health.

If you’re running a cold or temperature or suffering from a sore throat, avoid exercise until you’re feeling better.

And keep a regular check on your blood pressure, especially if you’re over 35.

Build up gradually. It takes time to get fit. Begin slowly, perhaps just introducing more overall activity into your life. Gradually increase your exercise periods to 5 to 10 minutes twice a week, then to 15 to 30 minutes three or four times a week. You’ll lower your risk of sprains, strains and other injuries.

Avoid abrupt starts and stops. Ease in and out of exercise. Abruptly starting or stopping can cause soreness or injury (especially in older people). Stopping suddenly can also sharply reduce blood pressure, causing fainting or even a heart attack. So it’s important to take the time to warm up and cool down sufficiently. Begin and end each workout with 5 to 15 minutes of stretching exercises, slow walking or gentle calisthenics.

Don’t push your heart to the brink. Avoid exercising so strenuously that you exceed 90 per cent of your maximum heart rate. To find out your own maximum, use this rough formula: Subtract your age from 220. For most people, exceeding their upper limit may mean nothing more than approaching utter exhaustion. But those with underlying coronary disease risk a possible heart attack. (To be safe, they should keep their heart rate well below the level where abnormalities appear on an exercise stress test).

Don’t be a weekend warrior. Though regular, sustained exercise reduces the risk of heart disease, occasional bouts of overexertion will achieve just the opposite — weekend warriors are at war with their hearts! If you save all your exercise or all your heavy chores for the weekend, you are one of those weekend warriors and you could be setting the stage for a heart attack if you’re unfit. Recent studies have shown a powerful link between heavy physical exertion and an increased risk of heart attack in people who are out of condition. According to one study reported in Circulation, a sudden bout of exertion activates blood platelets in sedentary people, but not in those who are physically active. Activated platelets clump together and can form clots, which may cut off blood flow to the heart.

Preferably, avoid high-impact aerobics. This is the kind of aerobic exercise marked by high jumps and percussive bounces which are hard on your body. (In contrast, in low-impact aerobics one foot is always on the ground).

Be kind to your body. If you’re doing aerobic dance, or even if you’re skipping rope, the surface you’re working out on should be sufficiently padded. Especially avoid bare cement floors — you might pay with severe shin splints and other injuries.

Also, never do aerobic dance bare-footed. It’s important that you cushion the jolt of your foot hitting the floor, with proper shoes.

The right shoes are also important if your exercise of choice is walking or jogging — they should be well-padded, with good arches and ankle supports.

Don’t neglect strength-training. All sports emphasize a limited number of muscle groups. This can cause injury to the overworked muscles. Strength-training, by compensating for these muscle imbalances, may prevent the damage (such as tendinitis, if you’re a tennis player) that could otherwise result. Work out with light weights to help strengthen the rotator cuff (muscles and tendons in your shoulder).

Use correct technique. If you do sit-ups with straight legs instead of knees bent, for instance, you can hurt your back. If you walk with your toes pointed outward, you can expect knee pain, arthritis, bunions and lower-back pain. In general, perform your exercises slowly avoid jerky, fast movements.

Listen to your body. If you’re exercising with faulty technique, or if you’re exercising in excess of what you should, your mind will often send messages to your body to stop. Pain is one of the most direct messages you’ll get. If you ignore the command, soreness and muscle injury can result. Stay alert to symptoms such as chest pain, shortness of breath, aching joints or muscle cramps. Get to medical attention if any of them occurs, especially if you’re elderly or suffer from a chronic ailment.

Protect your lungs. Polluted air — a cocktail of noxious gases and particulate matter — is a particular hazard for exercisers. Because exercise makes you breathe faster and more deeply, it can dramatically increase the adverse effects of pollutants on your lungs and heart. Add to this the fact that joggers, runners and cyclists often breathe through the mouth (thus bypassing the nasal passages which help filter out some pollutants).

Several studies have found that those who exercise strenuously outdoors run much higher risks of pollution-related symptoms: coughing, throat irritation, headaches, shortness of breath and tightness in the chest. For people with coronary disease, exercise in highly polluted air can lead to irregular heart rhythm or angina.

You can’t avoid air pollution completely, especially in the urban jungle, but you can minimize your risks while exercising:

Schedule your outdoor workouts for times when there’s less car exhaust and the sun is not to strong. (Ozone, one of the more dangerous components of urban smog, forms when sunlight acts on car and industrial emissions).

Protect your lungs. Something as simple as not smoking, and taking deep breaths several times a day, can minimize lung damage so that by age 70 you’ll still have the lungs of a 45-year-old.

If you exercise during rush hour, choose areas with little traffic. Open, windy areas are preferable since air currents can disperse pollutants.

While exercising outdoors, breathe through your nose, not your mouth. This should reduce the amount of pollutants reaching your lungs.

The so-called anti-oxidant nutrients (such as Vitamin C and E and beta-carotene) help fight the damaging "free radicals" created by pollution and thus may ward off or repair long-term lung and cellular damage. Boost your intake of these nutrients.

Stay away from second-hand cigarette smoke — a known source of hazardous pollutants — especially before and after strenuous exercise.

And if you have asthma or any other lung condition, consult your doctor about your exercise options.

Tears flow from the eye to the nose via a narrow tube called the nasolachrymal duct or tear duct. About 1 in 50 babies are born with some degree of blockage in one or both of these ducts.

Cause

The cause for a blocked tear duct is uncertain although it is thought to be due to a retained plug of mucus or cells. The blockage is usually present at birth, but may not become obvious until your baby is around 1 month old.

Clinical features

If your baby has a blocked tear duct, his eye will be constantly watering. The eye is otherwise perfectly normal.

Treatment

Massaging the inner lower corner of the eye several times a day can encourage the duct to open, but only do this under guidance from your doctor. Make sure your hands are clean and using your little finger massage in a downward direction starting from the tear sac in the corner of the eye. If despite this treatment the tear duct remains blocked after your child has reached 6 months of age, your doctor may refer you to a specialist, who may suggest passing a fine probe under general anaesthetic to open up the duct.

When to see your doctor

• if there is a greenish discharge from the eye, which may mean the eye has become infected. It is important to stop massaging as soon as you suspect that your child has an eye infection;

• if the tear duct is still blocked after your child has reached 6 months of age.

Cataracts are a clouding over of the lens of the eye and are rare in children. Certain conditions are associated with cataract formation in children, such as the mother contracting rubella during her pregnancy. In most cases the cause is unknown. If left untreated, cataracts can lead to blindness. Surgery is usually indicated.

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    You should never let a boy touch you down there. If you get it

touched, then you will want more touching, and then you just get

more and more, like you just have to have it.

THIRTEEN-YEAR-OLD GIRL

That’s right. You should never let a boy, or anybody, ever touch your genitals or any part of your body except for two purposes. One is for health, when a doctor or nurse or some professional person is trying to help you. The other is for love, for loving for a long long time. You should decide if you will let someone touch you or whether or not you will touch someone based on whether or not you love that person. It’s that simple. When someone wants to touch you, it should be to help or to love, and in both cases the person should have earned your trust so you believe that he or she is giving the real reason for touching. One more important thing to know about this is that even if someone does touch you, it is not like you jumped off a cliff and can’t stop. You can stop anytime, and you can, if you want to, just touch and touch without going any further. Touching someone you love, letting that someone touch the one thing that God gave you that you can see, your body, is the most special act in the world.

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I have tried holding back, gritting my teeth, thinking terrible thoughts, even biting my own cheek. Nothing works. I cannot control it. 1 just come too quick for her, probably for anybody.

HUSBAND

One of the major paradoxes of clinical sex therapy is that the more men try to control themselves, the less control they have. There is absolutely no reason to control ejaculation, to time the sex act, to work toward simultaneous fulfillment and punctual penile performance.

Masters and Johnson originally defined’ ‘premature ejaculation” as a situation in which a man ejaculated too soon for his partner to be orgasmic. A corollary to this definition is “If you finish your meal before me, you are a premature eater.” Men do not ejaculate for women. There is no such thing as a “mature ejaculation” any more than there can be tardy female orgasm. Like sneezes, ejaculations happen as a natural human reflex. We respond as a system. We cannot be late for each other because we are happening with each other.

Sex manuals and clinics have focused considerable attention on techniques to control ejaculation. The well-publicized “squeeze technique” through which the partner grabs the end of the penis and squeezes hard before the man ejaculates, has been used to “train” men to last longer. This approach has been around for decades, and we now have quick-treatment programs for quick ejaculators.

One of the couples in my clinic described their sexual encounters as similar to a fire drill. The wife reported, “As soon as I sense he is getting ready to ejaculate, we hurry up and change postures.” The husband added, “Yeah, and when I sense it, too, I start to yell or scream to distract myself. We have to do something to hold back the floodgates.”

To illustrate the absurdity of this couple’s sex life, I asked then to put their favorite piece of music on the tape player. I told them to hold back any emotional reaction, not to tap their fingers or toes, not to enjoy the music. “That’s ridiculous,” reported the wife. “It’s automatic.” This automatic nature of the ejaculation is just the point. Ejaculation is a procreative reflex. It feels good, but it is not one and the same with male response and has little to do with female response.

Another mini-myth is that men are not multiply orgasmic because they have a refractory period. Men, not women, are viewed as being unable to continue sexual response beyond the contraction phase. They may be able to struggle to hold back ejaculation, but once they come, they go. You have already learned in Chapter Five that men and women both have neurological limits to physical response, but emotions and thoughts are not determined by the body. Sexual response is not a one-directional cycle, but a reverberating system.

Super marital sex depends on reassessment of the early sex perspectives. If men or women are in training to learn control, then they will never learn surrender, a surrender to a more natural mind/body interaction allowing for equality of sexual response beyond nonexistent gender-dependent limitations.

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